Minimally Invasive Approach versus Sternotomy for Cardiac Surgery in Jehovah's Witness Patients.

OBJECTIVE: To evaluate the outcomes of minimally invasive cardiac surgery (MICS) compared with the sternotomy approach for Jehovah's Witness (JW) patients who cannot receive blood transfusions DESIGN: This was a retrospective observational study. SETTING: The study was conducted at a specialized cardiovascular intervention and surgery institute. PARTICIPANTS: The study cohort comprised JW patients undergoing cardiac surgery between September 2016 and July 2022. INTERVENTIONS: None MEASUREMENTS AND MAIN RESULTS: Patients (n = 63) were divided into MICS (n = 19) and sternotomy (n = 44) groups, and clinical outcomes were analyzed. There was no difference in types of operation except coronary bypass grafting (n = 1 [5.3%] in the MICS group v n = 20 [45.5%] in the sternotomy group; p = 0.005). There were no between-group differences in early mortality and morbidities. Overall survival did not differ significantly during the follow-up period (mean, 43.9 ± 24.4 months). The amount of chest tube drainage was significantly lower in the MICS group on the first postoperative day (mean, 224.0 ± 122.7 mL v 334.0 ± 187.0 mL in the sternotomy group; p = 0.022). The mean hemoglobin level was significantly higher in the MICS group on the day of operation (11.7 ± 1.3 mg/dL v 10.6 ± 2.0 mg/dL in the sternotomy group; p = 0.042) and the first postoperative day (12.3 ± 1.8 mg/dL v 11.2 ± 1.9 mg/dL; p = 0.032). CONCLUSIONS: MICS for JW patients showed favorable early outcomes and mid-term survival compared to conventional sternotomy. MICS may be a viable option for JW patients who decline blood transfusions.

Mid-term outcomes of tricuspid annuloplasty using the Tri-Ad Adams tricuspid annuloplasty ring.

OBJECTIVES: The Tri-Ad Adams tricuspid annuloplasty ring is a recent innovative prosthesis characterized by a semi-rigid central component and fully flexible extremities. The goal of this study was to assess the short-term and mid-term results following implantation of the Tri-Ad Adams ring. METHODS: A retrospective analysis was conducted on patients who underwent tricuspid annuloplasty using the Tri-Ad Adams ring between August 2016 and October 2021. RESULTS: Our study enrolled a total of 248 participants. The median age was 64.0 (interquartile range: 56.0-71.5) years. The median EuroSCORE II was 4.3% (2.7-7.5%), with 37 patients (14.9%) having a history of cardiac operations. Tricuspid regurgitation of grade 2-3 was observed in 63.7% of cases, and the median tricuspid annular diameter was 3.3 (2.8-3.6) cm. Concurrent procedures included mitral valve replacement (n = 160, 64.5%), mitral valve repair (n = 75, 30.2%), aortic valve replacement (n = 72, 29.0%) and the maze procedure (n = 170, 68.5%). Immediate postoperative tricuspid regurgitation≥moderate was present in 1 patient (0.4%). Early death occurred in 14 patients (5.6%). Major complications included low cardiac output syndrome (n = 18, 0.3%), acute kidney injury (n = 14, 5.6%) and permanent pacemaker placement (n = 15, 6.0%). According to the Kaplan-Meier analysis, the 4-year rates of freedom from overall mortality and moderate-to-severe tricuspid regurgitation were 96.9% and 91.6%, respectively. There were no incidents of tricuspid valve reoperations, ring detachment or significant tricuspid stenosis (trans-tricuspid valve gradient ≥ 5 mmHg). CONCLUSIONS: Tricuspid annuloplasty utilizing the Tri-Ad Adams ring demonstrated favourable outcomes in both the early and midterm periods. Further studies are warranted to confirm the long-term results.

Tricuspid Edge-to-Edge Repair Versus Tricuspid Valve Replacement for Severe Tricuspid Regurgitation.

