Minimal invasive coronary surgery is not associated with increased mortality or morbidity during the period of learning curve.

BACKGROUND: Minimally invasive procedures for coronary revascularization have been performed for over 20 years; however, their technical complexity, steep learning curves and absence of training programs explain the weak acceptance of these techniques. The aim of this study is to describe the step-by-step learning process on how to establish a minimally invasive coronary artery revascularization program. The short-term outcomes of our first 30 patients were compared to our left internal mammary artery (LIMA) to left anterior descending (LAD) artery off pump coronary artery bypass (OPCAB) cohort as a quality control baseline. METHODS: All patients who benefited from an endoscopic atraumatic coronary artery bypass (Endo-ACAB) in our hospital, from July 2018 to May 2020 (n = 30) were identified. Baseline demographics, peri, postoperative and laboratory data were extracted from each patient's medical records. These results were compared to our LIMA-LAD OPCAB cohort (n = 23). RESULTS: Twenty-eight patients were planned for a single LIMA-LAD Endo-ACAB. The remaining two had a T-graft double Endo-ACAB. Ten patients had a hybrid revascularization with the culprit lesion being treated first. Three patients were converted to sternotomy because of a LIMA lesion during thoracoscopic harvesting. We accounted three major adverse cardiovascular events (MACE). Demographic, peri and postoperative data showed no significant differences between the Endo-ACAB and the OPCAB group. CONCLUSION: Endo-ACAB is a technically demanding operation, however, it can safely be introduced in centers with no previous experience with no extra cost in terms of morbidity or mortality. Thoracoscopic LIMA harvesting is the most demanding surgical skill to acquire.

An asymptomatic Lima dissection after a programmed hybrid revascularization procedure turned to nightmare.

A 71-year-old female with symptomatic bitroncular coronary ischemic disease was admitted in our hospital for hybrid revascularization. She presented significant stenosis of the proximal and middle left anterior descending artery (LAD) and of the second segment of right coronary artery (RCA). She was scheduled for an Endoscopic Atraumatic Coronary Artery Bypass (EACAB) of the left internal mammary artery (LIMA) to LAD and staged percutaneous coronary intervention (PCI) to RCA after the EACAB. Control of LIMA permeability after RCA PCI showed LIMA dissection with TIMI 2 flow to LAD. Decision to stent a freshly implanted LIMA led to LIMA rupture. An emergent LAD revascularization with a saphenous vein graft and control of bleeding was successfully performed. Patient was discharged at day 10 from the hospital.

Outcomes from cardiac surgery in Jehovah's witness patients: experience over twenty-one years.

BACKGROUND: Cardiac surgery in Jehovah's Witnesses may be challenging during the operation and postoperative period given their refusal of blood products. The aim of this study was to document our center's experience with Jehovah's Witnesses undergoing major cardiac surgery and to compare surgical outcomes with a matched control group. METHODS: We retrospectively reviewed the demographic, perioperative, and in-hospital postoperative data for 31 Jehovah's Witness patients undergoing surgery from 1991 to 2012 and compared findings with a control group of 62 patients of the same sex and age, who underwent the same type of operations in the same period. Early mortality, major in-hospital morbidity, laboratory findings, and hospital stays were compared between groups. RESULTS: Demographic data were similar between groups, except that more patients in the Jehovah's Witness group had extracardiac arteriopathy compared with controls (p = 0.04). There was no difference in predicted mortality, calculated by the Euroscore II, between groups (2.8 ± 3.3 in study group versus 2.4 ± 2.2 in control group, p = 0.469). For postoperative outcomes, there were no differences between Jehovah's Witnesses versus controls in hospital mortality (3 % versus 2 %, p = 0.548), total drain loss (847 ± 583 mL versus 812 ± 365 mL, p = 0.721), mechanical ventilation time (1.26 ± 2.24 versus 0.89 ± 0.55 days, p = 0.218), intensive care unit stay (4.3 ± 3.9 versus 3 ± 1.4 days, p = 0.080), and hospital stay (12.9 ± 7.6 versus 10.9 ± 6.6 days, p = 0.223). CONCLUSIONS: Outcomes after cardiac surgery are similar between Jehovah's Witnesses and general population, in centers applying rigorous blood patient management protocols.

'Fast-implantable' aortic valve implantation and concomitant mitral procedures.

