First Experiences with MANTA Vascular Closure Device in Minimally Invasive Valve Surgery.

BACKGROUND: To more minimize the minimally invasive valve surgeries, percutaneous vascular access and closure has been used for the establishment of extracorporeal circulation. This study investigates early clinical outcomes of patients who received MANTA for femoral artery closure as first experiences in minimally invasive valve surgery. METHODS: Between January 2019 and July 2019, 103 consecutive patients (mean age: 58 ± 11 years) underwent video-assisted minimally invasive valve surgery through right anterior minithoracotomy at two cardiac surgery referral centers in Germany. Percutaneous cannulation for cardiopulmonary bypass and femoral artery closure with MANTA were performed in all patients: 18-F and 14-F MANTA were used in 88 (85.4%) and 15 (14.6%) patient, respectively. Mitral, aortic, tricuspid, and double valve surgeries were performed in 51 (49.5%), 39 (37.9%), 7 (6.8%), and 6 (5.8%), patients, respectively. Clinical data were prospectively entered into our institutional database. RESULTS: Cardiopulmonary bypass time and cross-clamping time were 69 ± 23 and 38 ± 14 minutes, respectively. Except for two patients with late pseudoaneurysm on 15th and 23th postoperative day, neither major nor minor vascular complications nor vascular closure device failure according to the Valve Academic Research Consortium-2 definition criteria was observed. Additionally, no wound healing disorders or conversion to surgical closure was observed. CONCLUSIONS: MANTA as percutaneous femoral artery closure after decannulation of cardiopulmonary bypass is a safe, feasible, and effective approach and yields excellent early outcomes. Larger size studies are needed to evaluate more the efficacy and safety of MANTA.

Longer-term outcomes after bicuspid aortic valve repair in 142 patients.

BACKGROUND: The aim of this study was to evaluate the longer-term results of bicuspid aortic valve (BAV) repair with or without aortic root replacement. METHODS: From 1999 to 2017, 142 patients with or without aortic root dilatation who underwent repair of a regurgitant BAV were included in the study. Ninety-four patients underwent isolated BAV repair (Group 1; median age 43 years) and 48 patients underwent valve-sparing aortic root replacement plus BAV repair (aortic valve reimplantation-Group 2; median age 48 years). Median clinical follow-up time was 5.9 years (range 0.5-15) in Group 1 and 3 years (range 0.5-16) in Group 2, respectively. RESULTS: In-hospital mortality was 1% in Group 1, and 2% in Group 2 (p = .6). The 5- and 10-year survival was 93 ± 2.9% and 81 ± 5.8% in Group 1 and 96 ± 3.1% and 96 ± 3.1% in Group 2, respectively (p = .31). Eleven patients of Group 1 (1.7%/patient-year) and five patients of Group 2 (2.2%/patient-year) underwent reoperation of the aortic valve (p = .5). The 5- and 10-year freedom from reoperation were 93.0 ± 2.1% and 77.1 ± 7.1% in Group 1 and 93.0 ± 5.0% and 76.7 ± 9.6% in Group 2 (p = .83), respectively. At the latest follow-up, only two patients of Group 1 and 1 patient of Group 2 had AV regurgitation = 2° (p = .7). The cumulative linearized incidence of all valve-related complications (bleeding, stroke, endocarditis, and reoperation) was 2.9%/patient-year in Group 1% and 4%/patient-year in Group 2, respectively (p = .6). CONCLUSIONS: Isolated BAV repair and combined aortic valve reimplantation plus BAV repair provide good clinical longer-term outcomes with relatively low reoperation rate and durable valve function.

Midterm Results of a Minimally Invasive Approach in David Procedure.

