Isolated Minimally Invasive Mitral Valve Surgery in Octogenarians: Perioperative Outcome.

INTRODUCTION: Despite the feasibility, safety, and excellent outcomes of mitral valve surgery through a right mini-thoracotomy, there is data paucity about its use in octogenarians. In this study, we assess the outcomes of mitral valve surgery via right mini-thoracotomy in octogenarians. METHODS: We performed a retrospective analysis of the in-hospital perioperative data of 38 octogenarian patients with severe mitral regurgitation undergoing isolated mitral valve surgery via right mini-thoracotomy from 2013 to 2021 in our institution. RESULTS: The median patient age was 82 (81-83) years, and the median EuroSCORE II was 3.1% (2.3-4.9). A total of 19 (50%) patients underwent mitral valve repair. The median cardiopulmonary bypass duration was 78 (54-100) min and the median aortic cross-clamping duration was 57 (40-70) min. Two (5.3%) patients were converted to sternotomy, 1 (2.6%) underwent renal replacement therapy, 5 (13.2%) underwent reexploration for bleeding or tamponade, and 12 (31.6%) underwent permanent pacemaker implantation. The surgical repair success rate was 89.5%, with 2 (10.5%) patients requiring reoperation due to repair failure. No other patients required reoperation on the mitral valve. The median intensive care unit stay was 1 (1-2) day, and the median postoperative stay was 9.5 (8-14) days. There was no perioperative stroke or death. CONCLUSION: Despite a relatively increased risk of pacemaker implantation and reexploration for bleeding, our data support the feasibility of mitral valve surgery via a right mini-thoracotomy in octogenarians, with short ischemic times, low overall in-hospital morbidity, and no mortality. Preferring replacement in mitral diseases with a high risk for repair failure could minimize reoperations in this high-risk subgroup.

Thrombocytopenia after Implantation of the Perceval, Intuity, and Sapien Aortic Valve Prostheses.

BACKGROUND: An increased incidence of thrombocytopenia was reported after implantation of the LivaNova Perceval and the Edwards Sapien aortic valve bioprostheses. Aim of this study is to assess the perioperative platelet count and bleeding complications in three different types of aortic valve bioprostheses intended for high-risk patients, the sutureless LivaNova Perceval, the rapid deployment Edwards Intuity, and the transcatheter Edwards Sapien. METHODS: We performed a retrospective analysis of the perioperative data of patients receiving the Perceval, Intuity, and Sapien aortic valve bioprosthesis. The platelet count was collected preoperatively, at nadir postoperatively, and at discharge. The bioprostheses were compared for between-group differences in platelet count and postoperative bleeding complications. RESULTS: Overall, 37 patients received the Perceval, 42 the Intuity, and 58 the Sapien bioprosthesis. There was no significant between-group difference in the preoperative platelet count [Perceval 203(178-246)G/l, Intuity 214(190-232)G/l, Sapien 201(178-275)G/l, p = 0.800]. There was a significant between-group difference in the postoperative platelet count, both at nadir value [Perceval 57(37-80)G/l, Intuity 91(73-109)G/l, Sapien 126(105-170)G/l, p < 0.0001] and at discharge [Perceval 150(83-257)G/l, Intuity 239(200-343)G/l, Sapien 232(179-284)G/l, p = 0.001]. There was no significant between-group difference regarding red blood cell transfusions (p = 0.242), platelet transfusions (p = 0.656), and rethoracotomy for bleeding (p = 0.847). CONCLUSION: We found a significant platelet count reduction in all three bioprostheses which was more marked in the Perceval group. The platelet count reduction was transient and fully recovered in the Intuity and Sapien groups, whereas the Perceval group showed only a partial platelet count recovery. However, bleeding complications were not different between the three bioprostheses.

Ejection Fraction Recovery after Coronary Artery Bypass Grafting for Ischemic Cardiomyopathy.

