Predictors of Outcome for Aortic Valve Reimplantation Including the Surgeon-A Single-Center Experience.

INTRODUCTION: Aortic valve reimplantation is considered technically demanding. We searched for predictors of long-term outcome including the surgeon as risk factor. METHODS: We selected all aortic valve reimplantations performed in our department between December 1999 and January 2017 and obtained a complete follow-up. The main indications were combined aortic aneurysm plus aortic valve regurgitation (AR), 69% and aortic dissections (15%). In 14%, valves were bicuspid. Cusp repair was performed in 27% of patients. One-third received additional procedures (coronary artery bypass grafting, mitral, or arch surgery). We performed multivariable analyses for independent risk factors of short- and long-term outcomes, including "surgeon" as variable. Twelve different surgeons operated on 193 patients. We created three groups: surgeons A and B with 84 and 64 procedures, respectively, and surgeon C (10 surgeons for 45 patients). RESULTS: Cardiopulmonary bypass and clamp times were 176 ± 45 and 130 ± 24 minutes, respectively. In-hospital mortality was 2%. Postoperatively, 5% had mild and 0.5% had moderate AR. Kaplan-Meier's survival estimates, freedom from reoperation, and freedom from severe AR at 12 years were 97 ± 1, 93 ± 2, and 91 ± 3%, respectively. Age and chronic obstructive pulmonary disease appeared as risk factors for perioperative complications by univariate analysis. Age, coronary artery disease, and duration of cardiopulmonary bypass, but not surgeon, presented as risk factors by multivariable analysis. CONCLUSION: The results suggest that if a David procedure is performed successfully, long-term durability may be excellent. They also suggest that good and durable results are possible even with limited experience of the operating surgeon.

Coronary Artery Bypass Grafting using Bilateral Internal Thoracic Arteries through a Left-Sided Minithoracotomy: A Single-Center Starting Experience.

BACKGROUND: Coronary artery bypass grafting (CABG) using bilateral internal thoracic artery (BITA) is associated with the best long-term survival. However, using BITA increases the risk of sternal wound infections with conventional sternotomy. We describe here our initial results of minimally invasive CABG (MICS-CABG) using BITA. METHODS: Patients were operated through an incision similar to that of standard minimally invasive direct CABG. All operations were performed off-pump. We evaluated patient's quality of life (QoL) using the Medical Outcomes trust, 36-Item Short Form Health Survey (SF-36). RESULTS: Between February 2016 and August 2017, we performed 21 cases of MICS-CABG using BITA. There was no intraoperative complication and no conversion to sternotomy or to on-pump. Two patients required reexploration through the same minithoracotomy for postoperative bleeding. Two cases of early postoperative graft failure were identified. There was no stroke or in-hospital mortality. The median duration of follow-up was 13 months, with a maximum of 19 months. Relief of angina was achieved in all patients. There was one readmission for superficial wound infection, which was conservatively treated. An 84-year-old man died 4 months after the operation. The remaining 20 patients attested good QoL with the SF-36 questionnaire. CONCLUSIONS: Myocardial revascularization using BITA can be safely achieved off-pump through a left-sided minithoracotomy with good postoperative and short-term outcomes.

Acute Microcirculatory Effects of Remote Ischemic Conditioning in Superficial Partial Thickness Burn Wounds.

Microcirculation is a critical factor in burn wound healing. Remote ischemic conditioning (RIC) has been shown to improve microcirculation in healthy skin and demonstrated ischemic protective effects on heart, kidney, and liver cells. Therefore, we examined microcirculatory effects of RIC in partial thickness burn wounds. The hypothesis of this study is that RIC improves cutaneous microcirculation in partial thickness burn wounds. Twenty patients with partial thickness burn wounds within 48 hours after trauma were included in this study. RIC was performed with an upper arm blood pressure cuff on a healthy upper arm using three ischemia cycles (5 min inflation to 200 mm Hg) followed by 10-minute reperfusion phases. The third and final reperfusion phase lasted 20 minutes. Microcirculation of the remote (lower/upper extremities or torso) burn wound was continuously quantified, using a combined Laser Doppler and white light spectrometry. The capillary blood flow in the burn wounds increased by a maximum of 9.6% after RIC (percentage change from baseline; P < .01). Relative hemoglobin was increased by a maximum of 2.8% (vs. baseline; P < .01), while cutaneous tissue oxygen saturation remained constant (P > .05). RIC improves microcirculation in partial thickness burn wounds by improving blood flow and elevating relative hemoglobin.

Changes in inflammatory and vasoactive mediator profiles during valvular surgery with or without infective endocarditis: A case control pilot study.

BACKGROUND: More than 50% of patients with infective endocarditis (IE) develop an indication for surgery. Despite its benefit, surgery is associated with a high incidence of multiple organ dysfunction syndrome (MODS) and mortality, which may be linked to increased release of inflammatory mediators during cardiopulmonary bypass (CPB). We therefore assessed plasma cytokine profiles in patients undergoing valve surgery with or without IE. METHODS: We performed a prospective case-control pilot study comparing patients undergoing cardiac valve surgery with or without IE. Plasma profiles of inflammatory mediators were measured at 7 defined time points and reported as median (interquartile). The degree of MODS was measured using sequential organ failure assessment (SOFA) score. RESULTS: Between May and December 2016 we included 40 patients (20 in each group). Both groups showed similar distribution of age and gender. Patients with IE had higher preoperative SOFA (6.9± 2.6 vs 3.8 ± 1.1, p<0.001) and operative risk scores (EuroSCORE II 18.6±17.4 vs. 1.8±1.3, p<0.001). In-hospital mortality was higher in IE patients (35% vs. 5%; p<0.001). Multiple organ failure was the cause of death in all non-survivors. At the end of CPB, median levels of following inflammatory mediators were higher in IE compared to control group: IL-6 (119.73 (226.49) vs. 24.48 (40.09) pg/ml, p = 0.001); IL-18 (104.82 (105.99) vs. 57.30 (49.53) pg/ml, p<0.001); Mid-regional pro-adrenomedullin (MR-proADM) (2.06 (1.58) vs. 1.11 (0.53) nmol/L, p = 0.003); MR- pro-atrial natriuretic peptide (MR-proANP) (479.49 (224.74) vs. 266.55 (308.26) pmol/l, p = 0.028). IL-1ß and TNF- α were only detectable in IE patients and first after starting CPB. Plasma levels of IL-6, IL-18, MRproADM, and MRproANP during CPB were significantly lower in survivors than in those who died. CONCLUSION: The presence of infective endocarditis during cardiac valve surgery is associated with increased inflammatory response as evident by higher plasma cytokine levels and other inflammatory mediators. Actively reducing inflammatory response appears to be a plausible therapeutic concept. TRIAL REGISTRATION: ClinicalTrials.gov, ID: NCT02727413.

An 86-Year-Old Female with Mitral Regurgitation and Significant Pectus Excavatum.

Background We report the case of minimally invasive mitral valve repair in an 86-year-old female with symptomatic structural mitral regurgitation and severe pectus excavatum. Case Description The case summarizes four areas of repetitive heart team discussions. First, should an 86-year-old patient still be treated invasively? Second, if so, should treatment be interventional or surgical? Third, if surgical, should we replace or repair at that age and fourth which surgical access is best with respect to her chest deformation? Conclusion We chose to surgically repair the valve using a minimally invasive approach. The patient was extubated 3 hours after surgery and discharged after 7 days.