BACKGROUND: The David procedure is a well-known technique in selected patients with aortic root pathology. A minimally invasive approach in heart surgery increases open interest. METHODS: From 1991 to 2015, the David technique was performed in 296 patients in our unit. In 90 cases, operations were performed through partial upper sternotomy. The patient mean age was 57 ± 14 years in the minimally invasive group (n = 90) and 58 ± 14 years in the complete sternotomy group (n = 206; p = 0.2). The neosinus modification was performed in 80 patients (89%) in the minimally invasive group and in 79 patients (38%) in the complete sternotomy group (p < 0.01). Mean follow-up was 3 ± 2 years in the minimally invasive group and 8 ± 4 years in the complete sternotomy group. RESULTS: Thirty-day mortality was zero in the minimally invasive group and was 3% (n = 6) in the complete sternotomy group (p = 0.1). The need for packed red blood cells was significantly lower in the minimally invasive group (1.6 ± 3 U) than in the complete sternotomy group (3.7 ± 6 U; p < 0.01). Thirty late deaths (2% per patient-year) were observed in the complete sternotomy group versus zero in the minimally invasive group (p < 0.01). One patient (0.5% per patient-year) in the minimally invasive group and 12 patients (0.8% per patient-year) in the complete sternotomy group required reoperation in the follow-up period (p = 0.05). CONCLUSIONS: Minimally invasive David technique for patients with ascending aortic aneurysm and aortic valve insufficiency offers a good solution with low perioperative blood transfusion rate. Our midterm results show low valve-related complications and reoperation rate. However, long-term follow-up of the minimally invasive group is necessary.

Mid-Term Clinical Outcome of Patients Undergoing Coronary Artery Bypass Grafting with Valvulotomized Vein Grafts.

BACKGROUND: The lower patency rate of vein grafts (VG) in comparison to arterial grafts may be related to vein valves, which favor turbulences and thrombosis that lead to graft failure. The aim of this study was to determine the outcome of patients with valvulotomized VG after coronary artery bypass grafting (CABG) procedure. METHODS: From 2007 to 2014, 233 patients with a mean age of 67 ± 9 years had CABG or combined CABG and valve procedures. Valvulotomized saphenous VG and arterial grafts were used. Clinical follow-up and outcome were evaluated after 6.3 ± 2 years. The graft patency was rated with multislice computed tomography in 57 patients and coronary angiography in 29 patients 3.1 ± 2 years postoperatively. RESULTS: Overall, 168 patients had segregated CABG surgery, and 65 patients received additional procedures, with mean 2.7 ± 1 arterial and 1.5 ± 0.7 venous anastomoses. The 30-day-mortality in isolated CABG patients was 2%. Survival at five years was 80%. Major adverse cardiac and cerebrovascular events (MACCE) free rate at five years was 80%. At the last follow up (mean 6.3 years), 94% of the patients were in Canadian Cardiovascular Society (CCS) class 0. The quote of patent valvulotomized VG was 96.1% compared to a patency rate of 96.7% for the arterial grafts in the subgroup undergoing angiography or computed tomography of the heart. CONCLUSION: Our data demonstrate good mid-term results of graft patency, and comparable clinical results in patients undergoing CABG with valvulotomized VG. A longer follow-up period and a higher number of bypass graft imaging examinations are necessary to affirm our results.

One-Year Patency of Valvulotomized Vein Grafts Is Similar to That of Arterial Grafts.

BACKGROUND: Inferior vein graft patency after coronary artery bypass grafting (CABG) is attributed to various factors. Venous valves may limit flow, cause thrombus formation, and diminish diastolic backflow. The aim of our study was to compare clinical outcome and midterm patency rate of valvulotomized vein grafts and arterial grafts in patients undergoing CABG. METHODS: Between 2007 and 2010, valvulotomized saphenous vein segments were used to graft the right coronary artery (RCA) in 147 patients undergoing CABG with mean 2.8 ± 1 arterial and 1.5 ± 0.6 venous anastomoses. Outcome, reintervention, and reoperation were assessed after 4 ± 1.6 years. Intraoperative bypass flow rate was measured before and after valvulotomy of venous bypass grafts in 12 patients. Patency of the grafts was assessed by means of multislice computed tomography (MSCT) in 45 patients. RESULTS: A total of 102 patients underwent isolated CABG and 45 had combined procedures. In-hospital mortality was 2%. At 4 years' clinical follow-up, 95% of the patients were asymptomatic. Five patients underwent recoronary angiography because of angina pectoris. The MSCT and reangiography patency rate of all valvulotomized saphenous vein grafts was 97.1 versus 95.8% of arterial grafts 18 ± 6 months postoperatively. Intraoperative measurements showed a significant increase (+20.2 mL/min; p = 0.01) of flow in the venous bypass grafts to the RCA after valvulotomy. There were no reoperations at the latest follow-up. CONCLUSION: Patients with valvulotomized venous grafts had good clinical outcome. The one-year patency rate of those grafts is comparable to that of arterial grafts. However, long-term results and angiography studies will be needed to strengthen these findings.