BACKGROUND: Controversy exists about left ventricular systolic function recovery after coronary artery bypass grafting in patients with ischemic cardiomyopathy. The aim of this study is to evaluate the temporal evolvement of left ventricular systolic function after coronary artery bypass surgery in patients with ischemic cardiomyopathy. PATIENTS AND METHODS: A total of 50 patients with coronary artery disease and left ventricular ejection fraction (LVEF) ≤35% underwent isolated coronary artery bypass grafting in a single center in the period 2017 to 2019. We performed a retrospective analysis of the echocardiographic and clinical follow-up data at 3 months and 1 year postoperatively. RESULTS: Median LVEF preoperatively was 25% (20-33%), mean patient age was 66 ± 8.2 years, 33 (66%) patients were operated off-pump, and 22 (44%) procedures were non-elective. There was no in-hospital myocardial infarction, stroke, and repeat revascularization. Three (6%) patients underwent re-exploration for bleeding or tamponade. In-hospital mortality was 8% and 1-year mortality was 12%. At 1 year postoperatively, there was no repeat revascularization, no myocardial infarction, 1 (2.6%) patient had a transient ischemic attack, and 10 (20%) patients required an implantable defibrillator. There was a statistically significant median ejection fraction increase at 3 months (15% [5-22%], p < 0.0001) and 1 year (23% [13-25%], p < 0.0001) postoperatively, with an absolute increase ≥10% in 32 (74.4%) and 30 (78.9%) patients at 3 months and 1 year, respectively. CONCLUSION: Patients with ischemic cardiomyopathy undergoing coronary artery bypass surgery show continuous recovery of left ventricular systolic function in the first postoperative year.

Aortic Root Replacement with Reimplantation of the Aortic Valve: A Low-Volume Center Experience.

BACKGROUND: Most data after root replacement with reimplantation of the aortic valve originate from high-volume centers. This raises concerns about the generalizability of these data and the reproducibility of this complex procedure. Aim of this study is to assess the perioperative and midterm outcomes of this procedure in a low-volume center. METHODS: We performed a retrospective analysis of the data of 72 patients, who underwent root replacement with reimplantation of the aortic valve in a single center between 2011 and 2020. Time to event analysis was performed with Kaplan-Meier curves. Longitudinal analysis of serial echocardiographic data was performed with a mixed-effects ordinal logistic regression model. RESULTS: In-hospital mortality was 1.4%, with absence of any neurological events during the perioperative period. At midterm follow-up, two further patients died. Overall survival rates at 1 and 5 years were 98.5% (95% confidence interval [CI]: 97-100%) and 96.3% (95% CI: 93.8-98.8%), respectively. During follow-up, five patients (6.9%) required reoperation on the aortic valve. The incidence of moderate and severe aortic regurgitation at 5 years was 6.6% (95% CI: 2.4-13.6%) and 0.6% (95% CI: 0.1-3.2%), respectively. Mild aortic regurgitation at hospital discharge (p < 0.001) and cusp plication (p = 0.0121) were associated with a higher incidence of moderate or severe aortic regurgitation at follow-up. CONCLUSION: Reimplantation of the aortic valve is safe and feasible even in a low-volume center. Mortality, freedom from reoperation, and incidence of moderate or severe aortic regurgitation at follow-up are comparable to those of high-volume centers.

Aortic valve replacement in patients with preexisting liver disease: Transfemoral approach with favorable survival.

INTRODUCTION: The treatment of aortic stenosis has been revolutionized by transcatheter aortic valve replacement (TAVR), but the experience in patients with liver disease is limited. To address this open question, we report the outcome of patients with liver disease undergoing surgical aortic valve replacement (SAVR), transapical (TA), and transfemoral (TF) TAVR. METHODS AND RESULTS: Between January 2004 and August 2016, 4,394 patients received aortic valve replacement at our institution. We identified 85 patients (mean follow-up 504 ± 733 days, age 73.4 ± 9.2 years, 44.7% female) with preexisting liver disease (median model of end-stage liver disease score 11, MELD-Na), who underwent TF-TAVR (n = 30), TA-TAVR (n = 13), or SAVR (n = 42). Baseline Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) and of Mortality and Morbidity (STS-PROMM) were the lowest in SAVR patients (related to TF- and TA-TAVR, both p < 0.01). Operative mortality (18.8%) was high, but no procedure showed superior short-term outcome. Need for renal replacement therapy (31.5% vs. 10.3%, p = 0.046) and reoperation occurred more frequently after SAVR than after TF-TAVR (26.6% vs. 6.7%, p = 0.021). Moreover, TF-TAVR patients had superior long-term survival compared to SAVR (log-rank test p = 0.048 and Cox regression adjusted for MELD and STS-PROM, p = 0.01, HR 0.25, CI95 0.09-0.71). Baseline MELD-Na (p = 0.013) and STS PROMM (p = 0.01) were predictors for operative mortality (ROC-analysis). CONCLUSIONS: Our results indicate increased perioperative risks for patients with liver disease undergoing AVR, but favorable long-term survival after TF-TAVR compared to SAVR. For baseline risk, stratification in patients with liver disease undergoing AVR, MELD-Na and STS-PROMM are valuable predictors.