BACKGROUND AND OBJECTIVES: Tricuspid valve (TV) repair techniques other than annuloplasty remain challenging and frequently end in tricuspid valve replacement (TVR) in complicated cases. However, the results of TVR are suboptimal compared with TV repair. This study aimed to evaluate the clinical effectiveness of TV edge-to-edge repair (E2E) compared to TVR for severe tricuspid regurgitation (TR). METHODS: We retrospectively reviewed 230 patients with severe TR who underwent E2E (n=139) or TVR (n=91) from 2001 to 2020. Clinical and echocardiographic results were analyzed using inverse probability of treatment weighting analysis and propensity score matching. RESULTS: The two groups showed no significant differences in early mortality and morbidities. During the mean follow-up of 106.2±68.8 months, late severe TR and TV reoperation rates were not significantly different between groups. E2E group, however, showed better outcomes in overall survival (p=0.023), freedom from significant tricuspid stenosis (TS) (trans-tricuspid pressure gradient ≥5 mmHg, p=0.021), and freedom from TV-related events (p<0.001). Matched analysis showed consistent results. CONCLUSIONS: E2E for severe TR presented more favorable clinical outcomes than TVR. Our study supports that E2E might be a valuable option in severe TR surgery, avoiding TVR.

Midterm outcomes of isolated tricuspid valve surgery with a mini-thoracotomy and beating heart strategy.

Background: Isolated tricuspid valve (TV) operation is considered high-risk surgery; thus, early surgical referral is frequently discouraged. Our study aims to evaluate the outcomes of isolated TV surgery with a mini-thoracotomy and beating heart strategy. Methods: We retrospectively reviewed 25 patients [median age, 65.0 years (Q1-Q3, 59.0-72.0 years)] who had undergone mini-thoracotomy beating heart isolated TV surgery from January 2017 to May 2021. TV repair was performed in 16 patients (64.0%), and TV replacement in 9 patients (36.0%). Among them, 18 patients (72.0%) had previous cardiac surgery, including TV replacement (n=4, 16.0%) and TV repair (n=4, 16.0%). Results: The median cardiopulmonary bypass time was 75.0 minutes (Q1-Q3, 61.0-98.0 minutes). There was 1 early mortality (4.0%) due to low cardiac output syndrome. Acute kidney injury requiring dialysis occurred in 3 patients (12.0%), and a permanent pacemaker was required in 1 patient (4.0%). The median lengths of stay in the intensive care unit and hospital were 1.0 day (Q1-Q3, 1.0-2.0) and 9.0 days (Q1-Q3, 6.0-18.0), respectively. The median follow-up duration was 30.3 months (Q1-Q3, 19.2-43.8). Freedoms from overall mortality, severe tricuspid regurgitation (TR), and significant tricuspid stenosis [i.e., trans-tricuspid pressure gradient (TTPG) ≥5 mmHg] at 4 years were 89.1%, 94.4%, and 83.3%, respectively. There was no TV reoperation. Conclusions: Mini-thoracotomy beating heart strategy for isolated TV surgery showed favorable early and midterm outcomes. This strategy may be a valuable option for isolated TV operations.

Trends in Heart Valve Surgery in Korea: A Report from the Heart Valve Surgery Registry Database.

Background: In this study, we present recent trends in heart valve surgery in Korea through analyses of data from the Korea Heart Valve Surgery Registry (KHVSR). Methods: We enrolled 8,981 patients who were registered in the KHVSR from 2017 to 2020. Yearly trends in patients' baseline characteristics, surgical profiles, and early mortality rates were explored. The observed/expected mortality ratio (O/E ratio), calculated from the actual mortality in the KHVSR and the predicted mortality estimated using the EuroSCORE II, was also analyzed. Results: The proportion of aortic valve surgery significantly increased from 56.8% in 2017 to 60.3% in 2020. The proportion of all combined procedures and minimally invasive surgery significantly increased over the 4-year study period. The operative mortality rate was 2.9% in the entire cohort, while mitral valve repair showed the lowest mortality risk (0.9%). The mortality rates of isolated aortic valve replacement (AVR) significantly decreased from 2.1% in 2017 to 0.8% in 2020 (p=0.016). Overall, the O/E ratio was 0.784 (95% confidence interval [CI], 0.677-0.902) demonstrating significantly lower actual mortality risks than expected based on the EuroSCORE II. In particular, the O/E ratios were as low as 0.364 (95% CI, 0.208-0.591) for isolated AVR. Conclusion: The recent data from the KHVSR showed increasing trends for complex procedures and minimally invasive surgery in heart valve surgery in Korea, and demonstrated remarkably low risks of operative mortality.

