Hybrid total arterial minimally invasive off-pump coronary revascularization and percutaneous coronary intervention strategy for multivessel coronary artery disease: a cohort study with a median 11-year follow-up.

Background: Hybrid coronary revascularization (HCR) is a treatment approach that combines the benefits of coronary artery bypass grafting (CABG) techniques such as minimally invasive direct coronary artery bypass (MIDCAB) or minimally invasive multivessel CABG (MICS-CABG) with percutaneous coronary intervention (PCI) for carefully selected patients with multivessel coronary artery disease (MV CAD). The extant body of research primarily concentrates on the comparison of outcomes between HCR and CABG or PCI. Furthermore, HCR is defined primarily as MIDCAB and PCI. Given the various criteria for HCR identified in the current body of literature, as well as several hybrid revascularization techniques, our primary goal was to analyse the characteristics and track the development of HCR patients operated on in our centre (Robert Bosch Hospital) over both short and long periods of time. Additionally, we sought to validate the practical challenges that arise during the implementation of an HCR methodology. Methods: This cohort study included 138 patients with MV CAD who had an HCR approach in conjunction with isolated total arterial off-pump MICS-CABG or MIDCAB between 2007 and 2018 at Robert Bosch Hospital in Stuttgart. Data on major adverse cardiac and cerebral events (MACCE), defined as all-cause mortality, myocardial infarction, repeat revascularization and stroke were gathered through a questionnaire. Long-term follow-up, with a mean duration of 8.7±0.3 years and a median duration of 11 years, was available for a significant majority of the patients (92.8%, n=128). Results: The average age was 69.6±11.2 years, with 79% being male. The mean European System for Cardiac Operative Risk Evaluation score I additive (EuroSCORE I) additive was 7.6±10.2 and the mean SYNergy between PCI with TAXUS and Cardiac Surgery (SYNTAX) Score I was 22.9±9.4. A total of 97 MIDCAB surgeries and 41 MICS-CABG procedures were performed without any instances of conversion to sternotomy or cardiopulmonary bypass (CPB). A total of 70 patients, or 50.7% of the sample, received the planned PCI treatment. This percentage was substantially lower in the subgroup with chronic CAD, with just 27, equivalent to 39.1%. The observed 30-day death rate was 2.1% (3/138). During follow-up, 3 myocardial infarctions, 18 PCI repeats, no CABG, and 4 strokes occurred. From 128 followed-up patients, 28 died (21.9%), 7 of which were heart deaths (5.5%). Total MACCE was 36.7%. The survival rates at 3 and 5 years were 92% and 85% respectively. Patients who didn't get the planned PCI had a mean survival rate of 6.8-9.1 years, while those with completed hybrid treatment had a higher mean survival rate of 8.4-10.2 years. Conclusions: In selected individuals with MVCAD, current evidence suggests that HCR is a safe and effective coronary artery revascularization approach. After coronary bypass surgery, the attention going forward needs to be devoted toward the organization of the PCI step in the treatment process.

Minimally invasive strategies of surgical coronary artery revascularization for the aging population.

BACKGROUND: The increasing prevalence of elderly or frail patients with severe coronary disease, who are not suitable for interventional coronary revascularization, necessitates the exploration of alternative treatment options. A less invasive approach, such as minimally-invasive off-pump coronary-artery-bypass (MICS-CABG) grafting through mini-thoracotomy, which avoids both extracorporeal circulation and sternotomy, may be more appropriate for this patient population. This study, a retrospective, monocentric analysis, aimed to evaluate the long-term outcomes of these patients. METHODS: The study included 172 patients aged 80 years or older, who underwent MICS-CABG between 2007 and 2018. The patients underwent single, double, or triple-vessel revascularization using the left internal thoracic artery, and in some cases, the radial artery or saphenous vein. Follow-up, mean duration of 50.4±30.8 months, was available for 163 patients (94.7%). RESULTS: The mean age of the patients was 83.2±3.0 years, 77.3% of them were male. The EuroSCORE I additive was 11.0±12.1. There were no conversions to sternotomy or cardiopulmonary-bypass. The postoperative 30-day mortality rate was 2.9%, with 5 deaths. The in-hospital rate of major adverse cardiac and cerebrovascular events was 4.7% (perioperative myocardial infarction 1.2%, perioperative stroke 2.3%, repeat revascularization 1.2%). Acute renal kidney injury, (stage 3 KDOQI or more), occurred in 5 patients (2.9%) and new-onset atrial fibrillation in 6 patients (3.5%). The 1-, 3-, 5- and 8-year actuarial survival rate of the 30-day survivors was 97%, 82%, 73%, and 42%, respectively. CONCLUSIONS: MICS-CABG grafting is associated with excellent early and long-term outcomes in eligible octogenarians.