Post/preprocedural ratio of hemodynamically assessed aortic regurgitation index as a marker for the need for corrective measures during transcatheter valve replacement: A first confirmatory study in patients receiving a new generation transcatheter self-expandable prosthesis.

OBJECTIVES: We aimed to investigate the value of post/preprocedural aortic regurgitation index (ARI) ratio as a marker for more-than-mild aortic regurgitation (AR) after transcatheter aortic valve replacement (TAVR) and as an indication of the need for corrective measures, provided that the implantation depth was acceptable. BACKGROUND: Post/preprocedural ARI increases accuracy of residual AR assessment by considering hemodynamic status prior to TAVR. METHODS: ARI ratio was calculated in 70 patients undergoing TAVR. ARI ratios were defined as post/preprocedural ARI (ARI ratio 1), and as postcorrective measure/preprocedural ARI (ARI ratio 2). Intraprocedurally, corrective measures use was decided based on angiographically assessed AR severity. The relationship of such decisions to ARI ratios based on a recently proposed threshold (ARI ratio < 0.6) was evaluated. ARI ratios in corrected versus noncorrected patients and precorrection versus postcorrection values were assessed. RESULTS: Overall, mean (±SD) ARI ratio 1 (n = 70) was 0.81 (±0.36). Corrective measures were used in 22 patients (31.4%). Mean ARI ratio 1 in such patients was 0.55 (±0.25) versus 0.93 (±0.34) in the 48 noncorrected patients (P < 0.0001). Mean ARI ratio 1 in 21 patients requiring postdilation was 0.56 (±0.25), which was below the previously suggested 0.6 threshold. After postdilation, ARI ratio 2 increased to 0.85 (±0.16) (P < 0.0001), with all patients showing an ARI ratio 2 ≥ 0.6. CONCLUSIONS: ARI ratio is closely related to intraprocedural decisions to perform corrective measures based on angiography. Routine use of intraprocedural ARI ratio could be useful as a complementary quantitative marker for residual AR and for the need for corrective measures.

Moderate Hypothermic Circulatory Arrest (≥ 28°C) with Selective Antegrade Cerebral Perfusion for Total Arch Replacement with Frozen Elephant Trunk Technique.