Effects of early postoperative shower after cardiac surgery.

BACKGROUND: Little is known regarding the effects of early showers after cardiac surgery. We evaluated the influence of early showers on postoperative wound complications following cardiac surgery. METHODS: This was a prospective observational study of 100 cardiac surgery patients (mean age, 63.0±13.5 years) who underwent early postoperative showers from September 2020 to March 2021 at our institution. Postoperative showers were initiated after the drain was removed. Postoperative wound complications were examined and patient satisfaction was evaluated using questionnaires. RESULTS: Surgery was performed through sternotomy in 48 patients (48.0%) and through minimally invasive approaches (right or left mini-thoracotomy) in 52 patients (52.0%). The mean time from surgery to shower was 6.0±1.4 days. No wound dehiscence, superficial wound infection, or deep wound infection was observed. Questionnaires showed that more than 50% of patients thought they were not allowed to shower until more than 2 weeks after the operation. Patient satisfaction score was 7.4±2.3 out of 10 for early showers after cardiac surgery. CONCLUSIONS: Our study suggests that postoperative early showers after cardiac surgery are not associated with an increased risk of wound complications. Patient satisfaction was also high. Early postoperative showering can be considered after cardiac surgery.

Is Prophylactic Tricuspid Annuloplasty Beneficial for Degenerative Mitral Valve Repair?

BACKGROUND: This study aimed to evaluate the long-term clinical impacts of prophylactic tricuspid annuloplasty (TAP) in patients with mild tricuspid regurgitation (TR) who underwent mitral valve repair. METHODS: One hundred fifty-one patients with mild TR who underwent mitral valve repair for degenerative mitral regurgitation between 1997 and 2013 were categorized into the TAP (n = 85) or no TAP (n = 66) groups. The indications for TAP were atrial fibrillation and tricuspid annular dilatation. The mean follow-up duration was 115.5 ± 48.6 months. Inverse probability of treatment weighting analysis and propensity score matching with 53 patients in each group were used to adjust for the baseline differences between the 2 groups. RESULTS: There were no early mortalities in either group, and early morbidities, including heart block, were not different between the groups. Inverse probability of treatment weighting-adjusted survival analysis did not reveal any difference in overall survival (P = .862), freedom from cardiac-related mortality (P = .535), or major adverse valve-related events (P = .972) between the groups. There was no difference in late TR progression (moderate or greater) between the groups (P = .316). These results were consistent in the matched analysis. CONCLUSIONS: Prophylactic TAP in mild TR may not have a beneficial effect on TR progress in degenerative mitral regurgitation. Further large studies are necessary to define the role of prophylactic TAP in mild TR.

Long-term Clinical and Hemodynamic Outcomes of Edge-to-Edge Repair for Tricuspid Regurgitation.

BACKGROUND: The edge-to-edge technique (Alfieri stitch) has been widely adopted in mitral valve but not tricuspid valve (TV) repair. We evaluated long-term clinical and hemodynamic outcomes of tricuspid edge-to-edge repair. METHODS: We retrospectively reviewed 237 patients (mean age, 58.4 ± 13.9 years) who had undergone tricuspid edge-to-edge repair from January 2001 to March 2019 in our institution. Tricuspid annuloplasty was performed in 175 patients (73.8%) using ring (91 [38.4%]) or suture (84 [35.4%]) annuloplasty. Concomitant procedures were mitral valve replacement (133 [56.1%]), mitral valve repair (52 [21.9%]), aortic valve replacement (41 [17.3%]), and maze operation (138 [58.2%]). RESULTS: Postoperative echocardiography revealed mild or less tricuspid regurgitation (TR) in 220 patients (92.8%). Early mortality (<30 days) occurred in 9 patients (3.8%), reoperation for bleeding in 16 (6.8%), and low cardiac output syndrome in 15 (6.4%). Freedom from all-cause mortality was 87.2% at 5 years and 80.6% at 10 years. Freedom from moderate or severe TR was 97.1% at 5 years and 84.9% at 10 years. Transtricuspid pressure gradient was 3.8 ± 4.2 mm Hg at discharge and 3.2 ± 5.6 mm Hg at the last follow-up (P = .60). Freedom from significant tricuspid stenosis (transtricuspid pressure gradient ≥5 mm Hg) was 96.4% and 88.4% at 5 and 10 years, respectively. There was 1 early TV reoperation for severe TR on postoperative day 3 (0.4%). Freedom from TV reoperation was 99.1% at 10 years. CONCLUSIONS: Tricuspid edge-to-edge repair showed acceptable long-term clinical and hemodynamic results and is an effective and safe option in TV surgery.

