Freestyle aortic root prosthesis in combination with aortic replacement and open anastomosis: a retrospective analysis.

BACKGROUND: The Freestyle® bioprosthesis is used for pathologies of the aortic root. Additional resection of the ascending aorta and the proximal arch in dissections or aneurysms might be indicated. The aim was to assess mid-term outcome regarding prosthetic performance, stroke, reoperations, and survival in various pathologies comparing patients with and without additional procedures on the ascending aorta and proximal arch focusing on the standardised technique of unilateral antegrade cerebral perfusion under moderate hypothermia. METHODS: Retrospective data analysis of 278 consecutive patients after Freestyle® root replacement between September 2007 and March 2017. Patients were divided in three categories due to the pathology of the aortic root (re-operation vs endocarditis vs dissection). Two groups based on the aortic anastomosis technique (open arch anastomosis (OA) versus non-open arch anastomosis (non-OA) were compared (119 OA vs 159 non-OA). Cardiovascular risk, previous cardiac events, intra- and postoperative data were evaluated. Inferential statistics were performed with Mann-Whitney U-test. Nominal and categorical variables were tested with Fisher-Freeman-Halton exact test. Kaplan-Meier estimate was used to assess survival. RESULTS: The follow-up rate was 90% (median follow-up: 39.5 months). There were differences in the indication (endocarditis: OA 5 (4.2%) vs non-OA 36 (24%), p < 0.0001; dissection: OA 13 (10.9%) vs non-OA 2 (1.3%); p = 0.0007). OA patients had less perioperative stroke (1 (1%) vs 15 (10%), p = 0.001) and shorter hospital stay (9 vs 12 days, p = 0.0004). There were no differences in the mortality (in-hospital: OA 8 (7%) vs non-OA 8 (5%); p = 0.6; death at follow-up: OA 5 (5%) vs non-OA 15 (11%); p = 0.1). Overall valve performance showed a well-functioning valve in 97.3% at follow-up. CONCLUSION: The valve performance showed excellent results regardless of the initial indication. The incidence of stroke was lower in patients receiving an open arch anastomosis using unilateral antegrade cerebral perfusion without elevated mortality or prolonged hospital stay.

Early silent graft failure in off-pump coronary artery bypass grafting: a computed tomography analysis†.

OBJECTIVES: The purpose was to assess predictors of early silent graft failure prior to discharge by multislice computed tomography in patients after off-pump coronary artery bypass grafting. METHODS: From January 2017 until April 2018, 192 computed tomographic scans of consecutive asymptomatic patients were performed (seventh postoperative day ± 4 days) and analysed retrospectively. In total, 359 arterial and 278 venous anastomoses were evaluated. Two patient groups (overall patent anastomoses versus at least 1 occluded anastomosis) were compared. Cardiovascular risk factors, collateralization according to Rentrop, grade of native vessel stenosis and intraoperative flow measurements were analysed. Inferential statistics were performed with the Mann-Whitney U-test. Nominal and categorical variables were tested with the Fisher-Freeman-Halton exact test. RESULTS: In 33 patients, at least 1 occluded anastomosis could be identified, predominantly in women (P = 0.04). The patency of the arterial anastomoses was 96.4% and 88.9% for the venous anastomoses. In 14 patients with occluded anastomoses, a successful interventional revascularization was performed before discharge. There were significant differences in lower bypass flow [P = 0.02, odds ratio 3.2, 95% confidence interval (CI) 1.7-6.0] and higher pulsatility index (P < 0.001, odds ratio 4.5, 95% CI 2.4-8.5) in the occluded group. A calculated cut-off value identified an increased probability for graft occlusion at a flow under 23 ml/min and a pulsatility index greater than 2.3. CONCLUSIONS: Early silent graft failure occurred predominantly in venous grafts, with a tendency to female gender. A lower flow rate and a higher pulsatility index were significantly associated with graft occlusion, whereas collateralization and the degree of native vessel stenosis seem to play a tangential role. Fourteen patients had a successful percutaneous revascularization before discharge. CLINICAL TRIAL REGISTRATION NUMBER: NCT03657199.

Antimicrobial prophylaxis and the prevention of surgical site infection in cardiac surgery: an analysis of 21 007 patients in Switzerland†.