Concomitant aortic and mitral valve replacement or concomitant aortic valve replacement and mitral repair can be a challenge for the cardiac surgeon: in particular, because of their structure and design, two bioprosthetic heart valves or an aortic valve prosthesis and a rigid mitral ring can interfere at the level of the mitroaortic junction. Therefore, when a mitral bioprosthesis or a rigid mitral ring is already in place and a surgical aortic valve replacement becomes necessary, or when older high-risk patients require concomitant mitral and aortic procedures, the new 'fast-implantable' aortic valve system (Intuity valve, Edwards Lifesciences, Irvine, CA, USA) can represent a smart alternative to standard aortic bioprosthesis. Unfortunately, this is still controversial (risk of interference). However, transcatheter aortic valve replacements have been performed in patients with previously implanted mitral valves or mitral rings. Interestingly, we learned that there is no interference (or not significant interference) among the standard valve and the stent valve. Consequently, we can assume that a fast-implantable valve can also be safely placed next to a biological mitral valve or next to a rigid mitral ring without risks of distortion, malpositioning, high gradient or paravalvular leak. This paper describes two cases: a concomitant Intuity aortic valve and bioprosthetic mitral valve implantation and a concomitant Intuity aortic valve and mitral ring implantation.

Cryoablation for a right atrial myxoma arising from the Koch's triangle: a case report.

A 78-year-old caucasian patient with compromised cardiac function presenting recurrent episodes of pulmonary embolism was referred to our center for resection of a voluminous right atrial myxoma arising from the Koch's triangle. To preserve the conduction system, we performed an excision of the myxoma associated with cryoablation of its stalk. This case is of special interest for discussing possibilities of preservation of the atrioventricular conduction system in such situations, provided that the contemporary literature does not propose concrete guidelines.

Impaired left ventricular function as a predictive factor for mid-term survival in octogenarians after primary coronary artery bypass surgery.

BACKGROUND: The impact of preoperative impaired left ventricular ejection fraction (EF) in octogenarians following coronary bypass surgery on short-term survival was evaluated in this study. METHODS: A total of 147 octogenarians (mean age 82.1 ± 1.9 years) with coronary artery diseases underwent elective coronary artery bypass graft between January 2000 and December 2009. Patients were stratified into: Group I (n = 59) with EF >50%, Group II (n = 59) with 50% > EF >30% and in Group III (n = 29) with 30% > EF. RESULTS: There was no difference among the three groups regarding incidence of COPD, renal failure, congestive heart failure, diabetes, and preoperative cerebrovascular events. Postoperative atrial fibrillation was the sole independent predictive factor for in-hospital mortality (odds ratio (OR), 18.1); this was 8.5% in Group I, 15.3% in Group II and 10.3% in Group III. Independent predictive factors for mortality during follow up were: decrease of EF during follow-up for more that 5% (OR, 5.2), usage of left internal mammary artery as free graft (OR, 18.1), and EF in follow-up lower than 40% (OR, 4.8). CONCLUSIONS: The results herein suggest acceptable in-hospital as well short-term mortality in octogenarians with impaired EF following coronary artery bypass grafting (CABG) and are comparable to recent literature where the mortality of younger patients was up to 15% and short-term mortality up to 40%, respectively. Accordingly, we can also state that in an octogenarian cohort with impaired EF, CABG is a viable treatment with acceptable mortality.

How to improve flow during cardiopulmonary bypass in an acardia experimental model.

OBJECTIVES In extreme scenarios, such as hyperacute rejection of heart transplant, an urgent heart explantation might be necessary. The aim of this experimental study was to determine the feasibility and to improve the haemodynamics of a venoarterial cardiopulmonary bypass after cardiectomy. METHODS A venoarterial cardiopulmonary bypass was established in seven calves (56.4 ± 7 kg) by the transjugular insertion to the caval axis of a self-expanding cannula, with a carotid artery return. After baseline measurements (A), ventricular fibrillation was induced (B), great arteries were clamped (C), the heart was excised and the right and left atria remnants, containing the pulmonary veins, were sutured together leaving an atrial septal defect over the cannula in the caval axis (D). Measurements were taken with the pulmonary artery clamped and declamped. RESULTS Initial pump flow was 4.16 ± 0.75 l/min dropping to 2.9 ± 0.63 l/min (P(AB )< 0.001) 10 min after induction of ventricular fibrillation. After cardiectomy with the pulmonary artery clamped, the pump flow increased non-significantly to 3.20 ± 0.78 l/min. After declamping, the flow significantly increased close to baseline levels (3.61 ± 0.73 l/min, P(DB )= 0.009, P(DC )= 0.017), supporting the notion that full cardiopulmonary bypass in acardia is feasible only if adequate drainage of pulmonary circulation is assured to avoid pulmonary congestion and loss of volume from the left-to-right shunt of bronchial vessels.