Outcomes of transported and in-house patients on extracorporeal life support: a propensity score-matching study.

OBJECTIVES: Patients on extracorporeal life support (ECLS), like other critically ill patients, are transported to other institutions for various reasons. However, little has been reported concerning the characteristics and clinical outcomes of transported patients compared with those of in-house patients. METHODS: A total of 281 adult patients received ECLS between January 2014 and August 2016. Patients who underwent cannulation at another institution by our team were excluded. Patients were divided into 2 groups: transported group (N = 46) and in-house group (N = 235). All 46 patients were safely transported without serious adverse events. The mean travel distance was 206±140 km, with a mean travel time of 78 ± 57 min. Following propensity score matching, 44 transported patients were matched to 148 in-house patients. RESULTS: In the matched population, the mean age was 48 ± 13 years in the transported group and 49 ± 17 years in the in-house group (P = 0.70). The ECLS type (venoarterial/venovenous) comprised 35/9 (79.5/20.5%) in the transported group and 119/29 (80.4/19.6%) in the in-house group (P = 0.93). Seventeen (38.6%) extracorporeal cardiopulmonary resuscitations were performed in the transported group and 59 (39.9%) were performed in the in-house group (P = 0.91). The incidence of limb ischaemia and acute kidney injury was higher in the transported group (P = 0.007 and P = 0.001, respectively). However, the rate of survival to discharge did not differ between the groups (63.6% in the transported group vs 64.2% in the in-house group, P = 0.94) and there was no difference in overall mortality (P = 0.99). CONCLUSIONS: Although transported patients had more complications than in-house ECLS patients, clinical outcomes were comparable in the matched population. Transporting ECLS patients to an experienced centre may be justified based on our experience.

Comparison between noninvasive and conventional skin closure methods in off-pump coronary artery bypass grafting using bilateral internal thoracic artery.

BACKGROUND: Sternal wound complications could increase the hospital cost while decreasing the satisfaction of surgery. Furthermore, it can potentially also lead to life-threatening mediastinitis especially after coronary artery bypass grafting using bilateral internal thoracic artery (BITA). Skill levels of suture technique vary among surgeons and may contribute to an increased wound complication rate. Thus, standardization of surgical wound closure could potentially decrease the surgeon factor. The aim of the study is to compare the wound complication rate between non-invasive surgical skin closure devices (zip surgical skin closure device, Zipline Medical, Campbell, CA, USA) and conventional suture closure. METHODS: Three hundred seventy-nine patients who underwent off-pump coronary artery bypass grafting (OPCAB) using BITAs at our institution between 2016 and 2018 were included in this study. Patients were divided into two groups; the Zipline group (zip-group, N=100), and conventional group (con-group, N=279). Following propensity score matching, 95 con-group patients were matched to 169 zip-group patients. RESULTS: The average age and history of cancer were significantly higher in the zip-group (P=0.021 and P=0.023, respectively). However, after propensity score matching, no differences were observed in the demographic data between the groups. In total patients (unmatched), although there was no significant difference in the incidence of deep sternal wound infection (DSWI) between the two groups (zip vs. con, 0% vs. 1.1%, P=0.569), the incidence of post-operative superficial sternal wound infection (SSWI) or dehiscence was significantly higher in the con-group than in the zip-group (1.0% vs. 7.9%, P=0.013). The results were consistent in the matched patients. (DSWI: 0% vs. 0.6%, P>0.999; SSWI or dehiscence: 1.1% vs. 7.1%, P=0.036). Multivariable analysis revealed use of the zip surgical skin closure device showed a preventive effect against wound complications [odds ratio (OR): 0.128, 95% confidence interval (CI): 0.017-0.976, P=0.029]. CONCLUSIONS: Zip surgical skin closure devices could decrease superficial wound complication rates compared to conventional suture techniques in OPCAB using BITAs.