Can Perioperative Right Ventricular Support Prevent Postoperative Right Heart Failure in Patients With Biventricular Dysfunction Undergoing Left Ventricular Assist Device Implantation?

OBJECTIVES: Depending on the pre-existing condition of the right ventricle (RV), left ventricular assist device (LVAD) implantation may have a detrimental effect on RV function, subsequently leading to right heart failure. This study details the authors' experience with perioperative mechanical RV support in patients with biventricular impairment but primarily scheduled for isolated LVAD implantation. DESIGN: Retrospective study. SETTING: Two center study, university hospital. PARTICIPANTS: This study included LVAD recipients with preoperative biventricular impairment who received an additional right ventricular assist device (RVAD) after a failed weaning attempt from cardiopulmonary bypass due to acute RV failure. INTERVENTIONS: Outcomes of 25 patients who underwent LVAD and unplanned temporary RVAD implantation were analyzed. MEASUREMENTS AND MAIN RESULTS: All patients experienced significant preoperative RV impairment (tricuspid annular plane systolic excursion: 10.2±26.3 mm; right atrium pressure: 17.9±10.4 mmHg) and pulmonary hypertension (pulmonary artery pressure: 54.8±25.7 mmHg). In 15 patients, additional tricuspid valve annuloplasty was performed. Mean duration of temporary RVAD support was 11.1±7.2 days. In 23 patients (92%), the RVAD was removed successfully. None of the patients developed RV failure after RVAD removal. Hospital survival and the 1-year survival rate of the study group were 68% and 56%, respectively. CONCLUSIONS: The results of perioperative RVAD support in LVAD recipients with biventricular dysfunction are encouraging. Temporary RVAD support allows an already compromised RV to become attuned to the hemodynamic conditions after LVAD implantation. This strategy provides patients with preoperative impaired RV function a high likelihood to permanently undergo LVAD support only.

Aortic valve reimplantation for aortic root aneurysms: trainer and trainee differences on long-term results.

PURPOSE: The advantages of aortic valve-preserving surgery are still hampered by a higher rate of reoperations compared to root replacement with valved conduits. This study evaluates whether valve deterioration rate is related to the method or depends on stringent adherence to technical concepts, which might be lost once trainees perform this complex surgery on their own. METHODS: From 1991 to 2011, the David procedure was performed in 209 consecutive patients. Mean age was 57 ± 14 years. The patients were operated either by the senior author or trainees under his supervision (group 1, n = 130) or by surgeons on their own after training by the senior author (group 2, n = 79). Clinical and echocardiography data were evaluated pre- and postoperatively and at follow-up (mean 6.0 ± 4 years). RESULTS: In-hospital mortality was 1.5 % in group 1 and 5 % in group 2 (p = 0.29), and late mortality was 12 % (n = 12 in group 1 and n = 14 in group 2, p = 0.11), three were cardiac related. Nine patients (4.3 %) had to be reoperated; three for endocarditis in group 1, six for structural valve deterioration in group 2 (p = 0.14). The 9-year freedom from reoperation or aortic valve insufficiency (AI) ≥2° was 93 % in group 1 and 78 % in group 2 (p < 0.01). As groups showed differences in preoperative variables, results were compared also in a propensity matched subgroup. Despite no difference in perioperative results, long-term valve competence remained inferior in group 2. CONCLUSIONS: With stringent adherence to technical concepts, structural valve deterioration may virtually be considerably reduced in aortic valve reimplantation. Once performing this operation on their own, trainees-after training by the senior-achieved results as independent surgeons well comparable to published series. As long-term performance seems to depend more on judgment of the geometry achieved intraoperatively than on technical steps, a means of measurement of effective coaptation height with a caliper might facilitate evaluation of perfect repair.

Hematologic Effects of Heart Valve Prostheses and Vascular Grafts after Aortic Root Replacement.

