Partial versus Complete Sternotomy for Aortic Valve Replacement-Multicenter Study.

BACKGROUND: The benefits of minimally invasive techniques in cardiac surgery remain poorly defined. We evaluated the short- and mid-term outcomes after surgical aortic valve replacement through partial upper versus complete median sternotomy (MS) in a large, German multicenter cohort. METHODS: A total of 2,929 patients underwent isolated surgical aortic valve replacement via partial upper sternotomy (PUS, n = 1,764) or MS (n = 1,165) at nine participating heart centers between 2016 and 2020. After propensity-score matching, 1,990 patients were eligible for analysis. The primary end point was major adverse cardiac and cerebrovascular events (MACCE), a composite of death, myocardial infarction, and stroke at 30 days and in follow-up, up to 5 years. Secondary end points were acute kidney injury, length of hospital stay, transfusions, deep sternal wound infection, Dressler's syndrome, rehospitalization, and conversion to sternotomy. RESULTS: Unadjusted MACCE rates were significantly lower in the PUS group both at 30 days (p = 0.02) and in 5-year follow-up (p = 0.01). However, after propensity-score matching, differences between the groups were no more statistically significant: MACCE rates were 3.9% (PUS) versus 5.4% (MS, p = 0.14) at 30 days, and 9.9 versus 11.3% in 5-year follow-up (p = 0.36). In the minimally invasive group, length of intensive care unit (ICU) stay was shorter (p = 0.03), Dressler's syndrome occurred less frequently (p = 0.006), and the rate of rehospitalization was reduced significantly (p < 0.001). There were 3.8% conversions to full sternotomy. CONCLUSION: In a large, German multicenter cohort, MACCE rates were comparable in surgical aortic valve replacement through partial upper and complete sternotomies. Shorter ICU stay and lower rates of Dressler's syndrome and rehospitalization were in favor of the partial sternotomy group.

A Strategy for Minimizing Circulatory Arrest Duration in Complex Aortic Arch Procedures.

Background and Objectives: Aortic arch pathologies represent a surgical challenge. The challenge is partly due to the necessity of complex cerebral, visceral, and myocardial protection measures. Aortic arch surgery generally requires a significant duration of circulatory arrest, which includes deep hypothermia levels with the associated sequelae. This retrospective observational study shows the feasibility of a strategy that reduces circulatory arrest duration and eliminates the need for deep hypothermia during the procedure. Materials and Methods: Between January 2022 and January 2023, 15 patients (n = 15) with type A aortic dissection underwent total arch replacement with a frozen elephant trunk. Cardiopulmonary bypass and organ perfusion were established via arterial lines in the right axillary artery and one of the femoral arteries. In the latter vessels, a y-branched arterial cannula was used (ThruPortTM), allowing for endo-clamping of the stent part of the frozen elephant trunk with a balloon and subsequent perfusion of the lower body. Results: Applying this modified perfusion technique, circulatory arrest time could be reduced to a mean of 8.1 ± 4.2 min, and surgery was performed at a mean lowest body temperature of 28.9 ± 2.3 °C. The mean ICU and hospital stays were 18.3 ± 13.7 days and 23.8 ± 11.7 days, respectively. The rate for 30-day survival was 100%. Conclusions: By applying our modified perfusion technique, the circulatory arrest duration was below ten minutes. As a consequence, deep hypothermia could be avoided, and surgery could be performed at moderate hypothermia. Future studies will have to show whether these changes may be translated into a clinical benefit for our patients.

Pass On What You Have Learned: A Structured Mentor-Mentee Concept for the Implementation of a Minimally Invasive Mitral Valve Surgery Program.