A prospective, international, bicentric study to evaluate PremiCron suture material for cardiac valve surgery - PREMIVALVE a cohort study.

The most common age-related heart valve diseases include aortic valve stenosis and mitral valve insufficiency. The suture material is not the focus of most studies. The aim of the study was to assess the performance of PremiCron suture material for cardiac valve reconstruction and/or replacement under clinical routine. Performance was evaluated using the incidence of major adverse cardiac and cerebrovascular events (MACCE) combined with endocarditis. Materials and methods: The study was designed as an international, prospective, bicentric, observational, single-arm study to evaluate the PremiCron suture material in cardiac valve surgery and compare the outcome with literature data regarding postoperative complications. The primary endpoint was a composite of MACCE acquired in the hospital, combined with endocarditis occurring up to 6 months postoperatively. The secondary parameters were intraoperative handling of the suture, incidence of MACCE and other relevant complications and quality of life up to 6 months after surgery. Patients were examined at discharge, 30 days, and 6 months postoperatively. Results: A total of 198 patients were enrolled in two centers in Europe. The cumulative primary endpoint event rate was 5.0%, lower than the reference value of 8.2% from the literature. Comparison of the incidence of individual MACCE until discharge and endocarditis rate 6 months postoperatively also showed that our data were within the range of the published rates. Quality of life significantly increased from preoperatively to 6 months after surgery. Ease of handling of the suture material was rated as very good. Conclusion: The PremiCron suture material is safe and very eligible for cardiac valve replacement and/or cardiac valve reconstruction in a broad patient population with a cardiac valve disorder treated under daily clinical practice.

Concomitant intra-atrial excision of the left atrial appendage during robotic-assisted minimally invasive cardiac surgery.

Objective: Surgical closure of the left atrial appendage (LAA) in patients with atrial fibrillation undergoing cardiac surgery can decrease the risk of stroke and thromboembolism and should therefore be considered. In minimally invasive, thoracoscopic, or robotic-assisted mitral valve surgery, however, external procedures such as clip application or epicardial resection are not feasible due to anatomic limitations and the reduced size of the access port. Internal suture closing techniques bear the risk of recurrent LAA reperfusion, so far. We present a novel surgical technique of LAA excision and subsequent defect closure from the interior aspect of the atrium. Methods: We developed this novel technique during robotic-assisted cardiac surgeries. In short, the LAA is invaginated into the left atrium, excised completely at the base using scissors and the stump is then closed from the inside with a two-layer looped PTFE suture. We give a detailed step-by-step description of the technique. Results: A total of 20 patients received intra-atrial LAA excision so far. Complete resection of the LAA without any residual stump or bleeding was achieved in all cases. There were no procedure-related complications. Conclusion: The intra-atrial LAA excision technique shows promising preliminary results regarding efficacy, safety, and reproducibility during robotic-assisted cardiac operations and could be recommended for all right-sided minimally invasive cardiac surgical procedures.

A propensity matched comparison of robotic vs. traditional minimal access approach for mitral valve repair with concomitant cryoablation.