BACKGROUND: Heart valve prosthesis as well as vascular grafts cause changes in blood parameters. This may correlate with valve-related complications, less frequently observed after repair surgery. We thus studied changes in rheology after Bentall, Ross, or Tirone David (TD) procedure. METHODS: Seventeen patients underwent a TD, 17 patients underwent a Ross, and 16 patients underwent a Bentall procedure. Venous blood samples were collected 4 ± 3 (TD), 4 ± 3 (Ross), and 6 ± 3 years mean (Bentall) postoperatively. Concentrations of fibrinogen, leucocytes, platelets, haptoglobin, hemoglobin, lactate dehydrogenase (LDH), bilirubin, hematocrit, and ß-thromboglobulin were determined. Platelet function and activity were analyzed. Results were compared with those of healthy control subjects. RESULTS: Level of fibrinogen was higher in the Bentall than in the other two groups (338 ± 63 vs. 298 ± 43 Ross and 308 ± 48 mg/dL TD, p > 0.05). LDH was also elevated in the Bentall group (311 ± 45 vs. 205 ± 30 Ross, p < 0.01 and 203 ± 34 U/l TD, p < 0.01). Platelet count and haptoglobin levels were significantly reduced in the Bentall (190 ± 43/nL, 2.4 ± 1 mg/dL) and TD groups (183 ± 52/nL, 89 ± 57 mg/dL) in comparison to the control group (250 ± 86/nL, 140 ± 53 mg/dL) with p < 0.05, whereas there were no significant differences in the Ross group (214 ± 47/nL and 129 ± 54 mg/dL) in comparison to the control group. Leucocyte count and platelet function showed no significant differences between the groups. CONCLUSION: Polyester ascending aortic prostheses and more pronounced when combined with a prosthetic aortic valve cause hematologic changes compared with minimal deviations in Ross patients. We observed mild hemolysis, a decreased platelet count, and an increase in fibrinogen level in patients after conduit root replacement compared with procedures retaining an autologous aortic valve at midterm follow-up.

Evaluation of monoenergetic late iodine enhancement dual-energy computed tomography for imaging of chronic myocardial infarction.

OBJECTIVES: To evaluate image quality and diagnostic accuracy of selective monoenergetic reconstructions of late iodine enhancement (LIE) dual-energy computed tomography (DECT) for imaging of chronic myocardial infarction (CMI). METHODS: Twenty patients with a history of coronary bypass surgery underwent cardiac LIE-DECT and late gadolinium enhancement (LGE) magnetic resonance imaging (MRI). LIE-DECT images were reconstructed as selective monoenergetic spectral images with photon energies of 40, 60, 80, and 100 keV and the standard linear blending setting (M_0.6). Images were assessed for late enhancement, transmural extent, signal characteristics and subjective image quality. RESULTS: Seventy-nine myocardial segments (23 %) showed LGE. LIE-DECT detected 76 lesions. Images obtained at 80 keV and M_0.6 showed a high signal-to-noise ratio (15.9; 15.1), contrast-to-noise ratio (4.2; 4.0) and sensitivity (94.9 %; 92.4 %) while specificity was identical (99.6 %). Differences between these series were not statistically significant. Transmural extent of LIE was overestimated in both series (80 keV: 40 %; M_0.6: 35 %) in comparison to MRI. However, observers preferred 80 keV in 13/20 cases (65 %, κ = 0.634) over M_0.6 (4/20 cases) regarding subjective image quality. CONCLUSIONS: Post-processing of LIE-DECT data with selective monoenergetic reconstructions at 80 keV significantly improves subjective image quality while objective image quality shows no significant difference compared to standard linear blending. KEY POINTS: Late enhancement dual-energy CT allows for detection of chronic myocardial infarction. Monoenergetic reconstructions at 80 keV significantly improve subjective image quality. 80 keV and standard linear blending reconstructions show no significant differences. Extent of CMI detected with LIE-DECT is overestimated compared with MRI.

Anesthesia for Minimal Invasive Cardiac Surgery: The Bonn Heart Center Protocol.

The development and adoption of minimally invasive techniques has revolutionized various surgical disciplines and has also been introduced into cardiac surgery, offering patients less invasive options with reduced trauma and faster recovery time compared to traditional open-heart procedures with sternotomy. This article provides a comprehensive overview of the anesthesiologic management for minimally invasive cardiac surgery (MICS), focusing on preoperative assessment, intraoperative anesthesia techniques, and postoperative care protocols. Anesthesia induction and airway management strategies are tailored to each patient's needs, with meticulous attention to maintaining hemodynamic stability and ensuring adequate ventilation. Intraoperative monitoring, including transesophageal echocardiography (TEE), processed EEG monitoring, and near-infrared spectroscopy (NIRS), facilitates real-time assessment of cardiac and cerebral perfusion, as well as function, optimizing patient safety and improving outcomes. The peripheral cannulation techniques for cardiopulmonary bypass (CPB) initiation are described, highlighting the importance of cannula placement to minimize tissue as well as vessel trauma and optimize perfusion. This article also discusses specific MICS procedures, detailing anesthetic considerations and surgical techniques. The perioperative care of patients undergoing MICS requires a multidisciplinary approach including surgeons, perfusionists, and anesthesiologists adhering to standardized treatment protocols and pathways. By leveraging advanced monitoring techniques and tailored anesthetic protocols, clinicians can optimize patient outcomes and promote early extubation and enhanced recovery.