INTRODUCTION: Starting a minimally invasive cardiac surgery (MICS) for mitral valve repair (MVR) program is challenging as it requires a new learning curve, but compromising surgical results at the same time is not acceptable. Here, we describe our surgical educational experience of starting a new MICS program at a university heart center in Germany. METHODS: A dedicated team for the new MICS program including 2 cardiac surgeons, 1 cardiac anesthetist, 1 perfusionist, and 1 scrub nurse was chosen. The use of long shafted instruments was trained in a low-cost self-assembled MICS simulator, and the EACTS endoscopic dry lab course was visited. Thereafter, 1 MICS center was visited for direct observation and peer-to-peer education for 6 weeks. The mentor observed the first 10 cases performed by the mentee. The surgical mitral valve expertise of 1 single cardiac surgeon was retrospectively analyzed between April 2016 and April 2021. RESULTS: Before the implementation of the MICS-MVR program, 18 mitral valve operations have been performed through sternotomy between April 2016 and October 2018 including 12 replacements and 6 ring annuloplasties. After starting the MICS-MVR program, 73 mitral operations have been performed by the same surgeon of which 53 video-assisted through minithoracotomy (72.6%). 83.1% of the MICS procedures included complex repair (n = 38) and ring annuloplasty (n = 6). Open heart MV surgery was necessary in 20 patients due to concomitant procedures (n = 8), redo procedures (n = 2), severe endocarditis (n = 4), or contraindication for MICS such as PAD (n = 6). There have been no deaths, 1 stroke, and 1 cardiac vascular (RCX) complication. Two patients required conversion to sternotomy and one pericardiocentesis in the long term. CONCLUSION: Typically, excellent exposure and high repair rates of the MV has led us offer MICS approach to a majority of patients with isolated MV disease. Careful planning and a strict mentor-mentee concept facilitated a safe startup of an MICS program in a busy university heart center.

Recurrent Syncope and Cardiopulmonary Resuscitation Due to a Papillary Fibroelastoma.

Symptoms of papillary fibroelastomas are often related to thromboembolic events but are rarely caused by a mechanical impairment of blood supply by the tumor itself. We describe a case of a papillary fibroelastoma in a 91-year-old female patient leading to a cardiac arrest through intermittent occlusion of the left coronary artery.

Postoperative ST-segment elevation caused by mechanical compression of the native right coronary artery by a pericardial drainage tube.

ST-segment elevation is often the first remarkable sign of postoperative cardiac ischaemia. It requires prompt diagnostic measures and an early treatment to improve the patient's outcome. We describe a case of early postoperative ST-segment elevation due to mechanical compression of the native right coronary artery by a pericardial drainage tube in a patient after replacement of the ascending aorta.

Coronary Anastomosis In Stent-Useful to Do When No Other Alternative Is Given?

Background Many patients being referred for coronary artery bypass grafting have a history of percutaneous coronary intervention (PCI). Case Description In a patient after multiple PCI of the left anterior descending artery (LAD), repeated in-stent stenosis was diagnosed. The LAD being covered with stents to the periphery, no meaningful anastomosis with stent-free vessel was possible. After thorough discussion with the patient, the referring cardiologist, and our local heart team, an in-stent anastomosis was planned and created, that was found to be angiographically patent 21 months after surgery with the patient free from angina. Conclusion Without any alternative treatment method given, our approach of in-stent anastomosis confers a good mid-term angiographic result.

Conduction Disorders after Surgical Aortic Valve Replacement Using a Rapid Deployment Aortic Valve Prosthesis: Medium-Term Follow-Up.