Evaluation of a novel collagen hemostatic matrix in a porcine heart and cardiac vessel injury model.

BACKGROUND: Flowable hemostatic agents may be more advantageous than nonflowable hemostats, as they have capability to cover irregular wound surfaces, fill deep lesions, and easily remove excess materials with irrigation. In this study, we evaluated the hemostatic efficacy of the collagen hemostatic matrix (CHM) compared to FloSeal® via incisions in the heart and cardiac vessels in a porcine model. METHODS: In each of the two female pigs, a total of two incisions were made in seven locations: right atrium (RA), right ventricle (RV), and cardiac vessels, such as the innominate vein (IV), superior vena cava (SVC), pulmonary artery (PA), coronary artery (CA), and aorta. Hemostatic agents were applied directly to the bleeding wounds. In certain location, one incision was treated with the CHM and the other with FloSeal®, and the time to hemostasis and the degree of bleeding of the two agents were assessed and compared. One week after surgery, the animals were sacrificed, and specimens were collected for histologic evaluation. RESULTS: Bleeding from the vessels with relatively low pressure (the IV, SVC, and RA) was controlled within 1-2 minutes using both a CHM and FloSeal®. Bleeding from the vessels with high blood pressure (the RV, PA, CA, and aorta) was controlled within 3-10 minutes with the CHM. However, hemostasis in the PA and CA was not achieved with FloSeal®. Histological analysis revealed that the use of both the CHM and FloSeal® resulted in foreign body reactions of similar severity. CONCLUSIONS: The hemostatic effect and safety of the CHM may be similar to that of FloSeal®. Further clinical studies must be conducted to validate our results.

Comparison of Off-Pump Coronary Artery Bypass between Octogenarians and Septuagenarians: A Propensity Score Analysis.

BACKGROUND: Coronary artery bypass grafting (CABG) is being offered increasingly frequently to octogenarians. However, old age is known to be an independent risk factor in CABG. The aim of this study was to compare the outcomes of off-pump coronary artery bypass (OPCAB) between octogenarians and septuagenarians. METHODS: We retrospectively reviewed the data of 1,289 consecutive patients aged ≥70 years who underwent OPCAB at a single institution between 2001 and 2016. We compared the outcomes of 115 octogenarians and 1,174 septuagenarians. Using propensity score matching, based on preoperative clinical characteristics, 114 octogenarians were matched with 338 septuagenarians. RESULTS: Propensity score analysis revealed that the incidence of acute kidney injury (14.9% vs. 7.9%, p=0.028) and respiratory complications (8.8% vs. 4.2%, p=0.040) was significantly higher in octogenarians. The early mortality rate (2.6% vs. 1.0%, p=0.240) and 1-year survival rate (89.5% vs. 94.4%, p=0.097) were not statistically significant between the groups. However, the 5-year survival rate (67.3% vs. 79.9%, p<0.001) was significantly lower in octogenarians. Previous myocardial infarction and a left ventricular ejection fraction ≤35% were associated with a poor 1-year survival rate. CONCLUSION: Early and 1-year outcomes of OPCAB in octogenarians were tolerable when compared with those in septuagenarians. OPCAB could be a suitable option for octogenarians.

Outcomes of Coronary Artery Bypass Grafting after Extracorporeal Life Support in Patients with Cardiac Arrest or Cardiogenic Shock.

BACKGROUND: Extracorporeal life support (ECLS) is used as a bridge to revascularization in high-risk patients with ischemic heart disease. We reviewed our experiences of coronary artery bypass grafting (CABG) after ECLS in patients with cardiac arrest or refractory cardiogenic shock. METHODS: We retrospectively reviewed 4,616 patients who underwent CABG at our institution between May 2006 and February 2017. We identified patients who underwent CABG following ECLS for cardiogenic shock or cardiac arrest. Twenty-three patients (0.5% of all CABG cases) were enrolled in the analysis. Their median age was 65 years (Q1-Q3, 58-77 years). Nine patients (39.1%) were diagnosed with ST-elevation myocardial infarction. Mechanical complications after acute myocardial infarction, including acute mitral regurgitation, left ventricular rupture, and ventricular septal defect, occurred in 9 patients (39.1%). RESULTS: The median time from cardiopulmonary resuscitation to ECLS initiation was 25 minutes (Q1-Q3, 18.5-28.5 minutes). Conventional CABG was performed in 10 patients (43.5%) who underwent concomitant intracardiac procedures. Postoperative ECLS was required in 16 patients (69.5%). The rate of successful ECLS weaning was 91.3% (n=21). There were 6 early mortalities (26.1%). CONCLUSION: CABG after ECLS was very rare in real-world circumstances. Although the early mortality rate was high, the risk of mortality may be acceptable under such devastating circumstances.