OBJECTIVES: Our goal was to determine the optimal timing and choice of surgical antimicrobial prophylaxis (SAP) in patients having cardiac surgery. METHODS: The setting was the Swiss surgical site infection (SSI) national surveillance system with a follow-up rate of >94%. Participants were patients from 14 hospitals who had cardiac surgery from 2009 to 2017 with clean wounds, SAP with cefuroxime, cefazolin or a vancomycin/cefuroxime combination and timing of SAP within 120 min before the incision. Exposures were SAP timing and agents; the main outcome was the incidence of SSI. We fitted generalized additive and mixed-effects generalized linear models to describe effects predicting SSIs. RESULTS: A total of 21 007 patients were enrolled with an SSI incidence of 5.5%. Administration of SAP within 30 min before the incision was significantly associated with decreased deep/organ space SSI [adjusted odds ratio (OR) 0.73, 95% confidence interval (CI) 0.54-0.98; P = 0.035] compared to administration of SAP 60-120 min before the incision. Cefazolin (adjusted OR 0.64, 95% CI 0.49-0.84; P = 0.001) but not vancomycin/cefuroxime combination (adjusted OR 1.05, 95% CI 0.82-1.34; P = 0.689) was significantly associated with a lower risk of overall SSI compared to cefuroxime alone. Nevertheless, there were no statistically significant differences between the SAP agents and the risk of deep/organ space SSI. CONCLUSIONS: The results from this large prospective study provide substantial arguments that administration of SAP close to the time of the incision is more effective than earlier administration before cardiac surgery, making compliance with SAP administration easier. The choice of SAP appears to play a significant role in the prevention of all SSIs, even after adjusting for confounding variables.

Perioperative Endocarditis Management in a Patient with Homozygous Sickle Cell Disease.

Background Homozygous sickle cell disease (SCD) compounded with bacterial endocarditis makes open-heart surgery a multidisciplinary challenge. Case description A 45-year-old African male patient with homozygous SCD presented with right heart decompensation, tricuspid regurgitation, and endocarditis of the aortic valve. Blood coulters were positive for coagulase-negative staphylococci. An emergent double valve replacement was successfully performed involving a multidisciplinary team. Conclusion Homozygous SCD is associated with an increased risk of preoperative vaso-occlusive complications. Surgery with cardiopulmonary bypass can be performed, if hypothermia, hypoxia, acidosis, or low-flows are being avoided. Due to the lack of data, the adequate approach is still intuitive and requires standardization.

Skeletonized internal thoracic artery harvesting: a low thermal damage electrosurgical device provides improved endothelial layer and tendency to better integrity of the vessel wall compared to conventional electrosurgery.

BACKGROUND: Electrosurgery is fundamental to the precise, fast and bloodless preparation of internal thoracic artery grafts in cardiac surgery. The PEAK PlasmaBlade is a monopolar electrosurgical device that uses pulsed radiofrequency energy to generate a plasma-mediated discharge along an insulated electrode, creating a cutting edge while the blade stays near body temperature. The aim of this study is to compare the histological samples, cardiac computed-tomography of graft patency, and clinical outcomes of patients after off-pump coronary artery bypass grafting with preparation of the internal thoracic arteries by a conventional electrosurgical device and the PlasmaBlade. METHODS: In twenty subjects one internal thoracic artery was prepared with PlasmaBlade and the other artery with a conventional electrosurgical device. Histological samples were evaluated for three factors for potential graft failure: endothelial damage, integrity of the vessel wall and adventitial hemorrhage. Five samples per artery were evaluated by a novel scoring method based on the exposed circumference of the histological sample ("0": 0%, "1": 1-25%, "2": 26-50%, "3": 51-75%, "4": ≥76% of the circumference). The Wilcoxon signed ranks test for mean scores within subjects was performed. Six-month-follow up by cardiac computed tomography for evaluation of graft patency was completed in 16 patients. RESULTS: Histological results demonstrated significantly less endothelial damage after PlasmaBlade (83% vs 60%, absolute: 75/90 vs. 53/89 samples with score "0-1", p = 0.04). PlasmaBlade samples demonstrated a tendency to better wall integrity (72% vs. 54%, absolute: 64/89 vs. 47/87 samples with score "0-1", p = 0.32). There were no differences in endothelial bleeding (PlasmaBlade 46% vs. electrosurgery 53%, absolute: 41/88 vs. 48/90 samples with score "0-1", p = 0.63). Computed tomography confirmed non-inferiority of the PlasmaBlade to conventional electrosurgery with a patency rate of 94%. CONCLUSION: Histologically, internal thoracic arteries harvested with PlasmaBlade demonstrate a more intact endothelial layer and a tendency to better wall integrity. Computed tomography of graft patency speaks for non-inferiority to conventional electrosurgery. PlasmaBlade may be preferable to conventional electrosurgery, if further follow-up confirms patency of internal thoracic arteries. TRIAL REGISTRATION: NCT03510026 , registered 4th April 2018 (retrospectively registered).