BACKGROUND: We have previously reported that the incidence of postoperative conduction disorders, especially left bundle branch block (LBBB), after implantation of a rapid deployment Intuity™ Elite aortic valve prosthesis (Edwards Lifesciences, Irvine, CA, USA), was significantly increased compared with conventional aortic valve replacement. We were now interested in how these disorders behaved at intermediate follow-up. METHODS: All 87 patients who had undergone surgical aortic valve replacement (SAVR) using the rapid deployment Intuity™ Elite prosthesis and were shown to have conduction disorders at the time of hospital discharge were followed up after surgery. These patients' ECGs were recorded at least 1 year after surgery, and the persistence of the new postoperative conduction disorders was assessed. RESULTS: At hospital discharge, 48.1% of the patients had developed new postoperative conduction disorders, with LBBB being the predominant conduction disturbance (36.5%). At medium-term follow-up (526 days, standard deviation (SD) = 169.6, standard error (SE) = 19.3 days, respectively), 44% of the new LBBB and 50% of the new right bundle branch block (RBBB) had disappeared. There was no new atrio-ventricular block III (AVB III) that occurred. One new pacemaker (PM) was implanted during follow-up because of AVB II Mobitz type II. CONCLUSIONS: At medium-term follow-up after the implantation of a rapid deployment Intuity™ Elite aortic valve prosthesis, the number of new postoperative conduction disorders, especially LBBB, has considerably decreased but remains high. The incidence of postoperative AV block III remained stable.

Does the euroSCORE equally well predict perioperative cardiac surgical risk for men and women?

The euroSCORE is a widely applied scoring system to estimate perioperative risk in patients undergoing cardiac surgery. It acknowledges an increased risk in women but does not apply a gender-specific weighing of individual risk indicators. We separately investigated the performance of the euroSCORE for men and women. Cardiac surgical patients operated in 2002 and 2003 (n = 1930) served as training group. Patients operated in 2004 served as validation group (n = 870). Using binary regression analysis, we developed a gender-specific model on the basis of the original euroSCORE risk indicators. The individual risk indicators were assigned gender-specific correlation coefficients. Applying ROC analysis to the validation group, the original euroSCORE performed well, with an area under curve (AUC) of 0.758, for men but poor, with an AUC 0.676, for women. After gender-specific re-weighing, ROC analysis revealed considerably improved predictive values of the modified euroSCORE. AUC for women increased to 0.755, AUC for men further increased to 0.772. The original euroSCORE failed to accurately predict perioperative mortality in women. A binary regression model, assigning a gender-specific weight to each of the risk indicators of the original euroSCORE, considerably improved the predictive power of the modified euroSCORE.

Concomitant tumourous lesions in the left atrium and aortic valve suspected to be myxoma.

The occurrence of multiple primary cardiac tumours in a single patient is extremely rare. Despite growing expertise in non-invasive diagnostic modalities, especially in transoesophageal echocardiography, only a few cases report the coincidence of papillary fibroelastoma of the aortic valve and myxoma of the left atrium. Moreover, echocardiographic as well as a macroscopic distinction between cardiac myxoma and cardiac fibroelastoma may be difficult. Only post-excisional histopathology provides diagnostic safety. Cryoablation of the remnant tissue prevents recurrence in both the aortic valve and the left atrium.

Results of a propensity score-matched comparison of the Perimount Magna and Mosaic Ultra aortic valve prostheses.

BACKGROUND AND AIM OF THE STUDY: Hemodynamic function and clinical outcomes were compared between the bovine pericardial Edwards Perimount Magna (EPM) and the porcine Medtronic Mosaic Ultra (MMU) aortic valve prostheses. METHODS: Between January 2003 and June 2007, a total of 227 consecutive patients was prospectively enrolled, and received either the EPM (n = 125) or the MMU (n = 102) aortic valve prosthesis. The primary study end-point was the mean transvalvular gradient after surgery, at discharge and at six months follow up, as measured echocardiographically. The secondary study end-points were 30-day mortality and major adverse cardiac events (MACEs). RESULTS: The intraoperative transvalvular mean pressure gradients were 9.4 +/- 4.6 mmHg in the EPM group compared to 17.7 +/- 6.7 mmHg in the MMU group (p < 0.001), and these remained essentially unchanged at hospital discharge (11.2 +/- 4.2 mmHg versus 19.1 +/- 6 mmHg; p < 0.001) and at six months' follow up (10 +/- 5 mmHg versus 20 +/- 7 mmHg; p < 0.001). A multivariable risk-adjusted analysis of covariance revealed the MMU valve (p < 0.0001) to be strongly associated with elevated postoperative mean transvalvular gradients during the six-month follow up. In addition, renal insufficiency, concomitant valve surgery and reoperation were identified as being significantly associated with in-hospital mortality (OR 3.3, 95% CI 1.3-8.1; OR 3.7, 95% CI 1.4-9.8; OR 3.3, 95% CI 1.1-10.2, respectively) and major adverse cardiac events (OR 2.2, 95% CI 1.0-4.7; OR 3.7, 95% CI 1.7-8.2; OR 2.7, 95% CI 1.1-7.2, respectively). To further control for selection bias, the propensity score was computed based on the major risk factors of 12 patients. An analysis of covariance model, adjusted for the propensity score, also confirmed the MMU prosthesis to be strongly associated with elevated mean transvalvular gradients during the six-month follow up period (p < 0.0001). CONCLUSION: The study results clearly demonstrated a favorable hemodynamic function as shown by lower transvalvular gradients of the bovine pericardial Edwards Perimount Magna compared to the porcine Medtronic Mosaic Ultra aortic valve prosthesis.