Life-Threatening Acute on Chronic Pulmonary Thromboembolism Requiring Extracorporeal Membrane Oxygenation.

A 71-year-old female patient was admitted to the emergency department with sudden aggravation of chest pain and severe dyspnea. Computed tomography showed extensive pulmonary thromboembolism. Venoarterial extracorporeal membrane oxygenation (ECMO) was instituted due to sudden bradycardia and hypotension. An emergency operation was performed. However, chronic pulmonary thromboembolism combined with an acute pulmonary embolism was detected in the operating room. Embolectomy and endarterectomy were performed. ECMO was then discontinued. The patient was discharged on postoperative day 13 with warfarin for anticoagulation. The patient was followed up for 46 months as an outpatient without further thromboembolic events.

Clinical Outcomes of Root Reimplantation and Bentall Procedure: Propensity Score Matching Analysis.

BACKGROUND: This study aimed to evaluate the clinical outcomes of aortic root replacement (ARR) surgery: Root reimplantation as valve-sparing root replacement (VSR) and the Bentall procedure. METHODS: We retrospectively reviewed 216 patients who underwent ARR between 1995 and 2013 at Samsung Medical Center. Patients were divided into two groups, depending on the procedure they underwent: Bentall (n = 134) or VSR (n = 82). The mean follow-up duration was 100.9 ± 56.4 months. RESULTS: There were 2 early deaths in the Bentall group and none in the VSR group (p = 0.53). Early morbidities were not different between the groups. Overall mortality was significantly lower in the VSR group (HR = 0.12, p = 0.04). Despite the higher reoperation rate in the VSR group (p = 0.03), major adverse valve-related events (MAVRE) did not differ between the groups (p = 0.28). Bleeding events were significantly higher in the Bentall group during follow-up (10 in Bentall group, 0 in VSR group, p = 0.04). There were 6 thromboembolic events only in the Bentall group (p = 0.11). We performed a propensity score matching analysis comparing the groups (134 Bentall versus 43 VSR). Matched analysis gave similar results, namely, HR = 0.17, p = 0.10 for overall mortality and HR = 1.01, p = 0.99 for MAVRE. CONCLUSIONS: Although there was marginal significance in the propensity matched analysis, it is plausible to anticipate a survival benefit with VSR during long-term follow-up. Despite a higher reoperation for aortic valves, VSR can be a viable option in patients who decline life-long anticoagulation, especially the young or the patients in whom anticoagulation is contraindicated.

Erratum: Inter-Facility Transport on Extracorporeal Life Support: Clinical Outcomes and Comparative Analysis with In-house Patients.

[This corrects the article on p. 363 in vol. 50, PMID: 29124028.].

Inter-Facility Transport on Extracorporeal Life Support: Clinical Outcomes and Comparative Analysis with In-house Patients.

BACKGROUND: Extracorporeal life support (ECLS) is widely used in refractory heart or lung failure, and the demand for inter-facility transportation on ECLS is expanding. However, little is known about post-transportation outcomes, the clinical safety of such transportation, or the characteristics of the transported patients. METHODS: This was a retrospective review of a 3-year, single-institution experience with inter-facility ECLS transport, as well as a comparative analysis of clinical outcomes with those of in-house patients. We also analyzed the risk factors for hospital mortality in the entire ECLS population using univariate and multivariate analyses to investigate the effects of transport. RESULTS: All 44 patients were safely transported without adverse events. The average travel distance was 178.7 km, with an average travel time of 74.0 minutes. Early survival of the transported group seemed to be better than that of the in-house group, but the difference was not statistically significant (70.5% vs. 56.6%, p=0.096). The incidence of complications was similar between the 2 groups, except for critical limb ischemia, which was significantly more common in the transported group than in the in-house group (25.0% vs. 8.1%, p=0.017). After adjusting for confounders, being part of the transported group was not a predictor of early death (adjusted odds ratio, 0.689; p=0.397). CONCLUSION: Transportation of patients on ECLS is relatively safe, and the clinical outcomes of transported patients are comparable to those of in-house ECLS patients. Although matched studies are required, our study demonstrates that transporting patients on ECLS did not increase their risk of hospital mortality after adjustment for other factors.

