Simple Technique for Central Venous Cannulation with Cannula-Free Wound in Minimally Invasive Aortic Valve Surgery.

There are several approaches to venous cannulation in minimally invasive aortic valve surgery. Frequently used options include central dual-stage right atrial cannulation, or peripheral femoral venous cannulation. During minimally invasive aortic surgery via an upper hemisternotomy, central venous cannulas may obstruct the surgeon's visualization of the aortic valve and root, or require extension of the skin incision, while femoral venous cannulation requires an additional incision, time and resources. Here we describe a technique for central venous cannulation during minimally invasive aortic surgery, utilizing a novel device, to facilitate simple, convenient, and expedient central cannulation with a cannula-free surgical working space.

Global perspectives on cardiothoracic, cardiovascular, and cardiac surgical training.

OBJECTIVE: Various methods for cardiothoracic, cardiovascular, and cardiac surgical training exist across the globe, with the common goal of producing safe, independent surgeons. A comparative analysis of international training paradigms has not been undertaken, and our goal in doing so was to offer insights into how to best prepare future trainees and ensure the health of our specialty. METHODS: We performed a comparative analysis of available publications offering detailed descriptions of various cardiothoracic, cardiovascular, and cardiac surgical training paradigms. Corresponding authors from previous publications and other international collaborators were also reached directly for further data acquisition. RESULTS: We report various approaches to common challenges surrounding (1) selection of trainees and plans for the future surgical workforce; (2) trainee assessments and certification of competency before independent practice; and (3) challenges related to a changing practice landscape. CONCLUSIONS: Cardiothoracic surgery remains a dynamic and rewarding specialty. Current and future trainees face several challenges that transcend national borders. To foster collaboration and adoption of best practices, we highlight international strengths and weaknesses of various nations in terms of workforce selection, trainee operative experience and assessment, board certification, and preparation for future changes anticipated in cardiothoracic surgery.

Ministernotomy aortic valve surgery in patients with prior patent mammary artery grafts after coronary artery bypass grafting.

OBJECTIVES: Patients with patent internal thoracic artery (ITA) grafts after prior coronary artery bypass grafting surgery who require aortic valve replacement (AVR) pose unique technical challenges for safe and optimal myocardial protection. The purpose of this study is to review our short- and long-term outcomes with redo minimally invasive AVR in patients with patent in situ ITA grafts. METHODS: From 2008 to 2016, 48 patients with at least 1 patent in situ mammary artery graft underwent minimally invasive AVR. Preoperative computed tomography was performed in all patients to evaluate the relationship of patent grafts to the sternum. Retrograde coronary sinus and pulmonary vent catheters were placed via the right internal jugular vein. The in situ ITA grafts were not clamped during AVR. Transverse aortotomy, taking care to avoid the grafts arising from the aorta, was performed to expose the aortic valve. RESULTS: The median age of the patients was 78 years [Quartile 1 (Q1)-Quartile 3 (Q3): 71-81]. Thirty-nine (81%) patients were men, and 46 (96%) patients had aortic stenosis. The median cardiopulmonary bypass and cross-clamp times were 124 (Q1-Q3: 108-164) and 92 (Q1-Q3: 83-116) min, respectively. Moderate hypothermia at 28-30°C was used in all patients. Most patients received cold blood cardioplegia with antegrade induction and continuous retrograde delivery. Four patients received only retrograde delivery due to some degree of aortic insufficiency. Thirty-day mortality was 4% (2 of 48 patients). There was no conversion to full sternotomy, and no reoperations were performed for postoperative bleeding or sternal wound infection. Excluding the 2 patients who died in the hospital, the median postoperative length of stay was 7 days (Q1-Q3: 5-8). Overall survival at 1, 5 and 10 years was 94%, 87% and 44%, respectively. CONCLUSIONS: Percutaneous retrograde cardioplegia combined with antegrade cardioplegia and moderate hypothermia, without interruption of ITA flow, is a safe and reliable strategy in patients with patent ITA grafts undergoing aortic valve replacement. This strategy combined with a minimally invasive approach may reduce surgical trauma, and is a safe and effective technique in these challenging patients.

Perioperative avulsion of a left internal mammary artery graft in a patient with syphilis.

Avulsion of a graft after coronary artery bypass grafting surgery is a rare but very serious complication which leads to massive bleeding and possible life-threatening cardiac tamponade. In this paper we report a very rare case of a left internal mammary artery graft avulsion on the day of surgery in a patient with syphilis.

Does posterior pericardiotomy reduce the incidence of atrial fibrillation after coronary artery bypass grafting surgery?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether posterior pericardiotomy (PP) reduces the incidence of atrial fibrillation (AF) after coronary artery bypass grafting surgery. Twelve papers were found using the reported search, of which seven represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers were tabulated. One non-randomized prospective cohort controlled study generated early evidence that PP reduced the rate of postoperative AF and pericardial effusion. The operative details of PP were clearly explained in this paper. The efficacy of this procedure was subsequently examined in five prospective randomized controlled trials performed with some limitations, listed in the table. Meta-analysis of the randomized control trials examined a group of 763 patients (PP = 389, control = 374). It revealed a highly significant reduction in total arrhythmias and AF in the PP group (odds ratio 0.31 and 0.33, respectively). There was a 10.8% AF rate in the PP group (41/379) and a 28.1% AF rate in the control group (108/384). Furthermore, the PP group had a significant reduction in the rate of early and late pericardial effusion (P < 0.001). Moreover, the reduction in the incidence of arrhythmias was significantly associated with the reduction in the incidence of pericardial effusion. Referring to these studies, two guidelines recommend PP to reduce postoperative AF with grade B strength of recommendation. We conclude that PP significantly reduces the incidence of postoperative AF. The number needed to treat to prevent one case of AF is six.