OBJECTIVES: The optimal hypothermic level during circulatory arrest in aortic arch surgery remains controversial, particularly in frozen elephant trunk (FET) procedures. We describe herein our experience for total arch replacement with FET technique under moderate systemic hypothermic circulatory arrest (≥ 28°C) during selective antegrade cerebral perfusion. METHODS: Between January 2009 and January 2016, 38 consecutive patients underwent elective total arch replacement for various aortic arch pathologies with FET technique using the E-vita Open hybrid prosthesis (Jotec GmbH, Hechingen, Germany). Selective unilateral or bilateral cerebral perfusion under moderate systemic hypothermic circulatory arrest (28.7°C ± 0.5°C) was used in all patients. Minimally invasive total arch replacement with FET via partial upper sternotomy was performed in 15 patients (39%) and in the remaining 23 patients (61%) via full sternotomy. Mean late follow-up was 3 ± 2 years and was 98% complete. Clinical data were prospectively entered into our institutional database. RESULTS: Cardiopulmonary bypass time accounted for 198 ± 58 minutes and the myocardial ischemic time 109 ± 29 minutes. Selective antegrade cerebral perfusion time was 55 ± 6 minutes. Lower body circulatory arrest time was 39 ± 11 minutes. Unilateral cerebral perfusion was performed in 31 patients (82%), and bilateral in 7 patients (18%). Intensive care unit stay was 4 ± 3 days. Thirty-day mortality was 5% (n = 2). Late survival at 3 years was 87 ± 3%. Two patients (5%) required reexploration for bleeding. Patients were discharged after a hospital length of stay of 7 ± 2 days. Postoperative permanent neurologic complication occurred in two patients (5%). Three patients (8%) experienced a transient neurologic disorder. New transient renal replacement therapy was necessary in three patients (8%). No spinal cord injury was noted. CONCLUSIONS: Our data suggest that moderate systemic hypothermic circulatory arrest (≥ 28°C) in combination with antegrade cerebral perfusion can safely be applied for total aortic arch replacement with FET and offers sufficient neurologic and visceral organ protection.

Is More than One Hour of Selective Antegrade Cerebral Perfusion in Moderate-to-Mild Systemic Hypothermic Circulatory Arrest for Surgery of Acute Type A Aortic Dissection Safe?

OBJECTIVES: Surgery for acute type A aortic dissection (AAD) remains a surgical challenge with considerable risk of morbidity and mortality. Antegrade cerebral perfusion (ACP) has been popularized, offering a more physiologic method of brain perfusion during complex aortic arch repair, often necessary in setting of AAD. The safe limits of this approach under moderate-to-mild systemic hypothermic circulatory arrest (≥ 28°C) are yet to be defined. Thus, the current study investigates our clinical results after surgical treatment for AAD in patients with a selective ACP and systemic circulatory arrest time of ≥ 60 minutes in moderate-to-mild hypothermia (≥ 28°C). METHODS: Between January 2000 and April 2016, 63 consecutive patients underwent surgical treatment for AAD employing selective ACP during moderate-to-mild systemic hypothermia (≥ 28°C) with prolonged ACP and circulatory arrest times. Patients' mean age was 59 ± 15 years, and 39 patients (62%) were men. Hemiarch replacement and total arch replacement were performed in 13 (21%) and 50 (79%) patients, respectively. Frozen elephant trunk, arch light, and elephant trunk technique were performed in nine (14%), six (10%), and three patients (5%), respectively. Clinical data were prospectively entered into our institutional database. Mean late follow-up was 6 ± 4 years and was 98% complete. RESULTS: Cardiopulmonary bypass time accounted for 245 ± 81 minutes and the myocardial ischemic time accounted for 140 ± 43 minutes. Mean duration of ACP was 74 ± 12 minutes. The mean lowest core temperature accounted for 28.9 ± 0.8°C. Unilateral ACP was performed in 44 patients (70%); bilateral ACP was used in the remaining 19 patients (30%). Intensive care unit stay reached 6 ± 5 days. New onset of acute renal failure requiring hemofiltration was observed in 8% of patients (n = 5). New postoperative permanent neurologic deficits were found in five patients (8%) and transient neurologic deficits in six patients (10%). There was one case of paraplegia. Thirty-day mortality and in-hospital mortality were 8 (n = 5) and 11% (n = 7), respectively. Overall survival at 5 years was 76 ± 9%. CONCLUSION: Our preliminary data suggest that selective ACP during moderate-to-mild systemic hypothermic circulatory arrest (≥ 28°C) can safely be applied for more than 1 hour even in the setting of AAD.

Linear Closure of the Left Ventricular Apex Following Transcatheter-Based Aortic Valve Implantation.

Transcatheter-based aortic valve implantation (TAVI) provides a reliable and attractive alternative to the established gold standard of classic aortic valve replacement in patients with severe comorbidities carrying an unacceptably high perioperative risk. Despite the minimally invasive nature of the transfemoral approach, the transapical route remains an attractive alternative allowing antegrade valve deployment. Purse-string sutures with interrupted Teflon pledgets represent the classic approach for secure closure of the transapical access site. We describe herein a simple yet effective and time-saving linear technique for apical closure following transapical TAVI.