[Experience and learning curve with transapical aortic valve implantation]. / Erfahrungen und Lernkurve mit der transapikalen Aortenklappenimplantation.

BACKGROUND AND PURPOSE: Transapical transcatheter aortic valve implantation has emerged as an alternative to conventional aortic valve replacement in high-risk patients with degenerative aortic valve stenosis. The aim of this study was to assess a potential learning curve with the former technique based on the own experience with this novel procedure. PATIENTS AND METHODS: 40 consecutive high-risk patients (82 +/- 5 years, logistic EuroSCORE 42% +/- 16%) with symptomatic aortic valve stenosis underwent transapical aortic valve implantation (balloon expandable Sapien bioprosthesis, Edwards Lifesciences, Irvine, CA, USA) in the hybrid operating room between October 2007 and May 2009 at the West German Heart Center Essen. To assess a potential learning curve, patients were allocated and compared according to the implantation date (initial n = 20: 10/2007 to 10/2008; second n = 20: 11/2008 to 05/2009). RESULTS: All but one transapical aortic valve implantations were successful (procedural success rate 97.5%) and no prosthesis migration/embolization or coronary artery obstruction was observed. Comparing the groups, procedural time, fluoroscopy time, and contrast media volume decreased significantly (139 +/- 30 min vs. 112 +/- 41 min; 6.8 +/- 1.9 min vs. 5.5 +/- 1.5 min; 226 +/- 75 ml vs. 169 +/- 23 ml; p

Thrombophilia in cardiac surgery-patients with symptomatic factor V Leiden.

BACKGROUND AND AIM OF THE STUDY: Thrombophilia may cause severe complications in cardiac surgical patients. We analyzed our experience with symptomatic factor V Leiden patients. METHODS: Over an eight-year period, 14 symptomatic patients previously diagnosed with activated protein C resistance,caused by factor V Leiden, underwent a cardiac surgical procedure. We retrospectively reviewed the clinical data, operative and postoperative courses, and the intermediate-term results of these patients. RESULTS: Procedures performed were coronary artery bypass grafting (CABG, 10 patients), aortic valve replacement+ CABG, pulmonary thromboendarterectomy, left ventricular thrombus removal, and aortic valve reconstruction(one patient each). Eleven patients survived; three patients died perioperatively, one from sepsis (25 days after surgery), one from recurrent stroke (28 days after surgery), and one from multiorgan failure following perioperative stroke (31 days after surgery). In one patient, all bypass grafts occluded intraoperatively.Three patients underwent cardiac surgery under continuous anticoagulation with phenprocoumon. In these three patients, no perioperative thromboembolic events occurred. At a mean follow-up of 32 months,three patients had suffered from cerebral stroke, two from graft occlusion, of which one was recurrent. Two more patients had died (one after cerebral stroke and one from cerebral metastases of a renal cell carcinoma). CONCLUSION: In 14 patients with symptomatic factor V Leiden who underwent cardiac surgery, we observed a considerable number of fatal and nonfatal thromboembolic events in the perioperative period and during a 32 months' follow-up. As conducted in three patients, continued anticoagulation with coumarin was safe and prevented perioperative thromboembolic events.

