Transxiphoid Revascularization of the Anterior Descending Coronary Artery with the Left Mammary Artery.

Revascularization of the coronary arteries, via open sternotomy and on cardiopulmonary bypass, remains the most common cardiac surgical procedure in the United States. Patients, and cardiologists, seek an alternative to dividing the sternum while reaping the advantages of left internal mammary artery (LIMA) revascularization of the diseased left anterior descending (LAD) coronary artery. We describe a strictly transxiphoid mammary artery liberation with anastomosis to the anterior descending (TRAX CABG) without sternal division. Of the 26 patients who underwent attempted TRAX CABG, 18 had nonsternotomy LIMA-to-LAD revascularization with completion angiogram to document bypass patency. TRAX CABG offers surgeons a minimally invasive alternative to trans-sternal LIMA-to-LAD in select patients. Conversion to traditional sternotomy has limited unanticipated morbidity and completion angiogram confirms procedural success.

The convergent procedure: a multidisciplinary atrial fibrillation treatment.

BACKGROUND: Persistent atrial fibrillation (AF) and long-standing persistent AF (LSPAF) are difficult to treat. Epicardial surgical and percutaneous catheter ablations have lower success rates in these patients. The convergent procedure, an endoscopic transdiaphragmatic ablation procedure with conventional percutaneous endocardial ablation, is examined. METHODS: Twenty-eight patients with persistent AF or LSPAF underwent the convergent procedure. All underwent combined surgical epicardial radiofrequency ablation and electrophysiological transseptal endocardial ablation to electrically isolate the 4 pulmonary veins, to exclude the posterior left atrium, to ablate the coronary sinus, and to confirm block at the cavotricuspid isthmus. Follow-up was with 24-hour Holter monitoring at 3 months, and 24-hour or 7-day monitoring at 6 and 12 months. RESULTS: The mean duration of the procedure was 187 minutes (102 surgical ablation minutes; 85 endocardial ablation minutes). The mean total fluoroscopy time was 35.1 minutes. Two patients developed symptomatic pericardial effusions requiring percutaneous drainage, and 1 patient has demonstrated phrenic nerve paresis. There were no deaths. At 3 months, 87% were in sinus rhythm, and 43% were free of AF and antiarrhythmic medications (AADs). At 6 months, 76% were free from AF and AADs. CONCLUSION: The convergent procedure effectively combines surgical and electrophysiological AF expertise to provide a viable treatment option to patients with persistent AF or LSPAF. Long-term follow-up is under way.

Endocardial and Epicardial Rhythmia HDx™ Mapping Verifies Surgical Cox Maze IV Lesion Pattern.

Atrial fibrillation (AF) remains the most common cardiac dysarrhythmia, with a significant impact on the health-care economy. AF occurs as a result of electrical conduction delays within the atrial tissue, which may stem from fibrosis or other mediators that alter atrial tissue conduction substrate. The Cox maze III and IV procedures block these reentry circuits by directly dividing, or breaking, the self-perpetuating circuit and by isolating these circuits away from the intrinsic cardiac conduction pathway. The Convergent procedure, a hybrid approach to AF ablation, coordinates the electrophysiologist and the cardiac surgeon in a simultaneous or sequential endocardial and epicardial procedure. Because the heart remains electrically active, electroanatomical maps, not anatomical landmarks, guide therapy. However, lesion transmurality and contiguity remain inconsistent. The Rhythmia HDx™ mapping system (Boston Scientific, Natick, MA, USA) offers detailed maps of acute lesion patterns during the ablation procedure. However, these maps require instrumentation and technology found in the electrophysiology laboratory, not in the operating room. We herein present a case during which we performed a Cox maze IV procedure and also applied the Rhythmia HDx™ electroanatomical mapping system (Boston Scientific, Natick, MA, USA) at the time of operation. Through this novel approach, we were able to verify the completeness of the lesions created and reach a procedural endpoint confirmed by both epicardial and endocardial maps of successful electrical isolation of the left atrium posterior wall and pulmonary vein pedicle.

Hospital Variability Drives Inconsistency in Antiplatelet Use After Coronary Bypass.