Short-Term Clinical Results of Minimally Invasive Direct Coronary Artery Bypass (MIDCAB) Procedure.

Objectives: Minimally invasive direct coronary artery bypass (MIDCAB) is an alternative for revascularisation of the isolated left anterior descending (LAD) artery or as a multi-vessel (MV) procedure for the diagonal branch (RD) or the left circumflex coronary artery (LCX) region. Methods: From 2021 to 2022, 91 patients underwent MIDCAB or multi-vessel MIDCAB procedures in our heart center. The left internal mammary artery (LIMA) was anastomosed to the left anterior descending artery via the left minithoracotomy approach in all patients. Results: Of the patients, a total of 86.8% were male. Eighty percent of the patients had two- or three-vessel coronary artery disease. The mean age was 65.1 ± 10.1 years. The mean operation time was 2.6 ± 0.8 h. The 30-day mortality was 0. The mean required packed red blood cells (pRBC) was 0.4 ± 1.2 unit. The mean intensive care unit stay (ICU) was 1.5 ± 1.6 days. The mean follow-up time was 1.5 ± 0.5 years. One patient received percutaneous coronary intervention due to de novo stenosis of the RCA. Late mortality was 2.2%. The Kaplan-Meier survival rate was 98.8% at 1 and 2 years. Conclusions: The postoperative complication rate of our MIDCAB cohort is low, and the short-term survival is favorable. Our postoperative and short-term clinical results demonstrate that this procedure is safe and feasible.

Comparison of Two Surgical Approaches for Coronary Artery Bypass of Left Anterior Descending Artery.

Background/Objectives: The minimally invasive approach through left mini-thoracotomy is a promising alternative to the median sternotomy for coronary artery bypass. The aim of this study was to compare the short-term outcomes of patients undergoing minimally invasive coronary artery bypass (MIDCAB) with off-pump coronary artery bypass through sternotomy (OPCAB) for single-vessel disease. Methods: From January 2017 to February 2023, 377 consecutive patients aged above 18 years undergoing off-pump bypass of the left anterior descending artery (LAD) with left internal thoracic artery underwent OPCAB. Propensity score matching was then applied. Primary endpoints were in-hospital mortality and 30-day mortality. Results: Prior to matching, 30-day mortality occurred in 2 (0.7%) patients in the MIDCAB group vs. 1 (1%) patient in the OPCAP group (p = 1). Transfusion of red blood cells (RBC) was required in 9.4% and 29% of patients within the MIDCAB and the OPCAB groups, respectively (p < 0.001). Median intensive care stay (ICU) was 1 [1-2] day in the MIDCAB group, vs. 2 [1-3] in the OPCAB (p < 0.001). In the matched cohort, 10% of MIDCAB patients received RBCs vs. 27.5% of OPCAB patients (p = 0.006). Median ICU stay was significantly lower in the MIDCAB group, 1 [1-2] vs. 2 [1-3] days. Conclusions: MIDCAB is as safe and effective as OPCAB for single coronary artery bypass of the LAD with the LITA in select patients. It is associated with a decreased ICU stay and lower transfusion rates when compared with OPCAB.

The CX3C chemokine fractalkine mediates platelet adhesion via the von Willebrand receptor glycoprotein Ib.