Tricuspid valve repair in acute endocarditis in a young patient with active IV drug abuse.

Right-sided infective endocarditis is common in patients who use intravenous drugs. However, even when leaflets are heavily damaged as a result of the endocarditis, an attempt of valve repair is worth a try. Tricuspid valve repair is superior to valve replacement because it is associated with  a lower rate of recurrence and reoperation.

New postoperative conduction abnormalities after the implantation of a rapid-deployment aortic valve prosthesis.

OBJECTIVES: Sutureless and rapid-deployment aortic valves have enlarged the selection of prostheses available for surgical aortic valve replacement. However, the rate of postoperative pacemaker implantation seems to have increased. METHODS: In addition to pacemaker implantation, we were interested in the incidence of new postoperative conduction abnormalities, namely left bundle branch block, right bundle branch block and atrioventricular block III after the implantation of the EDWARDS INTUITY Elite™ sutureless prosthesis. All patients undergoing isolated or concomitant surgical aortic valve replacement between May 2014 and May 2017 were included in the study. RESULTS: Two hundred patients were operated on. Of them, 14 patients dropped out because of concomitant endocardial or epicardial ablation or because of septal myectomy. Three more patients dropped out because the treatment was converted to conventional aortic valve replacement, and 183 patients remained. At the time of discharge from hospital, 38.1% of the 183 patients had new left bundle branch block, 2.5% of patients had new right bundle branch block and 9.6% had atrioventricular block III requiring either a pacemaker or defibrillator. The postoperative mean transvalvular gradient over the prosthesis was 8.4 ± 3.4 mmHg, the occurrence of paravalvular leakage more than trivial was 1% and hospital mortality was 3.3%. CONCLUSIONS: The incidence of new postoperative conduction abnormalities is considerable with the EDWARDS INTUITY Elite rapid-deployment aortic valve prosthesis. We will focus our future research on the follow-up of patients with postoperative left bundle branch block, which was the most frequently observed form of new conduction abnormality.

Coronary artery bypass surgery and acute kidney injury--impact of the off-pump technique.

BACKGROUND: Acute kidney injury (AKI) is a serious and frequent complication after coronary artery bypass grafting (CABG). Cardiopulmonary bypass (CPB) was identified as a major AKI risk factor after CABG. Our aim was to assess the impact of the off-pump coronary artery bypass (OPCAB) compared to the on-pump coronary artery bypass (ONCAB) technique on the rate and severity of AKI, while taking other risk factors for AKI into account. METHODS: An observational study of 201 consecutive adult patients was conducted; 100 were operated by the OPCAB and 101 by the ONCAB technique. All patients in each group were operated by a single, experienced surgeon. Fifteen pre-, intra- and postoperative variables that were repeatedly identified in previous studies as independent AKI risk factors were included in this analysis. AKI was defined as an increase of serum creatinine >/=50% or >/=0.3 mg/dL within 48 h and AKI severity was classified, according to current AKIN definitions. RESULTS: Significantly fewer OPCAB patients developed AKI compared to ONCAB (14.0 versus 27.7%; P = 0.03). OPCAB was associated with milder stages of AKI, whereas ONCAB patients had more severe AKI. Congestive heart failure and chronic kidney disease were independent risk factors for AKI. The OPCAB technique for CABG was identified as the only independent factor associated with lower incidence of AKI. CONCLUSIONS: Using current AKI definitions and classifications, the OPCAB technique for CABG, which avoids CPB; was associated with a significantly lower rate and less severe AKI compared to ONCAB. The OPCAB technique was identified as the only modifiable and potentially protective factor against postoperative AKI.

Contrast-enhanced cardiac MRI before coronary artery bypass surgery: impact of myocardial scar extent on bypass flow.