Multiple electrode aggregometry for the assessment of acquired platelet dysfunctions during extracorporeal circulation.

BACKGROUND: There have been many reports on how the usage of extracorporeal circulation (ECC) is independently associated with the induction of platelet dysfunctions. The aim of the present investigation was to study the capability of the multiple electrode aggregometry (MEA) using the Multiplate (Roche AG, Grenzach, Germany) device to reflect the extent of ECC-associated platelet dysfunctions. PATIENTS AND METHODS: The study population consisted of patients who were treated with either hypothermic (cardiopulmonary bypass [CPB]) or normothermic (extracorporeal membrane oxygenation) ECC. Hemostatic analyses included conventional laboratory coagulation tests and aggregometric measures following stimulation with different agonists using MEA. The area under the aggregation curve in the ADPtest (ex vivo adenosine diphosphate induced platelet aggregation) of the MEA was defined as the primary end point. The analyses were performed before the usage of ECC (baseline) and 90 minutes (T1), 120 minutes (T2), 150 minutes (T3), and 180 minutes (T4) after the usage of ECC. In the hypothermic ECC group, additional hemostatic analyses were performed after the patient's postoperative admission to the intensive care unit (T5). Periprocedural data and results of other hemostatic testing were defined as secondary end points. RESULTS: A total of n = 40 patients were assessed for eligibility and n = 25 patients were finally enrolled into the study (hypothermic ECC group: n = 20; normothermic ECC group: n = 5). The extent of ADP-induced platelet aggregation decreased significantly between baseline and consecutive measuring points during hypothermic ECC and remained unchanged between T4 and T5. In the normothermic ECC group, ADP-induced aggregability was significantly lower at T1 compared with baseline and remained unchanged from T1 onward. CONCLUSION: Data from the present study indicate that ex vivo ADP-induced platelet aggregation in MEA reflects the time-dependent extent of ECC-induced platelet dysfunction.

Long-term follow-up of minimally invasive cardiac surgery using an endoaortic occlusion system.

OBJECTIVES: We reviewed the initial patient series (n=116) of our institution performing minimally invasive coronary artery bypass grafting (CABG) (n=79), mitral valve surgery (n=1), or atrial septal closure (ASD) procedures (n=26) using an endoaortic occlusion system. With this technique relevant intra-aortic pressures are exerted on the aortic wall during the clamping time. This might lead to late aortic degeneration and aneurysm formation. Our study sought to evaluate postoperative aortic complications and the quality of life (modified SF-12). METHODS: One hundred sixteen patients (56% male; 54 years ± 14.5; range 19 years to 77 years) underwent a cardiac procedure using an endoaortic clamp. The endoaortic balloon clamp catheter was used to occlude the ascending aorta at pressures >300 mmHg. Patients were rescheduled for echocardiographic examination after a mean follow-up period of 8.8 years. RESULTS: The analysis performed among 78 patients showed no incidence of any structural damage to the ascending aorta at the intraoperative position of the endoaortic balloon. The physical and mental summary scores are equal to those of comparable patient groups. CONCLUSIONS: The endoaortic occlusion system causes no damage to the aortic wall. If the system causes any problems, they occur immediately during surgery. Patients treated with this minimally invasive technique exhibited the same quality of life as those undergoing conventional surgery.

Less invasive replacement of aortic root, ascending aorta and hemiarch via partial upper sternotomy: a propensity-score-matched comparison with full sternotomy.