The Mid-term Results of Thoracoscopic Closure of Atrial Septal Defects.

BACKGROUND AND OBJECTIVES: Recently, minimally invasive surgical (MIS) techniques including robot-assisted operations have been widely applied in cardiac surgery. The thoracoscopic technique is a favorable MIS option for patients with atrial septal defects (ASDs). Accordingly, we report the mid-term results of thoracoscopic ASD closure without robotic assistance. SUBJECTS AND METHODS: We included 66 patients who underwent thoracoscopic ASD closure between June 2006 and July 2014. Mean age was 27±9 years. The mean size of the ASD was 25.9±6.3 mm. Eleven patients (16.7%) had greater than mild tricuspid regurgitation (TR). The TR pressure gradient was 32.4±8.6 mmHg. RESULTS: Fifty-two (78.8%) patients underwent closure with a pericardial patch and 14 (21.2%) underwent direct suture closure. Concomitant procedures included tricuspid valve repair in 8 patients (12.1%), mitral valve repair in 4 patients (6.1%), and right isthmus block in 1 patient (1.5%). The mean length of the right thoracotomy incision was 4.5±0.9 cm. The mean cardiopulmonary bypass time was 159±43 minutes, and the mean aortic cross clamp time was 79±29 minutes. The mean hospital stay lasted 6.1±2.6 days. There were no early deaths. There were 2 reoperations. One was due to ASD patch detachment and the other was due to residual mitral regurgitation after concomitant mitral valve repair. However, there have been no reoperations since July 2010. There were 2 pneumothoraxes requiring chest tube re-insertion. There was one wound dehiscence in an endoscopic port. The mean follow-up duration was 33±31 months. There were no deaths, residual shunts, or reoperations during follow-up. CONCLUSION: Thoracoscopic ASD closure without robotic assistance is feasible, suggesting that this method is a reliable MIS option for patients with ASDs.

The Outcome of Extracorporeal Life Support After General Thoracic Surgery: Timing of Application.

BACKGROUND: Extracorporeal life support (ECLS) is widely used in refractory cardiac or pulmonary failure. Because complications of general thoracic surgery frequently involve the heart or lungs, ECLS can be a useful option. Therefore, we retrospectively reviewed our experience with ECLS after general thoracic surgery. METHODS: There were 17,185 adult general thoracic surgery procedures between 2005 and 2013 at our institution, including resection of the lung (n = 10,434; 60.7%), esophagus (n = 1,847; 0.7%), and other procedures (n = 4,904; 28.5%). Twenty-nine patients (0.2%) were supported by ECLS postoperatively. RESULTS: The median age was 64 years (range, 24 to 81). Primary operations were lobectomy (n = 13; 44.8%), pneumonectomy (n = 11; 37.9%), and bilobectomy (n = 5; 17.2%). The initial mode of ECLS was venovenous in 20 patients (69.0%) and venoarterial in 9 patients (31.0%). There were 10 patients (34.5%) who survived to decannulation and 7 patients (24.1%) who survived to discharge. Over the same period, the survival to decannulation rate and survival to discharge rate were 49.5% and 35.0%, respectively, among all ECLS patients (n = 759) at our institution. The hospital mortality of patients with surgery to ECLS time of longer than 2 days was 90.9%. Multivariate analysis revealed that a longer surgery to ECLS time was a risk factor for hospital mortality (odds ratio 1.720, 95% confidence interval: 1.039 to 2.849, p = 0.035). CONCLUSIONS: ECLS after general thoracic surgery can be a viable rescue therapy option. Late presentation of complications or ECLS for late complications of general thoracic surgery may be predictors of death.