Anomaly of Haughton type D left cervical aortic arch in combination with type B dissection: case report and literature review.

BACKGROUND: The anomaly of cervical aortic arch is a rare phenomenon first described by Reid in 1914 and categorized by Haughton in 1975. The left cervical aortic arch Type D consisting of an ipsilateral descending aorta and coarctation or aneurysmatic formation of the arch demonstrates a complicated form requiring surgical management. Because of its rarity and unspecific symptoms only few cases are documented with the focus on surgical management. CASE PRESENTATION: A 43-year old, asymptomatic woman presented with a mediastinal mass overlapping the aortic arch region in a routine x-ray. For verification, a computed tomography was performed and revealed incidentally a type B dissection originating from an aneurysm of a left cervical arch with a maximum diameter of 6 cm. Because of the huge diameter and the potential risk of rupture, an urgent surgical repair was planned. Surgical access was performed through median sternotomy and an additional left lateral thoracic incision through the fourth intercostal space. Simultaneously to the preparation, partial cardiopulmonary bypass was installed in the left groin. After preparation of the recurrent and phrenic nerve and the supraaortic branches, the descending aorta was clamped. Before the distal anastomosis to a straight graft, we performed a fenestration of the dissection membrane about a length of 5 cm to preserve the perfusion of both lumina. Then, the straight graft was sutured to the proximal part of descending aorta. The left axillary artery originated directly from the aneurysm and was dissected and reimplanted with a separate 8 mm sidegraft to the straight graft between the distal arch and proximal descending aorta. The patient was extubated on first postoperative day and recovered well. CONCLUSION: The left cervical aortic arch type D is a rare disease, which is prone to aneurysm formation due to abnormal flow patterns and tortuosity of the aorta. The difficulty lays in the identification of the pathology, especially in the physical examination, since a pulsating mass or cervical murmur seem to be the most specific symptoms in the majority of young, female patients. If diagnosed, surgical therapy with resection of the aneurysm and reimplantation of the axillary artery under cardiopulmonary bypass demonstrates the treatment of choice.

Global Health Estimate of Invasive Mycobacterium chimaera Infections Associated with Heater-Cooler Devices in Cardiac Surgery.

Investigations of a worldwide epidemic of invasive Mycobacterium chimaera associated with heater-cooler devices in cardiac surgery have been hampered by low clinical awareness and challenging diagnoses. Using data from Switzerland, we estimated the burden of invasive M. chimaera to be 156-282 cases/year in 10 major cardiac valve replacement market countries.

Sternal Anomalies in Asymptomatic Patients after Median Sternotomy and Potential Influencing Factors.

BACKGROUND: We aimed to assess asymptomatic patients who had open-heart surgery with median sternotomy for potential sternal anomalies (SA), their related patient-specific risk factors, and treatment options for the prevention of SA. METHODS: Multiplanar CT scans (CTs) from 131 asymptomatic consecutive patients were analyzed retrospectively. Of these, 83 underwent CABG (63.4%), and 48 had aortic valve (AV) procedures via median sternotomy. Sternal bone healing was analyzed for SA and their exact location. RESULTS: In total, 49 SA were identified in 42 (32.1%) patients; 65% SA were found in the manubrium (n = 32). Five hundred thirty-two wires were implanted (4.2 ± 0.5 wires/patient), out of which 96.1% (n = 511) were figure 8 wires. There was no difference between normal and abnormal sterna with regard to the number of wires used for sternal closure (4.2 ± 0.5 vs. 4.3 ± 0.6, p = ns). The distance between wire placement to the proximal edge of the manubrium in normal and abnormal sterna was comparable (11.2 ± 4.2 vs. 10.9 ± 4.8 mm, p = ns). Patients who underwent CABG had a significantly higher risk for SA (OR = 2.4, p ≤ 0.05, 95% CI [1.2-4.9]). The use of BIMA (OR = 4.4, p ≤ 0.05, 95% CI [1.1-17.9]) and body mass index (BMI) > 31 kg/m2 (OR = 3.4, p ≤ 0.01, 95% CI [1.4-8.3]) significantly increased the risk of SA. CONCLUSION: At least 30% of patients were at an increased risk for SA after receiving a median sternotomy. CABG, use of BIMA, and a BMI > 30 kg/m2 were potential risk factors for the development of SA and warrant close clinical follow-up. Sternal plate fixation, particularly in the manubrium, could be beneficial in such patients.