The membrane-anchored CX3C chemokine fractalkine (FKN) is expressed on activated endothelium and is associated with the development of atherosclerosis. The potential of FKN in mediating platelet adhesion beyond platelet activation remains unexplored to date. A flow-based adhesion assay was used to study the adhesion of platelets to immobilized FKN under physiologic flow conditions. Platelet adhesion to von Willebrand factor (VWF) was increased in the presence of FKN at 600 inverse seconds. Additional platelet adhesion to FKN coimmobilized with VWF was dependent on the FKN receptor CX3CR1 and activation of glycoprotein (GP) IIb/IIIa. The number of platelets rolling on VWF was likewise enhanced in the presence of FKN. The enhancement of rolling on FKN and VWF was insensitive to anti-CX3CR1 antibody but was fully inhibited by neutralizing GPIbα function. The extracellular domain of GPIbα was covalently coupled to fluorescent microspheres, and microsphere binding was significantly higher in the presence of FKN. Platelet adhesion to activated endothelium in vitro and to intact human arteries was substantially increased in an FKN-dependent manner. These data demonstrate that endothelial expressed FKN activates platelets via its cognate receptor CX3CR1, whereas platelet adhesion is predominantly mediated by GPIbα and independent of CX3CR1.

Hepatocyte growth factor mobilizes non-bone marrow-derived circulating mesoangioblasts.

AIMS: The identification of factors that mobilize subsets of endogenous progenitor cells may provide new therapeutic tools to enhance the repair of ischaemic tissue. We previously identified circulating mesenchymal cells that co-express endothelial markers (so-called circulating mesoangioblasts, cMABs) in children undergoing heart surgery with cardiopulmonary bypass (CPB). However, the mechanisms by which these cells are mobilized and their origin is unclear. METHODS AND RESULTS: Circulating CD73(+)CD45(-)KDR(+) cMABs were analysed in adults undergoing heart surgery with (n = 21) or without CPB (n = 8). During surgery with CPB, cMABs are mobilized with a maximal response at the end of the operation. In contrast, off-pump heart surgery does not stimulate cMAB mobilization, indicating that the stress mediated by CPB induces the mobilization of cMAB. Circulating mesoangioblasts were enriched in blood obtained from the coronary sinus. Histologically, CD73(+) cells were detected around vessels in the heart, indicating that the heart is one of the niches of cMABs. Consistently, studies in gender mismatched bone marrow transplanted patients demonstrated that cMABs did not originate from the bone marrow. Cytokine profiling of serum samples revealed that hepatocyte growth factor (HGF) was profoundly increased at the time point of maximal mobilization of cMABs. Hepatocyte growth factor stimulated the migration of cMABs. Importantly, injection of recombinant HGF increased cMABs in rats. CONCLUSIONS: Hepatocyte growth factor induces mobilization of non-haematopoietic progenitor cells with a cardiac repair capacity. This newly identified function together with the known pleiotrophic effects of HGF makes HGF an attractive therapeutic option for the treatment of ischaemic heart disease.

Postoperative results of minimally invasive direct coronary artery bypass procedure in 234 patients.

Introduction: Minimally invasive approach in cardiac surgery has gained popularity. In order to reduce surgical trauma in coronary surgery minimally invasive direct coronary artery bypass (MIDCAB) has already been established. This technique has been introduced for revascularisation of isolated left anterior descending (LAD). It can also be performed for hybrid revascularisation procedure in multi-vessel disease. Methods: From 2017 to 2021, 234 patients received MIDCAB operation in our heartcenter 73% were male. Most of the patients had two or three vessel disease (74%). The average age of the patients was 66 ± 12 years mean. The left internal mammary artery (LIMA) was anastomosed to the LAD through left minithoracotomy approach. Multi-vessel MIDCAB (MV-MIDCAB) including two anastomoses (T-graft to LIMA with additional saphenous vein graft) was done in 15% (n = 35). Results: The average operation time was 2.3 ± 0.8 h mean. The 30-day mortality was 1.7% (n = 4). The average amount of packed red blood cells (pRBC) that was given intra- and postoperatively was 0.4 ± 0.8 units mean. The mean intensive care unit stay (ICU) was 1 ± 1.2 days. Three patients (1.3%) had wound infection postoperatively. The rate of neurologic complications was 0.4% (n = 1). Two patients (0.9%) had myocardial infarction and received coronary re-angiography perioperatively including stent implantation of the right coronary artery. Discussion: The MIDCAB procedure is a safe and less traumatic procedure for selected patients with proximal LAD lesions. It is also an option for hybrid procedure in multi-vessel disease. The ICU stay and application of pRBC's are low. Our MIDCAB results show a good postoperative clinical outcome. However, follow-up data are necessary to evaluate long-term outcome.