BACKGROUND: Continuation of dual antiplatelet therapy (DAPT) after coronary artery bypass grafting (CABG) after acute myocardial infarction is recommended by current guidelines. We sought to evaluate guideline adherence over time and factors associated with postoperative DAPT within a regional consortium. METHODS: Isolated CABG patients from 2011 to 2017 who had a myocardial infarction within 21 days prior to surgery were included. Patients were stratified by DAPT prescription at discharge and by time period, early (2011-2014) vs late (2015-2017). Hierarchical regressions were then performed to evaluate factors influencing DAPT use after CABG. RESULTS: A total of 7314 patients were included with an overall rate of DAPT utilization of 31.2% that increased from 29.6% in the early to 33.4% in the late era (P < .01). There was considerable variability in hospital rates of DAPT (range 9.5%-92.1%) and hospital level changes over time (26% increased, 11% decreased, and 63% remained stable). After adjustment for clinical factors, era was not associated with DAPT use but treating hospital remained significantly associated with DAPT use. Other clinical factors associated with increased DAPT utilization included off-pump surgery (odds ratio [OR] 4.48, P < .01) and prior percutaneous coronary intervention (OR 2.02, P < .01), and atrial fibrillation (OR 0.39, P < .01) was associated with decreased utilization. CONCLUSIONS: Dual antiplatelet use has increased between 2011 and 2017, driven primarily by evolving patient demographics. Significant hospital-level variability drives inconsistency in DAPT utilization. Efforts to promote DAPT use for patients treated with CABG after myocardial infarction in concordance with current guidelines should be targeted at the hospital level.

Examination of a Proposed 30-day Readmission Risk Score on Discharge Location and Cost.

BACKGROUND: Readmissions cost an estimated $41 billion in the United States each year. To address this, a single institution recently developed a new risk model predictive of 30-day readmission after adult cardiac surgery. The purpose of this study is to validate and refine this new readmission risk model using a statewide database. METHODS: A total of 19,964 patients were analyzed using a statewide Society of Thoracic Surgeons database (2014-2017). The aforementioned multivariate model was replicated (model 1): race, hospital length of stay, chronic lung disease, operation type, and renal failure. Model 2 also included discharge location. Thirty-day readmission risk scores and low-risk (0%-10%), moderate-risk (10%-13%), and high-risk (≥13%) categories were calculated. RESULTS: The overall 30-day readmission rate was 11.1% with both models 1 and 2 predicting readmission (odds ratio, 1.09; 95% confidence interval, 1.08-1.11 vs odds ratio, 1.10; 95% confidence interval, 1.08-1.11). Statistically significant differences were observed across all risk categories in discharge location and total cost. For models 1 and 2, 86% of low-risk patients were discharged to home vs 66.9% and 42.9% of patients in high-risk groups, respectively (P < .001). The largest increases were observed with a hospice discharge location for both model 1 (from $37,930 to $89,285) and model 2 (from $37,930 to $89,230). CONCLUSIONS: Both risk models significantly predicted 30-day readmission in our multiinstitutional dataset, confirming the score is valid and a generalizable quality improvement tool. The addition of discharge location and total cost adds valuable information of the ongoing efforts to identify patients at high risk for readmission.

Non-vitamin K oral anticoagulant use after cardiac surgery is rapidly increasing.

OBJECTIVE: The prevalence of non-vitamin K oral anticoagulant use after cardiac surgery is unknown, particularly in patients with bioprosthetic valves. We sought to define the contemporary use and short-term safety of non-vitamin K oral anticoagulants after cardiac surgery. METHODS: All patients undergoing bioprosthetic aortic valve replacement, bioprosthetic mitral valve replacement, or isolated coronary artery bypass grafting (2011-2018) were evaluated from a multicenter, regional Society of Thoracic Surgeons database. Patients were stratified by anticoagulant type (non-vitamin K oral anticoagulant vs vitamin K antagonist) and era (early [2011-2014] vs contemporary [2015-2018]). RESULTS: Of 34,188 patients, 18% (6063) were discharged on anticoagulation, of whom 23% were prescribed non-vitamin K oral anticoagulants. Among those receiving anticoagulation, non-vitamin K oral anticoagulant use has significantly increased from 10.3% to 35.4% in contemporary practice (P < .01). This trend was observed for each operation type (coronary artery bypass grafting 0.86%/year, bioprosthetic aortic valve replacement: 2.15%/year, bioprosthetic mitral valve replacement: 2.72%/year, all P < .01). In patients with postoperative atrial fibrillation receiving anticoagulation, non-vitamin K oral anticoagulant use has increased from 6.3% to 35.4% and 12.3% to 40.3% after bioprosthetic valve replacement and isolated coronary artery bypass grafting, respectively (both P < .01). In patients receiving anticoagulation at discharge, adjusted 30-day mortality (odds ratio, 1.94; P = .12) and reoperation (odds ratio, 0.79; P = .34) rates were not associated with anticoagulant choice, whereas non-vitamin K oral anticoagulant use was associated with an adjusted 0.9-day decrease (P < .01) in postoperative length of stay. CONCLUSIONS: Non-vitamin K oral anticoagulant use after cardiac surgery has dramatically increased since 2011. This trend is consistent regardless of indication for anticoagulation including bioprosthetic valves. Short-term outcomes support their safety in the cardiac surgery setting with shorter postoperative hospital stays. Long-term studies on the efficacy of non-vitamin K oral anticoagulants after cardiac surgery are still necessary.