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.

Heart Team: Joint Position of the Swiss Society of Cardiology and the Swiss Society of Cardiac Surgery.

The Swiss Society of Cardiology (SSC) and the Swiss Society of Cardiac and ThoracicVascular Surgery (SSCTVS) have formulated their mutual intent of a close, patient-oriented, and expertise-based collaboration in the Heart Team Paper. The interdisciplinary dialogue between the SSC and SSCTVS reflects an attitude in decision making, which guarantees the best possible therapy for the individual patient. At the same time, it is a cornerstone of optimized process quality, placing individual interests into the background. Evaluation of the correct indication for a treatment is indeed very challenging and almost impossible to verify retrospectively. Quality in this very important health policy process can therefore only be assured by the use of mutually recognized indications, agreed upon by all involved physicians and medical specialties, whereby the capacity of those involved in the process is not important but rather their competence. These two medical societies recognize their responsibility and have incorporated international guidelines as well as specified regulations for Switzerland. Former competitors now form an integrative consulting team able to deliver a comprehensive evaluation for patients. Naturally, implementation rests with the individual caregiver. The Heart Team Paperof the SGK and SGHC, has defined guide boards within which the involved specialists maintain sufficient room to maneuver, and patients have certainty of receiving the best possible therapy they require.

Global outbreak of severe Mycobacterium chimaera disease after cardiac surgery: a molecular epidemiological study.

BACKGROUND: Since 2013, over 100 cases of Mycobacterium chimaera prosthetic valve endocarditis and disseminated disease were notified in Europe and the USA, linked to contaminated heater-cooler units (HCUs) used during cardiac surgery. We did a molecular epidemiological investigation to establish the source of these patients' disease. METHODS: We included 24 M chimaera isolates from 21 cardiac surgery-related patients in Switzerland, Germany, the Netherlands, and the UK, 218 M chimaera isolates from various types of HCUs in hospitals, from LivaNova (formerly Sorin; London, UK) and Maquet (Rastatt, Germany) brand HCU production sites, and unrelated environmental sources and patients, as well as eight Mycobacterium intracellulare isolates. Isolates were analysed by next-generation whole-genome sequencing using Illumina and Pacific Biosciences technologies, and compared with published M chimaera genomes. FINDINGS: Phylogenetic analysis based on whole-genome sequencing of 250 isolates revealed two major M chimaera groups. Cardiac surgery-related patient isolates were all classified into group 1, in which all, except one, formed a distinct subgroup. This subgroup also comprised isolates from 11 cardiac surgery-related patients reported from the USA, most isolates from LivaNova HCUs, and one from their production site. Isolates from other HCUs and unrelated patients were more widely distributed in the phylogenetic tree. INTERPRETATION: HCU contamination with M chimaera at the LivaNova factory seems a likely source for cardiothoracic surgery-related severe M chimaera infections diagnosed in Switzerland, Germany, the Netherlands, the UK, the USA, and Australia. Protective measures and heightened clinician awareness are essential to guarantee patient safety. FUNDING: Partly funded by the EU Horizon 2020 programme, its FP7 programme, the German Center for Infection Research (DZIF), the Swiss National Science Foundation, the Swiss Federal Office of Public Health, and National Institute of Health Research Oxford Health Protection Research Units on Healthcare Associated Infection and Antimicrobial Resistance.

Tricuspid Valve Repair for the Poor Right Ventricle: Tricuspid Valve Repair in Patients with Mild-to-Moderate Tricuspid Regurgitation Undergoing Mitral Valve Repair Improves In-Hospital Outcome.