OBJECTIVES: Less invasive surgery has emerged as an option for aortic pathologies. The current study compared our experience on early postoperative results of patients with aortic surgery between partial upper sternotomy (PUS) and full sternotomy (FS). METHODS: We performed a retrospective analysis of the data of patients undergoing aortic root surgery with concomitant ascending aorta and hemiarch replacement. Exclusion criteria were type A aortic dissection and other concomitant major cardiac surgery. After propensity score matching, we compared the perioperative outcomes of patients undergoing surgery with PUS versus FS. RESULTS: A total of 161 patients operated on between January 2013 and September 2022 met the inclusion criteria (PUS: n = 22, FS: n = 139). Propensity score matching yielded 22 pairs with a balanced distribution of propensity scores and covariates between the compared groups. There was no evidence that PUS affects cardiopulmonary bypass [108 (67-119) vs 113 (87-148) min, P = 0.154; PUS vs FS] and circulatory arrest duration [9 (7-10) vs 9 (8-13) min, P = 0.264; PUS vs FS]. There was a reduced cross-clamp duration in the PUS group [88 (58-96) vs 92 (71-122) min, P = 0.032]. Cumulative sum charts have shown consistently low cross-clamp and circulatory arrest duration for 2 experienced surgeons who performed 20 of the procedures in the PUS group (10 each). Perioperative mortality and morbidity were low, with no in-hospital mortality in the PUS group [0 vs 1(4.5%), P > 0.999] and absence of strokes in both groups. CONCLUSIONS: In summary, our initial experience suggests that less invasive aortic root, ascending aorta and hemiarch replacement via PUS could be performed in our patient cohort as safely as via full sternotomy. Advantages for the patient are reduced surgical trauma, improved cosmetic results and-presumably-less pain.

Navigating the challenges of minimally invasive mitral valve surgery: a risk analysis and learning curve evaluation.

BACKGROUND: This study aimed to report the risk and learning curve analysis of a minimally invasive mitral valve surgery program performed through a right mini-thoracotomy at a single institution. METHODS: From January 2013 through December 2019, 266 consecutive patients underwent minimally invasive mitral valve surgery in our department and were included in the current study. Multiple logistic regression analysis was used for the adverse event outcome. Distribution over time of perioperative complications, defined as clinical endpoints in the Valve Academic Research Consortium-2 (VARC-2) consensus document, as well as CUSUM charts for assessment of cardiopulmonary bypass and aortic cross-clamping duration over time, has been performed for learning curve assessment. RESULTS: Overall incidences of postoperative stroke (1.1%), myocardial infarction (1.1%), and thirty-day mortality (1.5%) were low. The mitral valve reconstruction rate in our series was 95%. Multivariable analysis revealed that concomitant tricuspid valve surgery (OR 4.44; 95%CI 1.61-11.80; p = 0.003) was significantly associated with adverse event outcomes. Despite a trend towards adverse event outcomes in patients with preexisting active mitral valve endocarditis (OR 2.69; 95%CI 0.81-7.87; p = 0.082), mitral valve pathology did not significantly impact postoperative morbidity and mortality. Distribution over time of perioperative complications, defined as clinical endpoints in the VARC-2 consensus document, showed a trend towards an improved complication rate after the initial 65-100 procedures. CONCLUSIONS: Mitral valve surgery via right-sided mini-thoracotomy can be implemented safely with low perioperative morbidity and mortality rates. Careful patient selection regarding isolated mitral valve surgery in the presence of degenerative mitral valve disease may represent a significant safety issue during the learning curve. TRIAL REGISTRATION: The cantonal ethics commission of Zurich approved the study (registration ID 2020-00752, date of approval 24 April 2020).

External stenting for saphenous vein grafts reduces early postoperative graft failure.