Incremental Risk of Annular Enlargement: A Multi-Institutional Cohort Study.

BACKGROUND: Annular enlargement (AE) is a critical technique to avoid patient-prosthesis mismatch and may help facilitate future valve-in-valve (ViV) transcatheter replacement. We hypothesized that the addition of annular enlargement would increase risk of morbidity and mortality and that the number of annular enlargement procedures is increasing to accommodate future ViV procedures. METHODS: Patients undergoing aortic valve replacement ± coronary surgery (2012 to 2017) were extracted from a regional Society of Thoracic Surgeons database. Patients were stratified by annular enlargement and era, pre-ViV (2012 to 2014) vs ViV (2015 to 2017) for univariate analysis. Risk-adjusted outcomes were assessed by hierarchical regression modeling adjusting for predicted risk of mortality. RESULTS: Of 6045 patients, the 300 (5.0%) who received an annular enlargement were younger and more commonly female. Patients receiving an annular enlargement had higher complication rates including operative mortality (4.7% vs 2.5%, P = .024). After risk adjustment, AE was independently associated with increased mortality (odds ratio, 2.06, P = .016) and major morbidity (odds ratio, 1.41, P = .042). The rate of enlargement increased from 3.9% pre-ViV to 6.3% ViV (P < .001). The use of ViV capable valves (bioprosthetic ≥23 mm) from 61% to 67% (P = .001), and more in AE patients (30% vs 11% non-AE). Alternatively, the rate of patient prosthesis mismatch declined from 23% to 16%. CONCLUSIONS: Increasing utilization of AE coincides with a decline in patient prosthesis mismatch and may facilitate future ViV transcatheter aortic valve replacement. However, AE was independently associated with increased morbidity and mortality. High variability in AE volume may be increasing risk and deserves further investigation.

Outcomes After Acute Type A Aortic Dissection in Patients With Prior Cardiac Surgery.

BACKGROUND: Limited prior studies suggest patients with acute type A aortic dissection (ATAAD) and prior cardiac surgery are at increased risk for major complications compared with those without a prior sternotomy. We sought to investigate the impact of prior cardiac surgery on ATAAD outcomes across a multicenter regional consortium. METHODS: Patients undergoing surgical intervention for ATAAD in a regional Society of Thoracic Surgeons database between 2002 and 2017 were stratified by prior cardiac surgery (reoperative) status. Demographics, operative characteristics, outcomes and cost data were compared by univariate analysis. Multivariable regression models assessed risk-adjusted impact of reoperative status on outcomes. RESULTS: A total of 1,332 patients underwent surgery for ATAAD, of whom 138 (10.4%) were reoperations. Reoperative patients were older (63 vs. 58 years, p < 0.01) with more comorbidities. These patients had longer median cardiopulmonary bypass times (218 vs 177 minutes, p < 0.01) and increased blood product utilization; however rates of aortic arch, root, and valve procedures were similar. On unadjusted analysis operative mortality was higher in reoperative patients (28% vs 15%, p < 0.01) with a longer total length of stay (13 vs 10 days, p = 0.02). Reoperative patients exhibited a trend toward decreased mortality at high-volume centers (25.7% vs 37.9%, p = 0.19). After risk adjustment reoperative status remained associated with mortality (odds ratio, 2.1; p < 0.01) as well as composite morbidity-mortality (odds ratio, 2.2; p < 0.01). CONCLUSIONS: In this multicenter cohort undergoing repair of ATAAD prior cardiac surgery was associated with an increased morbidity and mortality. Centralization to high-volume centers and emerging technologies may improve outcomes in this high-risk population.

Socioeconomic Distressed Communities Index Predicts Risk-Adjusted Mortality After Cardiac Surgery.