Background Tricuspid regurgitation (TR) in patients undergoing surgery for mitral valve (MV) increases morbidity and mortality, especially in case of a poor right ventricle. Does repair of mild-to-moderate insufficiency of the tricuspid valve (TV) in patients undergoing MV surgery lead to a benefit in early postoperative outcome? Methods A total of 22 patients with mild-to-moderate TR underwent MV repair and concomitant TV repair with Tri-Ad (Medtronic ATS Medical Inc., Minneapolis, Minnesota, United States) and Edwards Cosgrove (Edwards Lifesciences Irvine, California, United States) rings. The severity of TR was assessed echocardiographically by using color-Doppler flow images. The tricuspid annular plane systolic excursion (TAPSE) was under 1.7 cm. Additional procedures included coronary artery bypass (n = 9) and maze procedure (n = 15). The following parameters were compared: postoperative and peak dose of noradrenaline (NA), pre/postoperative systolic pulmonary pressure (sPAP), extubation time, operation time, cross-clamp time, cardiopulmonary bypass (CPB) time, pre/postoperative ejection fraction (EF), intensive care unit (ICU)-stay, hospital stay, cell saver blood transfusion, intra/postoperative blood transfusion, and postoperative TR. Results The mean age was 67 ± 14.8 years, 45% were male. Mean EF was 47 ± 16.2%, postoperative 52 ± 12.4%. sPAP was 46 ± 20.1 mm Hg preoperatively, sPAP was 40.6 ± 9.4 mm Hg postoperatively, NA postoperatively was 12 ± 10 µg/min, NA peak was 18 ± 11 µg/min, operation time was 275 ± 92 minutes, CPB was 145 ± 49 minutes, ICU stay was 2.4 ± 2.4 days, hospital stay was 10.8 ± 3.5 days, cell saver blood transfusion was 736 ± 346 mL, intraoperative transfusions were 2.5 ± 1.6. Two patients needed postoperative transfusions. A total of 19 patients were extubated at the 1st postoperative day, 2 patients at the 2nd day, and 1 at the 4th postoperative day. Two patients required a pacemaker. No reintubation, no in-hospital mortality, and one reoperation because of bleeding complications. Conclusion Correction of mild-to-moderate TR at the time of MV repair does maintain TV function and avoid right ventricular dysfunction in the early postoperative period improving the clinical outcome.

Evaluation of a New Sonoclot Device for Heparin Management in Cardiac Surgery.

BACKGROUND: Sonoclot is used to measure kaolin-based activated clotting time (kACT) for heparin management. Apart from measuring kACT, the device assesses the patient's coagulation status by glass bead-activated tests (gbACTs; measuring also clot rate [CR] and platelet function [PF]). Recently, a new version of the Sonoclot has been released, and the redesign may result in performance changes. The aim of this study was to evaluate and compare the performance of the new (S2) and the previous (S1) Sonoclot. METHODS: The S1 was used in the routine management of 30 patients undergoing elective cardiac surgery. Blood samples were taken at baseline (T1), after heparin administration (200 U/kg, 100 U/kg; T2 and T3), during cardiopulmonary bypass (T4), after protamine infusion (T5), and before intensive care unit transfer (T6). Kaolin-based activated clotting time and gbACTs were measured in duplicate by both the old and the new device and performance compared by Bland-Altman analysis and percentage error calculation. RESULTS: A total of 300 kACT and 180 gbACTs were available. Bland-Altman analysis for kACT revealed that S2 consistently reported results in shorter time compared to S1 (overall = -14.7%). Comparing S2 and S1, the glass bead-activated tests showed mean percentage differences of -18.9% (gbACTs), +37.4% (CR), and -3.7% (PF). CONCLUSION: Since clotting is faster in the new S2 compared to S1, shorter clotting times have to be considered in clinical practice. The use of S2 kACT in heparin management will result in higher heparin and protamine dosing unless heparin kACT target values are adjusted to correct for the differences in results between S1 and S2.

Viscoelastic blood coagulation measurement with Sonoclot predicts postoperative bleeding in cardiac surgery after heparin reversal.

OBJECTIVES: The aim of the study was to determine if Sonoclot with its sensitive glass bead-activated, viscoelastic test can predict postoperative bleeding in patients undergoing cardiac surgery at predefined time points. DESIGN: A prospective, observational clinical study. SETTING: A teaching hospital, single center. PARTICIPANTS: Consecutive patients undergoing cardiac surgery (N = 300). INTERVENTIONS: Besides routine laboratory coagulation studies and heparin management with standard (kaolin) activated clotting time, additional native blood samples were analyzed on a Sonoclot using glass bead-activated tests. Glass bead-activated clotting time, clot rate, and platelet function were recorded immediately before anesthesia induction and at the end of surgery after heparin reversal but before chest closure. MEASUREMENTS AND MAIN RESULTS: Primary outcome was postoperative blood loss (chest tube drainage at 4, 8, and 12 hours postoperatively). Secondary outcome parameters were transfusion requirements, need for surgical re-exploration, time of mechanical ventilation, length of intensive care unit and hospital stay, and hospital morbidity and mortality. Patients were categorized into "bleeders" and "nonbleeders." Patient characteristics, operations, preoperative standard laboratory parameters, and procedural times were comparable between bleeders and nonbleeders except for sex and age. Bleeders had higher rates of transfusions, surgical re-explorations, and complications. Only glass bead measurements by Sonoclot after heparin reversal before chest closure but not preoperatively were predictive for increased postoperative bleeding. CONCLUSIONS: Sonoclot with its glass bead-activated tests may predict the risk for postoperative bleeding in patients undergoing cardiac surgery at the end of surgery after heparin reversal but before chest closure.