A novel approach for quantification of the future unmet medical need in right ventricular dysfunction.

Although 'unmet medical need' (UMN) is an increasingly used term in the healthcare sector instrumental to the approximate value of drug discovery projects relevant to portfolio management, no standardized approach exists for its quantification. Especially in diseases with different comorbidities, high patient heterogeneity, and incomplete epidemiological data, it is difficult to judge the need for new therapies. The approach presented here combines an expert assessment of key UMN indicators related to the individual patient with a literature search to collect epidemiological data describing the corresponding patient population with its underlying heterogeneity. This assessment supports decision-making within the portfolio management process in larger research and development organizations.

Right minithoracotomy and resternotomy approach in patients undergoing a redo mitral valve procedure.

OBJECTIVES: A minimally invasive approach via a thoracotomy is an alternative in challenging redo cardiac procedures. Our goal was to present our early postoperative experience with minimally invasive cardiac surgery via a right minithoracotomy (minimally invasive) and resternotomy in patients undergoing a mitral valve procedure as a reoperation. METHODS: From 2017 until 2020, reoperation of the mitral valve was performed through a right-sided minithoracotomy in 27 patients and via a resternotomy in 26 patients. Patients with femoral vessels suitable for cannulation underwent a minimally invasive technique. Patients requiring concomitant procedures regarding the aortic valve were operated on via a resternotomy. RESULTS: The mean age was 66 ± 12 years in the minimally invasive group and 65 ± 12 years in the whole cohort. The average Society of Thoracic Surgeons score was 11 ± 10% in the minimally invasive group and 13 ± 9% in all patients. The majority of the patients underwent reoperation because of severe mitral valve insufficiency (48% and 55%, respectively). The mean time to reoperation was 7 ± 9 years (minimally invasive group). The 30-day mortality was 4% in the minimally invasive group and 11% in the whole cohort. The blood loss was 566 ± 359 ml in the minimally invasive group and 793 ± 410 ml totally. There were no postoperative neurological complications in the minimally invasive group and 1 (2%) in the whole cohort. Postoperative echocardiography revealed competent mitral valve/prosthesis function in all patients. CONCLUSIONS: A minimally invasive approach for a mitral valve reoperation in selected patients is a safe alternative to resternotomy with a low transfusion requirement. Both surgical techniques are associated with good postoperative outcomes.

Cardiac metastasis causes paradoxical malignant embolism.

BACKGROUND: Embolic events play an important role in clinical everyday practice. Malignant arterial embolism is a rare nevertheless often fatal entity for cardiac, cerebral or systemic ischemia, requiring immediate diagnosis and treatment. CASE: This is a case report of a 65 years-old female, suffering from pulmonal adenocarcinoma, who was hospitalized due to neurological deficits caused by an acute ischemic stroke, followed by anterior myocardial infarction within 3 days. Diagnostic work-up revealed metastasis of the pulmonal adenocarcinoma in the right atrium and a patent foramen ovale. Histopathological examination of the coronary embolus verified paradoxical arterial embolism of the pulmonal adenocarcinoma into a coronary vessel and consequently cerebral arteries. CONCLUSION: The present case underlines the need for (i), consideration of malignant embolism, (ii) histopathological examination of the embolus to determine its etiology, and (iii) interdisciplinary discussion of individual therapeutic and prevention strategies in cancer patients with cerebral, cardiac or systemic embolic events.

Supra-annular stitch to avoid distortion of the right coronary cusp in aortic root resuspension.

BACKGROUND AND AIM OF THE STUDY: The David procedure has been described in order to preserve the native aortic valve during correction of aortic root aneurysms, and to restore its competence in the case of aortic valve insufficiency. In general, the long-term stability of this procedure is very promising; any recurrence of aortic valve incompetence during follow up can be attributed mainly to a primary suboptimal geometry. METHODS: A distortion of the right coronary cusp was frequently observed after using the technique as originally described. This was due to the base of the right coronary cusp (RCC) being placed deeper in the left ventricular outflow tract than the adherent septal myocardium. By placing the central stitch at the right coronary base supra-annularly, the right coronary base is not rotated outwards after tying. RESULTS: This modification of the David procedure was carried out in 10 patients, with near-perfect valve geometry and competence. CONCLUSION: This technical modification represents a simple and safe way to avoid distortion of the RCC in aortic root resuspension.