BACKGROUND: The effects of socioeconomic factors other than insurance status and race on outcomes after cardiac operations are not well understood. We hypothesized that the Distressed Communities Index (DCI), a comprehensive socioeconomic ranking by zip code, would predict operative mortality after coronary artery bypass grafting (CABG). METHODS: All patients who underwent isolated CABG (2010 to 2017) in the Virginia Cardiac Services Quality Initiative database were analyzed. The DCI accounts for unemployment, education level, poverty rate, median income, business growth, and housing vacancies, with scores ranging from 0 (no distress) to 100 (severe distress). Patients were stratified by DCI quartiles (I: 0 to 24.9, II: 25 to 49.9, III: 50 to 74.9, IV: 75 to 100) and compared. Hierarchical linear regression modeled the association between the DCI and mortality. RESULTS: A total of 19,756 CABG patients were analyzed, with mean predicted risk of mortality of 2.0% ± 3.5%. Higher DCI scores were associated with increasing predicted risk of mortality. Overall operative mortality was 2.1% (n = 424) and increased with increasing DCI quartile (I: 1.6% [n = 95], II: 2.1% [n = 77], III: 2.4% [n = 114], IV: 2.6% [n = 138]; p = 0.0009). The observed-to-expected ratio for mortality increased as level of socioeconomic distress increased. After risk adjustment for The Society of Thoracic Surgeons predicted risk of mortality, year of surgical procedure, and hospital, the DCI remained predictive of operative mortality after CABG (odds ratio, 1.14 for each 25-point increase in DCI; 95% confidence interval 1.04 to 1.26; p = 0.007). CONCLUSIONS: The DCI independently predicts risk-adjusted operative mortality after CABG. Socioeconomic status, although not part of traditional risk calculators, should be considered when building risk models, evaluating resource utilization, and comparing hospitals.

Myocardial electrical impedance as a predictor of the quality of RF-induced linear lesions.

Production of complete (i.e. continuous and transmural) cardiac lesions by radiofrequency (RF) ablation can cure certain cardiac arrhythmias. However, a predictor of lesion completeness that is reliable and can be measured intraoperatively is needed in order to maximize effectiveness of ablation therapy. Predictors that require membrane excitation or response to stimulation are not always practical. This study tested whether changes of myocardial impedance across the lesion can predict completeness. RF energy was applied epicardially on perfused rabbit ventricles to produce linear lesions that were complete (n = 25) or incomplete (noncontinuous or nontransmural, n = 25). Before and after creation of each lesion, the magnitude and phase of impedance at 1 kHz were measured with a four-electrode epicardial array across the lesion. For 16 of the lesions, the translesion stimulus-excitation delay was also measured. Lesion completeness was evaluated with 2,3,5-triphenyltetrazolium chloride stain. Complete lesions increased resistivity by 26 Omega cm (21% of the preablation value, p = 0.0007, n = 17) when the inactive RF electrode remained on the epicardium during impedance measurements. When the RF electrode was removed during measurements, the rise of resistivity by complete lesions increased to 58 Omega cm (30% of the preablation value, p = 0.022, n = 8). For incomplete lesions, resistivity did not change significantly. Ablation did not significantly alter the phase of impedance. Accuracies of predictions of lesion completeness by the change in resistivity or the change in translesion stimulus-excitation delay were comparable (Youden's index 0.75 and 0.625, respectively, n = 16). Thus, RF ablation increases myocardial resistivity. The resistivity can predict lesion completeness and may provide an alternative to predictors based on excitation.

Achieving metrics during beating-heart ex-maze procedures improves outcomes.