Mitral valve surgery in severe congenital factor VII deficiency.

The estimated incidence of congenital factor VII deficiency is 1:500 000. Severe FVII deficiency is associated with spontaneous bleeding such as intraarticular or intracranial haemorrhage. The risk of perioperative bleeding is high during cardiac surgery as a result of the exposure to extracorporeal circulation, systemic anticoagulation, loss of coagulation factors, and postoperative platelet malfunction. Effective treatment of pre-existing coagulopathy is crucial, as increased morbidity and mortality are associated with allogenic blood transfusions. We report a 67-year-old Caucasian male patient with severe congenital FVII deficiency, undergoing successful and uneventful elective mitral valve repair surgery, radiofrequency epicardial atrial fibrillation ablation, and exclusion of the left atrial appendage. He presented with severe symptomatic mitral valve regurgitation, moderate pulmonary artery hypertension, and paroxysmal atrial fibrillation; his left ventricular ejection fraction was 67%. Three years before surgery, during a routine assessment of a grade I renal failure, a spontaneous International Normalised Ratio of 4.1 was observed. He had no history of previous spontaneous bleeding. The diagnosis of a severe FVII deficiency, with an FVII activity below 2% (normal references values in City Hospital Triemli Zurich: 55-170%) was made.

Safe, effective and durable epicardial left atrial appendage clip occlusion in patients with atrial fibrillation undergoing cardiac surgery: first long-term results from a prospective device trial.

OBJECTIVES: Atrial fibrillation (AF) is a significant risk factor for embolic stroke originating from the left atrial appendage (LAA). This is the first report of long-term safety and efficacy data on LAA closure using a novel epicardial LAA clip device in patients undergoing cardiac surgery. METHODS: Forty patients with AF were enrolled in this prospective 'first-in-man' trial. The inclusion criterion was elective cardiac surgery in adult patients with AF for which a concomitant ablation procedure was planned. Intraoperative transoesophageal echocardiography (TEE) was used to exclude LAA thrombus at baseline and evaluate LAA perfusion after the procedure, while computed tomography (CT) was used for serial imagery workup at baseline, 3-, 12-, 24- and 36-month follow-up. RESULTS: Early mortality was 10% due to non-device-related reasons, and thus 36 patients were included in the follow-up consisting of 1285 patient-days and mean duration of 3.5 ± 0.5 years. On CT, clips were found to be stable, showing no secondary dislocation 36 months after surgery. No intracardial thrombi were seen, none of the LAA was reperfused and in regard to LAA stump, none of the patients demonstrated a residual neck >1 cm. Apart from one unrelated transient ischaemic attack (TIA) that occurred 2 years after surgery in a patient with carotid plaque, no other strokes and/or neurological events demonstrated in any of the studied patients during follow-up. CONCLUSION: This is the first prospective trial in which concomitant epicardial LAA occlusion using this novel epicardial LAA clip device is 100% effective, safe and durable in the long term. Closure of the LAA by epicardial clipping is applicable to all-comers regardless of LAA morphology. Minimal access epicardial LAA clip closure may become an interesting therapeutic option for patients in AF who are not amenable to anticoagulation and/or catheter closure. Further data are necessary to establish LAA occlusion as a true and viable therapy for stroke prevention. CLINICAL TRIAL REGISTRATION: The trial is registered at www.ClinicalTrials.gov, reference: NCT00567515.

Saphenous vein graft aneurysms: a growing problem? Presentation of two cases and surgical management.

Background Saphenous vein graft aneurysm is a rare complication after coronary artery bypass grafting leading to reoperations. Case Description In two patients with giant aneurysms, the subclavian artery and femoral vein were cannulated. The first patients' operation was combined with aortic valve replacement. The pulsating mass could be removed. The second patients' operation was planned as an off-pump coronary artery bypass grafting. Upon surgical entry, the aneurysm ruptured and the operation was continued as on-pump beating-heart procedure. Conclusion Because of better follow-up and increasing use of diagnostics, more patients with graft aneurysms will be identified. The question about a treatment algorithm might be answered by aging population and improved survival.