Background: Atrial fibrillation (AF) occurs frequently in patients with mitral valve disease. Results of cryoablation concomitant with either minimally invasive video-assisted [minimally invasive mitral valve surgery (MIMVS)] or with robotic-assisted (RMV) mitral valve surgery have previously been separately reported. However, there are up-to-date no studies comparing the two procedures in terms of safety, efficacy, and mid-term follow-up. Methods: Between January 2017 and March 2022, 294 patients underwent MIMVS, and 187 patients underwent RMV at our institution. After 1:1 propensity score matching using 22 preoperative variables, the study included 104 patients. Group 1 (MIMVS) included 52 patients operated on between 2017-2022 using a minimally invasive video-assisted right-sided mini-thoracotomy. Group 2 (RMV) included 52 patients operated on between 2019-2021 using a robotic-assisted approach. Early and mid-term outcomes were assessed, including maintenance of sinus rhythm. Follow-up was 100% complete at a median follow-up of 2 years. Results: For the entire propensity matched cohort, the median EuroSCORE II was 3.14 [interquartile range (IQR), 1.93-4.99], the median age was 68 (IQR, 61-74) years, and two thirds of the patients were male. Most (72.1%) underwent mitral valve surgery, and 26.9% had an additional tricuspid procedure. Only four patients underwent mitral valve replacement (3.8%). The majority (87.5%) received a left-sided atrial Maze and 12.5% a bi-atrial Maze. The left atrial appendage was occluded in 72.1% cases. Overall, there were no significant differences between the two propensity matched groups in baseline demographics or intra-operative characteristics. Similarly, there were no significant differences in the post-operative short and mid-term outcomes between the two groups. There were no in-hospital or 30-day deaths. At the mid-term survival was similar between groups, log-rank test P=0.056. Maintenance of sinus rhythm at follow-up was 76%. Conclusions: Mitral or double valve repair with concomitant cryoablation can be safely performed with either a MIMVS or RMV approach. Both methods demonstrated outstanding early and mid-term outcomes.

Robotically assisted mitral valve surgery-experience during the restart of a robotic program in Germany.

Background: Following the first robotic-assisted mitral valve operations in Paris and Leipzig, the era of this innovative technique expired after a few years in Germany. At that time, the main arguments against robotic surgery within the German cardiac surgical community were low cost effectiveness and operative time utilization. Encouraged by favorable results, we re-started our robotic-assisted cardiac program as the first and only center in Germany in 2019. Methods: Between July 2019 and December 2021, 329 patients underwent robotic-assisted operations using the daVinci Xi system, including mitral and coronary operations, myxoma resection, atrial septal closure and stand-alone atrial ablation. Of these, 182 patients underwent mitral valve repair (MVR). Isolated MVR was performed in 96 patients (isolated mitral group, IMG) and 86 underwent concomitant operations, such as tricuspid valve repair, Cox-Maze IV, pulmonary vein isolation (PVI) and left atrial appendage (LAA) closure (complex mitral group, CMG). For cost analysis, the InEK calculation for 2020 was used. Results: MVR was successful (MR ≤I°) in all patients. Patients in the IMG had a hospital mortality of 1.0% (O/E ratio 0.69) and stroke rate of 2.0%. Four patients (4.0%) required conversion to sternotomy and 6 patients (6.0%) needed re-exploration for bleeding. Mortality was 3.5% (O/E ratio 0.74) in the CMG and stroke rate 2.3%. The conversion and bleeding rates were 4.6% each, respectively. The steep learning curve resulted in significant reduction of operating times greater than 25% in the IMG. Comparing the results of robotic-assisted procedures to minimally-invasive mitral surgeries (MIMS) in 2020, a reduction in length of hospital stay of almost 25% resulted in significantly lower costs for the medical service and medical infrastructure. However, within the German health service, overall cost for robotic-assisted procedures were more expensive compared to MIMS by 5% due to higher material costs. Conclusions: The re-establishment of robotic mitral valve surgery in Germany was successful with comparable results to MIMS in terms of mortality and morbidity. Robotic-assisted cardiac operations resulted in accelerated postoperative recovery with significant shortening of the hospital length of stay. The avoidance of liver injury is one focus for the future.

Surgical atrial appendage closure: time for a randomized study.

Atrial fibrillation (AF) is the most common arrhythmia and is assumed to affect more than 30 million people worldwide. Studies report that the left atrial appendage (LAA) plays an important role in thrombus formation and is considered the embolic source in 90% of affected patients with non-valvular and 57% with valvular AF. Oral anticoagulants have been the standard of care for stroke prevention in patients with AF for decades. However, bleeding complications and noncompliance are barriers to effective embolic protection. Therefore, as an alternative to conventional anti-thrombotic therapy, surgical LAA occlusion, which may lead to a reduced risk of thromboembolism, has received increasing attention. However, the procedure can be associated with additional risks such as prolonged operation time, damage to the circumflex coronary artery, and incomplete LAA occlusion. This review discusses some of the observational studies that have examined the impact of LAA occlusion on stroke, the LAAOS III (Left Atrial Appendage Occlusion Study) trial, which provided definitive evidence for the benefit of surgical LAA occlusion on ischemic stroke, which surgical methods are safe and effective for LAA occlusion, and whether oral anticoagulation can be stopped after surgical removal of the LAA.