BACKGROUND: Current surgical treatments for atrial fibrillation (AF) lack intraoperative metrics that predict long-term outcomes. The extracardiac maze (Ex-Maze) procedure is a beating-heart maze procedure that causes spontaneous conversion to sinus rhythm (SR) during lesion creation. Spontaneous conversion and confirmation of pulmonary vein exit block are 2 important predictors of long-term freedom from AF. METHODS: A beating-heart Ex-Maze procedure was performed in 54 AF patients (paroxysmal, n = 2; persistent, n = 11; longstanding persistent, n = 41) undergoing concomitant cardiac surgery (mitral valve replacement [MVR] = 23, aortic VR [AVR] = 7, coronary artery bypass graft [CABG] = 17, CABG +/- AVR = 3, CABG +/- MVR = 2, atrial-septal defect = 2). The Ex-Maze lesion set is a comprehensive, biatrial ablation pattern created epicardially with unipolar, radiofrequency energy applied by a vacuum-integrated device. Electrocardiogram data were collected during the procedure and at 1, 3, 6, and 12 months postoperatively; 24-hour Holter monitors data were also obtained 12 month postprocedure. RESULTS: Mean left atrial size was 5.4 cm. Average procedure time was 39 minutes. There were no device- or procedure-related complications. At the time of surgery 48 patients were in AF; 32 (67%) patients spontaneously converted to SR during lesion creation. At a mean follow-up of 262 days, 42 of 48 patients (88%) were free from AF, 39 of 48 (81%) were in SR; and 35 of 47 (74%) were free from AF and had discontinued class I and III antiarrhythmic drugs. In 32 of 33 patients (97%), exit block at 15 mA was confirmed, in which pulmonary vein isolation was tested. Follow-up was completed for 30 of the exit-block patients; freedom from AF was observed in 29 of 30 (97%), SR in 26 of 30 (87%), and freedom from AF and class I/III antiarrhythmic drugs in 25 of 29 (86%). CONCLUSIONS: Recent advances in techniques and technologies permit the creation of a comprehensive biatrial lesion pattern on the epicardium of a beating heart. Observation of spontaneous conversion and confirmation of pulmonary vein exit block are important metrics that predict improved long-term outcomes.

Suprasternal Transcatheter Aortic Valve Replacement in Patients With Marginal Femoral Access.

OBJECTIVE: Recently, the PARTNER 2A trial reported results of transcatheter aortic valve replacement versus surgical aortic valve replacement in 2032 intermediate-risk patients at 2 years. Two hundred thirty-six patients (24%) required an access route other than transfemoral. Compared with transfemoral and surgical aortic valve replacement, nontransfemoral transcatheter aortic valve replacement was associated with a numerically higher rate of death and disabling stroke at 30 days. This underscores the need for a better alternative surgical approach for patients with marginal femoral access. We reviewed our multicenter experience with minimally invasive suprasternal transcatheter aortic valve replacement. METHODS: Consecutive patients with symptomatic severe aortic stenosis at high or intermediate risk for surgical aortic valve replacement underwent suprasternal transcatheter aortic valve replacement. A commercially available transcatheter heart valve was deployed under fluoroscopic guidance through the innominate artery or ascending aorta. Using a 3-cm skin incision just above the sternal notch, the Aegis Transit System (Aegis Surgical Ltd, Galway, Ireland) provided illuminated access to the mediastinum without bone disruption. Through a purse-string suture placed in the innominate artery or ascending aorta, transcatheter aortic valve replacement proceeded similarly to the direct aortic approach. RESULTS: Thirty patients at six medical centers successfully underwent suprasternal transcatheter aortic valve replacement. Implanted valves included 2 CoreValve and 12 Evolut-R (Medtronic, Inc, Minneapolis, MN USA), as well as 10 SAPIEN 3 and 6 SAPIEN XT (Edwards Lifesciences, Corp, Irvine, CA USA) with sizes ranging from 23 to 31 mm. Median procedure time was 90 minutes and median hospital stay was 4 days. Postoperatively, new permanent pacemaker (n = 3) was the most common Vascular Academic Research Consortium 2 complication. CONCLUSIONS: These data demonstrate the early clinical feasibility of suprasternal transcatheter aortic valve replacement. Key advantages of this approach include direct access to the innominate artery and ascending aorta, precise sheath control, and confident arterial closure. Additional experience is warranted to confirm these favorable results.

Increased risk of atrial fibrillation among patients undergoing coronary artery bypass graft surgery while receiving nitrates and antiplatelet agents.

Background Postoperative atrial fibrillation (POAF) is a frequent complication of coronary artery bypass graft (CABG) surgery. This arrhythmia occurs more frequently among patients who receive perioperative inotropic therapy (PINOT). Administration of nitrates with antiplatelet agents reduces the conversion rate of cyclic guanosine monophosphate to guanosine monophosphate. This process is associated with increased concentrations of free radicals, catecholamines, and blood plasma volume. We hypothesized that patients undergoing CABG surgery who receive PINOT may be more susceptible to POAF when nitrates are administered with antiplatelet agents. Methods Clinical records were examined from a prospectively maintained cohort of 4,124 patients undergoing primary isolated CABG surgery to identify POAF-associated factors. Results POAF risk was increased among patients receiving PINOT, and the greatest effect was observed when nitrates were administered with antiplatelet therapy. Adjustment for comorbidities did not substantively change the study results. Conclusions Administration of nitrates with certain antiplatelet agents was associated with an increased POAF risk among patients undergoing CABG surgery. Additional studies are needed to determine whether preventive strategies such as administration of antioxidants will reduce this risk.