The aim of the study was to relate the extent of myocardial late gadolinium enhancement (LGE) in cardiac MRI to intraoperative graft flow in patients undergoing coronary artery bypass graft (CABG) surgery. Thirty-three CAD patients underwent LGE MRI before surgery using an inversion-recovery GRE sequence (turboFLASH). Intraoperative graft flow in Doppler ultrasonography was compared with the scar extent in each coronary vessel territory. One hundred and fourteen grafts were established supplying 86 of the 99 vessel territories. A significant negative correlation was found between scar extent and graft flow (r = -0.4, p < 0.0001). Flow in grafts to territories with no or small subendocardial scar was significantly higher than in grafts to territories with broad nontransmural or transmural scar (75 +/- 39 vs. 38 +/- 26 cc min(-1); p < 0.0001). In summary, the extent of myocardial scar as defined by contrast-enhanced MRI predicts coronary bypass graft flow. Beyond the probability of functional recovery, preoperative MRI might add value to surgery planning by predicting midterm bypass graft patency.

Protection of the right ventricle from ischemia and reperfusion by preceding hypoxia.

We have previously shown that 2 weeks of hypoxia protect the right ventricle of the rat heart from subsequent ischemia and reperfusion (I/R). In the present study, we examined the following: (1) Do shorter periods of hypoxia protect from subsequent I/R? (2) Does intermittent normoxia increase the cardioprotective effect? (3) Is hypoxia-inducible factor-1alpha (HIF-1alpha), erythropoietin (EPO), or vascular endothelial growth factor (VEGF) involved in the protective effects? Preischemic cardiac work was followed by global ischemia, reperfusion, and postischemic cardiac work (15 min each). External heart work was determined at the end of both work phases. Four groups of hearts were investigated: hearts from normoxic rats (n=8), hearts from rats after 24 h of continuous hypoxia (10.5% inspired oxygen, n=7), hearts from rats after 24 h hypoxia with a single intermission of 30 min normoxia (n=9), and hearts from rats after 24 h hypoxia and multiple intermissions of 30 min normoxia (n=7). Protein levels of HIF-1alpha and mRNA levels of EPO and VEGF were determined in right ventricular tissue of normoxic and hypoxic hearts. Postischemic right heart recovery was better in all three hypoxic groups compared with normoxic hearts (61.8 +/- 5.9%, 65.6 +/- 3.0%, and 75.7 +/- 2.6% vs. 46.0 +/- 3.9%, p < 0.01). Hypoxia with multiple normoxic intermissions further improved right heart recovery compared to continuous hypoxia (p < 0.05). HIF-1alpha protein levels were 80.3 +/- 2.5 pg/microg in normoxic hearts and 108.0 +/- 10.3 pg/microg in hypoxic hearts (p = 0.02). No differences in EPO and VEGF mRNA levels were found between normoxic and hypoxic hearts. Twenty-four hours of continuous hypoxia protect the isolated working right heart from subsequent ischemia and reperfusion. When preceding hypoxia is interrupted by multiple reoxygenation periods, there is a further significant increase in cardiac functional recovery. HIF-1alpha may be involved in the protective effect.

Atrial myxoma: minimally invasive surgical approach and application of cryoablation to prevent recurrence.

The strategy for the successful removal of gigantic myxoma of the left atrium obstructing inflow into the left ventricle is presented. We consider an anterolateral minithoracotomy approach superior to median sternotomy for complete and comfortable atrial tumour excision because of the excellent exposure and the cosmetic outcome. After removal, local cryodestruction of potential remnant cells is mandatory to prevent recurrency.

Massive Left Atrial Thrombus in Two Patients with Heparin-Induced Thrombocytopenia Type II after Cardiac Surgery.

Heparin-induced thrombocytopenia type II (HIT type II) can have devastating consequences in cardiac surgical patients. We report two cases of massive left atrial thrombus after mitral valve replacement and endocardial cryoablation in patients with HIT type II.