Cryopreserved aortic homograft, lifeline treatment for infected vascular prosthesis with mediastinal abscess in a re-redo case.

We report about a 61-year-old man who, 6 years after initial uncomplicated mitral valve repair and 3 months after treatment of a pseudo-aneurysm of the ascending aorta with a Dacron patch, was admitted in our institution with an infection of the vascular graft, which was associated with sternal osteomyelitis and purulent cutaneous fistula. In a re-redo procedure, the proximal aortic arch and the ascending aorta were replaced with a cryopreserved aortic homograft. The infected part of the sternum was resected and the defect was covered by mobilizing the mediastinal tissue and with a bilateral muscle flap. The patient was discharged 20 days after surgery. This treatment concept outlines the benefit of cryopreserved aortic homograft when faced with a complex thoracic aortic infection.

Off-pump versus on-pump redo coronary artery bypass grafting: A propensity score analysis of long-term follow-up.

OBJECTIVE: Redo coronary artery bypass grafting (CABG) is associated with an increased early mortality reported up to 16%. The aim of this study was to analyze the early and long-term results after redo CABG with special focus on the feasibility and safety of the off-pump technique in the setting of a high-volume off-pump CABG center. METHODS: From January 2006 to June 2015, isolated redo CABG was performed in 304 patients (179 = on-pump redo CABG, 125 = off-pump redo CABG). We used propensity score matching with 14 preoperative variables to adjust for differences in baseline characteristics between the on-pump redo CABG and the off-pump redo CABG groups. After 1:1 matching we selected 108 pairs for each group. Mean follow-up rate was 4.01 years. RESULTS: The final sample was 83.9% men (n = 225) with a mean age of 69.77 ± 8 years. After propensity score matching there was a significant difference in the total number of grafts performed in favor of on-pump redo CABG (P = .011), whereas 66.7% (72 out of 108) of off-pump redo CABG patients received total arterial grafts. Off-pump redo CABG patients had a lower rate of postoperative renal failure necessitating dialysis (4.6% vs 0%; P = .06), required less recovery time in the intensive care unit (1.33 ± 1.03 days vs 4.4 ± 7.98 days; P < .001) and were discharged more quickly (10.08 ± 5.35 days vs 14.1 ± 10.6 days; P = .001). Off-pump redo CABG led to better long-term survival (log-rank test, P = .086). CONCLUSIONS: In our study, patients undergoing off-pump redo CABG had fewer postoperative complications, achieved faster recovery, and had better long-term survival. Hence, off-pump redo CABG is safe and feasible.

A retrospective comparative study of minimally invasive extracorporeal circulation versus conventional extracorporeal circulation in emergency coronary artery bypass surgery patients: a single surgeon analysis.

OBJECTIVES: At the moment, the main application of minimally invasive extracorporeal circulation (MiECC) is reserved for elective cardiac operations such as coronary artery bypass grafting (CABG) and/or aortic valve replacement. The purpose of this study was to compare the outcome of emergency CABG operations using either MiECC or conventional extracorporeal circulation (CECC) in patients requiring emergency CABG with regard to the perioperative course and the occurrence of major adverse cardiac and cerebral events (MACCE). METHODS: We analysed the emergency CABG operations performed by a single surgeon, between January 2007 and July 2013, in order to exclude the differences in surgical technique. During this period, 187 emergency CABG patients (113 MiECC vs 74 CECC) were investigated retrospectively with respect to the following parameters: in-hospital mortality, MACCE, postoperative hospital stay and perioperative transfusion rate. RESULTS: The mean logistic European System for Cardiac Operative Risk Evaluation was higher in the CECC group (MiECC 12.1 ± 16 vs CECC 15.0 ± 20.8, P = 0.15) and the number of bypass grafts per patient was similar in both groups (MiECC 2.94 vs CECC 2.93). There was no significant difference in the postoperative hospital stay or in major postoperative complications. The in-hospital mortality was higher in the CECC group 6.8% versus MiECC 4.4% (P = 0.48). The perioperative transfusion rate was lower with MiECC compared with CECC (MiECC 2.6 ± 3.2 vs CECC 3.8 ± 4.2, P = 0.025 units of blood per patient). CONCLUSIONS: In our opinion, the use of MiECC in urgent CABG procedures is safe, feasible and shows no disadvantages compared with the use of CECC. Emergency operations using the MiECC system showed a significantly lower blood transfusion rate and better results concerning the unadjusted in-hospital mortality.