Report of the Third Heart Surgery Forum Scientific Sessions: Zagreb, Croatia December 6-8, 2017: Conference Highlights.

The Heart Surgery Forum is an online community dedicated to topics related to all aspects of cardiothoracic surgery. It consists of an informative website (www.hsforum.com), a traditional indexed journal both in print and online, and an email-based "list-serv" for discussion of surgical cases and techniques. The email list-serv, "OpenHeart-L" (The Forum) is composed of surgeons and allied specialties (perfusion, anesthesia, nursing). Dr. Mark Levinson (USA) started The Forum originally in 1995. He also served as the first Editor-in-Chief of the print journal for many years. Coinciding with the popularity of The Forum, and the desire by many members to meet in person, the First Heart Surgery Forum Conference (#1 HSF) was held in Savudrija, Istria, Croatia in 2010. The overwhelming success of this meeting, in terms of attendance and scientific content, resulted in #2 HSF being held in Split, Croatia in 2014. Recently, the #3 HSF meeting was held in Zagreb, Croatia on December 6-8th, 2017. This report highlights the scientific events of this meeting, and more importantly aims to inspire greater involvement by the international cardiothoracic community. Substantial increasing attendance was seen at each subsequent meeting, not only in terms of the number of participants and lectures, but also in the number of countries represented.

Microsizing using inside suture placement. A simple and versatile technique for precision adjustment of ring annuloplasties.

INTRODUCTION: A new and simple technique for eliminating residual leaks during mitral annuloplasty, called microsizing, is described. METHODS: Microsizing is performed by moving one or more annuloplasty sutures from the outside to the inside of the prosthetic ring. This maneuver advances discrete segments of the annulus toward the opposing leaflet by a distance equal to the thickness of the ring (approximately 3 mm). Microsizing is a simple method for precision adjustment of annular shape and size to eliminate focal gaps, regardless of the cause. RESULTS: A series of 63 consecutive patients with moderate to severe mitral regurgitation (MR) were repaired over a 10 year period, all with intraoperative transesophageal echocardiography guidance. No patient required valve replacement (repair success rate 100%). Concomitant (non-mitral valve) procedures were performed in 53 patients (84.1%). Fifty patients (79.3%, Group 1) underwent successful repair using traditional suture placement in the prosthetic ring. Thirteen patients (20.6%, Group 2) had one or more sutures repositioned to the inside of the ring ("micro-sized") as a new strategy to eliminate residual leaks. Mean post repair MR grade was lower when microsizing was used (0.15 for Group 2 versus 0.30 for Group 1). No micro-sized patient experienced systolic anterior motion (SAM) or mitral stenosis. There were no repairs with greater than trace MR, late ring dehiscences, recurrent regurgitation, or reoperation in the entire series. There was one death (1.6%) in a non-micro-sized patient from intra-operative abdominal hemorrhage secondary to an IABP complication. CONCLUSION: Microsizing is a simple variation of suture placement that allows custom shaping of the mitral annulus by advancing selected portions toward the opposing leaflet, eliminating gaps, and improving coaptation. This technique is safe, simple, and reproducible without causing stenosis, SAM, or late failure.

Subxiphoid multi-arterial OPCAB: surgical technique and initial case report.

BACKGROUND: The surgical technique of transsternal coronary artery bypass grafting (CABG) has remained relatively stagnant for the past three decades. Unlike general and orthopedic surgery, cardiac surgery has made very little progress in converting our most common procedure into a minimally invasive alternative. Minithoracotomy techniques introduced in 1995 enjoyed a brief period of popularity but were inherently single vessel (LIMA-LAD) procedures and thus not an answer to the need for a less invasive multivessel operation. Totally endoscopic CABG has been performed in a small number of cases but the learning curve is very steep and the rate of conversion to open surgery remains high with only a few successful multivessel cases. There remains a great need for a less invasive approach that has the potential to graft all coronary targets without disturbing the chest wall and which can be performed by all current and future surgeons with acceptable hospital costs. A small subxiphoid incision has been used for single vessel grafting to anterior or inferior targets, but until now lateral wall grafting has not been considered possible. Development of a successful multivessel subxiphoid technique on the beating heart, including lateral wall grafting, is now reported in this article. METHODS: Subxiphoid multi-arterial bypass grafting was performed on a 79-year-old male using commercially available equipment but modified surgical techniques. Instead of midline sternotomy, full exposure to the heart was obtained by four essential steps: (1) removal of the xiphoid process, (2) vertical lifting of the lower sternum, (3) caudal retraction of the diaphragm, and (4) spreading of the wound using a specific retractor to create an adequate working portal. Both internal mammary arteries were harvested for their full length as skeletonized conduits using only direct vision (headlight and loupes). Off-pump distal anastomoses to the left anterior descending (LAD) and first obtuse marginal branch of the circumflex (OMB-1) were performed using available stabilizer systems. The obtuse marginal was exposed using the Medtronic Starfish suction-positioner without any hemodynamic compromise. The wound was closed with a simple running fascial suture and the patient discharged on postoperative day 4 with no complications and no angina. CONCLUSIONS: Most practicing surgeons are reluctant to perform multiple distal grafts through small incisions because of the difficulty in simultaneously mastering a host of new skills at the same time (robotics, endoscopics, beating heart techniques). The subxiphoid approach offers the potential to perform distal anastomoses to all regions of the beating heart with excellent exposure while utilizing the same skill sets that surgeons now possess. There is potential that further evolution of this technique will permit outpatient CABG while providing long-term clinical outcomes superior to coronary stenting.