OBJECTIVES: Multiple studies have shown that external stenting (ExSt) mitigates the progression of vein graft disease years after coronary artery bypass grafting (CABG). We used computed tomography to evaluate the effect of ExSt on perioperative vein graft patency. METHODS: This study assessed graft patency rates of saphenous vein grafts (SVG) in consecutive patients with isolated coronary artery bypass grafting (CABG) between 2018 and 2021. Logistic regression analyses were conducted to compare the outcomes of supported and non-supported groups at both patient and graft levels, with age, EuroSCORE II, gender, diabetes and arterial grafts as covariates. Subgroup analyses were performed based on different covariates. The goal of the study was to provide valuable insights into the clinical outcomes of SVG in patients having CABG. RESULTS: The study examined a total of 357 patients who met the inclusion criteria and evaluated 572 vein grafts. Of these, 150 patients (205 SVGs) received ExSt, whereas 207 patients (337 SVGs) did not receive ExSt. The study results indicated that the likelihood of overall SVG patency at discharge was higher in the stented group than in the non-stented group, both at the level of the grafts [93.8% vs 87.8%, odds ratio (OR) 2.1; 95% confidence interval (CI) 1.0-4.5; P = 0.05] and at the patient level (90.1% vs 83.5%, OR 1.8; 95% CI 0.9-3.6; P = 0.1). It is worth noting that the difference between the stented and non-stented groups was most significant in the subgroup that received 2 arterial grafts (96.5% vs 89.6%, OR 3.2; 95% CI 1.2-8.4; P = 0.02) and in the subgroup with a higher EuroSCORE II (median >1.1) (98.6% vs 88.6%, OR 8.8; 95% CI 1.1-72.7; P = 0.04). CONCLUSIONS: The ExSt is associated with improved perioperative SVG patency at both the graft and the patient levels. Moreover, SVGs to the right territory and high-risk patients appear to have an advantage using ExSt.

Chronic poststernotomy pain after cardiac surgery: correlation of computed tomography findings on sternal healing with postoperative chest pain.

BACKGROUND: The aim of this study was to correlate CT findings on sternal healing to late postoperative chest pain after median sternotomy. METHODS: 71 patients with a mean age of 69 ± 8.4 years were examined by CT-scan for normal or imperfect sternal healing at a mean follow-up time of 1.4 ± 1.6 years. Patients completed a questionnaire for chest and shoulder pain using a multidimensional pain score and visual analog scale. RESULTS: Total 48 patients showed complete and 23 incomplete sternal healing. Although pain incidence was insignificantly higher after incomplete then after complete sternal healing (56.5% vs. 43%) pain intensity in the regions of chest and shoulder was almost equal between the two groups. Yet patients with a dehiscence over 3 mm in width had a significant higher chest pain intensity (17.5 ± 20 mm) compared with patients with a minor dehiscence (3.7 ± 8, mm p = 0.04) and those with normal sternal healing (8.1 ± 16 mm, p = 0.05). Furthermore, a dehiscence in more than one sternal segment led to a significantly higher pain intensity (chest: 18.8 ± 26 mm, shoulder: 23 ± 24 mm) compared with a dehiscence localized in only one segment (chest: 8.1 ± 18 mm, p = 0.04, shoulder: 4.6 ± 8.7 mm, p = 0.037). CONCLUSION: In general, there is only a weak correlation between late postoperative chest pain and quality of sternal reunion. However, with an extent of failed sternal reunion over a width of 3 mm and the presence of imperfect ossification in more than one segment of the sternum, a significant increase of pain intensity in the regions of chest and shoulder was observed.

Simple and controlled method to avoid hyperperfusion of the right arm following axillary artery cannulation for extracorporeal membrane oxygenator support.

The right axillary artery has become the cannulation site of choice for establishment of extracorporeal membrane oxygenator support in many centers. Dissection and cannulation of this vessel are simple and safe in the majority of patients. Typically, a side graft is used to avoid malperfusion of the right arm. Although this protocol offers many advantages, a common complication is the critical hyperperfusion of the right arm. Subsequent compartment syndrome and decline of antegrade inflow of oxygenated blood, especially into the brain and coronary arteries, can be life threatening in such critical patients. We describe herein a simple yet effective and controlled technique to avoid this particular problem.