A propensity matched analysis of robotic, minimally invasive, and conventional mitral valve surgery.

OBJECTIVES: Institutional studies suggest robotic mitral surgery may be associated with superior outcomes. The objective of this study was to compare the outcomes of robotic, minimally invasive (mini), and conventional mitral surgery. METHODS: A total of 2300 patients undergoing non-emergent isolated mitral valve operations from 2011 to 2016 were extracted from a regional Society of Thoracic Surgeons database. Patients were stratified by approach: robotic (n=372), mini (n=576) and conventional sternotomy (n=1352). To account for preoperative differences, robotic cases were propensity score matched (1:1) to both conventional and mini approaches. RESULTS: The robotic cases were well matched to the conventional (n=314) and mini (n=295) cases with no significant baseline differences. Rates of mitral repair were high in the robotic and mini cohorts (91%), but significantly lower with conventional (76%, P<0.0001) despite similar rates of degenerative disease. All procedural times were longest in the robotic cohort, including operative time (224 vs 168 min conventional, 222 vs 180 min mini; all P<0.0001). The robotic approach had comparable outcomes to the conventional approach except there were fewer discharges to a facility (7% vs 15%, P=0.001) and 1 less day in the hospital (P<0.0001). However, compared with the mini approach, the robotic approach had more transfusions (15% vs 5%, P<0.0001), higher atrial fibrillation rates (26% vs 18%, P=0.01), and 1 day longer average hospital stay (P=0.02). CONCLUSION: Despite longer procedural times, robotic and mini patients had similar complication rates with higher repair rates and shorter length of stay metrics compared with conventional surgery. However, the robotic approach was associated with higher atrial fibrillation rates, more transfusions and longer postoperative stays compared with minimally invasive approach.

Translesion stimulus-excitation delay indicates quality of linear lesions produced by radiofrequency ablation in rabbit hearts.

Failure of cardiac antiarrhythmic ablation to block action potential conduction produces poor outcomes which lead to repeat procedures. To overcome this, an intraoperative index of the quality of an ablation lesion is needed. We hypothesized that a rise in the translesion stimulus-excitation delay (TED) can indicate a continuous, transmural, linear lesion, and that the TED is related to the path length in the viable tissue around the lesion. Rabbit hearts were isolated, perfused with a warm physiological solution and stained with transmembrane potential-sensitive fluorescent dye. Radiofrequency (RF) ablation was performed on ventricular epicardium with a vacuum-assisted coagulation device to produce either a complete or incomplete lesion. Complete lesions were both transmural and continuous. Incomplete lesions were noncontinuous or nontransmural. The TED was determined with bipolar stimulation at one side of the lesion and either a bipolar electrogram at the other side or optical mapping on both sides. Hearts were then stained with tetrazolium chloride and examined histologically to estimate minimum path lengths of viable tissue from the stimulation site to the recording site. Complete lesions increased the TED by factors of 2.6-3.1 (p < 0.05), whereas incomplete lesions did not significantly increase the TED. Larger minimum path lengths were found for cases that had an increased TED. The TED was quantitatively predictable based on a conduction velocity of 0.38-0.49 m s(-1), which is typical of rabbit hearts. The TED significantly increases when a linear lesion is complete, suggesting that an intraoperative measurement of the TED may help to improve ablation lesions and outcomes. Predictability of the TED based on the viable tissue path suggests that quantitative TEDs for clinical lesions may be anticipated provided that the conduction velocity is considered.

Suprasternal Aortic Valve Replacement: Key Technology and Techniques.

PURPOSE: Suprasternal transcatheter aortic valve replacement offers patients, with unsuitable femoral artery anatomy, an alternative to transapical, direct aortic, and subclavian approaches. DESCRIPTION: The Transit System (Aegis Surgical, Galway, Ireland) enables transcatheter aortic valve replacement directly into the ascending aorta or innominate artery through a small, suprasternal incision. The valve introducer sheath is inserted through a standard pursestring suture, which facilitates secure arterial closure. The proximity to the aortic valve promotes precise control. EVALUATION: Proper patient selection and preoperative imaging is essential. A heart team working collaboratively in a hybrid operating room ensures procedural success. Using this approach, four different manufacturer's transcatheter valves have been used successfully. CONCLUSIONS: Suprasternal transcatheter aortic valve replacement is a safe and effective addition to the surgeon's armamentarium.