Extracorporeal membrane oxygenation for influenza-associated acute respiratory distress syndrome.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) therapy for patients with influenza A (H1N1)-related acute respiratory distress syndrome (ARDS) has been described once all other therapeutic options have been exhausted. The current report reviews our institutional experience and lessons learned in 18 consecutive patients. METHODS: Between December 2009 and March 2011, 18 patients underwent ECMO therapy for severe H1N1-related ARDS. Mean age was 40 ± 18 years (range 4-67 years). Ten patients (56%) received venoarterial cannulation (v-a ECMO) while venovenous cannulation (v-v ECMO) was initiated in the remaining patients (n = 8, 44%). To identify risk factors of adverse outcome, univariate analysis was performed for clinical parameters. RESULTS: Successful ECMO weaning was possible in 44% (n = 8) of patients and overall mortality was 61% (n = 11). Seven of the eight patients who could be successfully weaned from ECMO support fully recovered. Survival within the v-a ECMO group (60%) was superior to the v-v ECMO group (13%; p = 0.06). Two patients (11%) required re-exploration of the axillary artery cannulation site. No further adverse events associated with ECMO implantation occurred. Outcome was better when the time of severe deoxygenation (Pao2 < 70 mm Hg) despite maximally invasive respiratory support to ECMO implantation was less than 6 hours (odds ratio: 2.4; p = 0.05). CONCLUSIONS: ARDS associated with H1N1 remains a devastating clinical picture. In our hands, ECMO support offered survival to 40% of patients with otherwise fatal prognosis. While v-v ECMO remains the method of choice for patients suffering an isolated ARDS in the setting of stable hemodynamic conditions, v-a ECMO may be considered if the clinical picture of ARDS is aggravated by systemic inflammatory response syndrome with the requirement of high dose vasopressor support.

[Update Valvular Heart Disease: Heart Team Decision-Making Based on Patient Examples]. / Update valvuläre Herzkrankheiten: Entscheidungen im interdisziplinären Herzteam anhand von Beispielen.

INTRODUCTION: In Europe, mitral regurgitation and aortic stenosis are the most common valve lesions requiring interventions. In advanced stages, these valve pathologies affect patients' quality of life and prognosis. The prevalence of mitral regurgitation and aortic stenosis is increasing with age. In view of an aging population and the comorbidities associated with age, these valve defects represent an increasing challenge to health care providers. Nowadays, surgical as well as catheter-based treatment options are available to treat affected patients. Therapeutic strategies suitable to the individual patient should be discussed in interdisciplinary heart teams. The aim of the present article is to give an overview of possible guideline-conform heart team decisions based on patient examples.

Beyond Conventional Operations: Embracing the Era of Contemporary Minimally Invasive Cardiac Surgery.

Over the past two decades, minimally invasive cardiac surgery (MICS) has gained a significant place due to the emergence of innovative tools and improvements in surgical techniques, offering comparable efficacy and safety to traditional surgical methods. This review provides an overview of the history of MICS, its current state, and its prospects and highlights its advantages and limitations. Additionally, we highlight the growing trends and potential pathways for the expansion of MICS, underscoring the crucial role of technological advancements in shaping the future of this field. Recognizing the challenges, we strive to pave the way for further breakthroughs in minimally invasive cardiac procedures.

Conversion from off-pump to on-pump coronary artery bypass grafting: impact of surgeon and anaesthetist experience.

OBJECTIVES: Intraoperative conversion from off-pump to on-pump coronary artery bypass grafting (CABG) is associated with increased postoperative morbidity and mortality. The aim of this study is to assess the impact of surgeon and anaesthetist experience on the conversion rate. METHODS: We performed a retrospective analysis of the data of all patients who underwent planned off-pump CABG in a single centre in 2007-2021, some of whom were non-electively converted to on-pump. Surgeon and anaesthetist experience were assessed by the number of off-pump bypass procedures per year. Multivariable logistic regression analysis was used to assess the impact of surgeon and anaesthetist experience on conversion rate. RESULTS: A total of 2742 patients met the inclusion criteria. Ninety-four (3.4%) patients underwent non-elective conversion to on-pump surgery. Converted patients had significantly higher mortality [11 (11.7%) vs 35 (1.3%), P < 0.0001] in comparison to non-converted patients. Anaesthetist experience was found to be a risk factor for conversion (P = 0.011). Surgeon experience did not significantly affect conversion rate (P = 0.51). Other risk factors for conversion were female gender [odds ratio 2.65 (95% confidence interval 1.65-4.26), P = 0.0001] and left ventricular ejection fraction ≤35% [odds ratio 1.91 (95% confidence interval 1.05-3.49), P = 0.040]. CONCLUSIONS: Conversion from off-pump to on-pump CABG is associated with worse postoperative outcomes. Limited experience of anaesthetists in off-pump bypass surgery is associated with a higher conversion rate.