Gender-related outcomes after open repair of descending thoracic and thoracoabdominal aortic aneurysms.

OBJECTIVE: Female sex has been associated with greater morbidity and mortality for a variety of major cardiovascular procedures. We sought to determine the influence of female sex on early and late outcomes after open descending thoracic aortic aneurysm (DTA) and thoracoabdominal aortic aneurysm (TAAA) repair. METHODS: We searched our aortic surgery database to identify patients having open DTA or TAAA repair. Logistic regression and Cox regression analyses were used to assess the effect of sex on perioperative and long-term outcomes. RESULTS: From 1997 until 2017, there were 783 patients who underwent DTA or TAAA repair. There were 462 male patients and 321 female patients. Female patients were significantly older (67.6 ± 13.9 years vs 62.6 ± 14.7 years; P < .001), had more chronic pulmonary disease (47.0% vs 35.7%; P = .001) and forced expiratory volume in 1 second <50% (28.3% vs 18.2%; P < .001), and were more likely to have degenerative aneurysms (61.7% vs 41.6%; P < .001). Operative mortality was not different between women and men (5.6% vs 6.2%; P = .536). However, women were more likely to require a tracheostomy after surgery (10.6% vs 5.0%; P = .003) despite a reduced incidence of left recurrent nerve palsy (3.4% vs 7.8%; P = .012). Logistic regression found female sex to be an independent risk factor for a composite of major adverse events (odds ratio, 2.68; confidence interval, 1.41-5.11) and need for tracheostomy (odds ratio, 3.73; confidence interval, 1.53-9.10). Women also had significantly lower 5-year survival. CONCLUSIONS: Women undergoing open DTA or TAAA repair are not at greater risk for operative mortality than their male counterparts are. Reduced preoperative pulmonary function may contribute to an increased risk for respiratory failure in the perioperative period.

AngioVac for extraction of venous thromboses and endocardial vegetations: A meta-analysis.

BACKGROUND: AngioVac is a new device for filtering intravascular thrombi and emboli. Publications on the device are limited and underpowered to objectively estimate its safety and efficacy. We aimed to overcome this by performing a meta-analysis on the results of AngioVac for treating venous thromboses and endocardial vegetations. METHODS: A systematic literature review was performed to identify all articles reporting cardiac vegetation and/or thrombosis extraction using AngioVac. Endpoints were successful removal, operative mortality, conversion to open surgery, hospital stay, recurrent thromboembolism, and follow-up mortality. Random effect model was used, and pooled event rates (PERs) and incidence rate (IR) were calculated. RESULTS: A total of 42 studies with 182 patients (81 vegetation and 101 thrombosis) were included. Overall mean follow-up times were 3.1 and 0.7 years in vegetation and thrombosis patients, respectively. The PERs for successful removal were 74.5 (confidence interval [CI]: 48.2-90.2), 80.5 (CI: 70.0-88.0), and 32.4 (CI: 17.0-52.8) in vegetation, right atrial/caval venous thrombi, and pulmonary emboli (PE) patients, respectively. The PERs for operative mortalities were 14.6 (CI: 7.7-25.8), 14.8 (CI: 8.5-24.5), and 32.3 (CI: 15.1-56.3), respectively. The PERs for conversion to open surgery were 25.0 (CI: 9.3-51.9) and 12.3 (CI: 5.4-25.6) in vegetation and thrombosis patients, respectively. The IR of recurrent thromboembolism was 0.18 per person per year (PPY) (CI: 0.00-14.69) in vegetation and 0.19 PPY (CI: 0.08-0.48) in thrombosis patients. IR of follow-up mortality was 0.37 PPY (CI: 0.11-1.21) in thrombosis patients. CONCLUSIONS: AngioVac is a viable option for extracting right-sided vegetations and right atrial/caval venous thrombi. Rates of successful extraction and mortality are significantly worse for PE.

Sinus of Valsalva aneurysm repairs: Operative technique and lessons learned.

OBJECTIVE: Sinus of Valsalva (SOV) aneurysms are rare and data on operative management are limited. They can cause right ventricular outflow tract or pulmonary artery compression, and rupture may be fatal. In this study, we describe our experience with the repair of 13 SOV aneurysms. METHODS: All patients who underwent SOV aneurysm repair from May 2001 to December 2017 at our single tertiary referral center were reviewed retrospectively. RESULTS: Thirteen patients (92% male) with a mean age of 60 years underwent repair of an SOV aneurysm; mean aneurysm diameter was 5.9 ± 0.8 cm and four patients (30.7%) presented with rupture into another cardiac chamber. Operative interventions included six Bentall procedures, five patch repairs (one with aortic valve replacement [AVR]), and two primary aneurysm closures both with concomitant AVR. There were no strokes, myocardial infarctions, re-explorations, or deaths in the postoperative period. After an average of 2.25 years, computed tomographic imaging in five patients demonstrated no aneurysm recurrence. CONCLUSIONS: Surgery is a safe option for both ruptured and nonruptured SOV aneurysms. A variety of repair strategies may be used. Larger studies are needed.

Pulmonary artery aneurysms: Preoperative, intraoperative, and postoperative findings.

BACKGROUND: Pulmonary artery aneurysms (PAAs) are a rare but potentially lethal cardiovascular pathology. PAAs tend to develop in young patients with no gender discrepancy; they are most often associated with congenital heart disorders but also with systemic infections, vasculitis, pulmonary arterial hypertension, chronic pulmonary embolism, and malignancies. Dissection and rupture carry significant morbidity and mortality, thus patients require careful management, especially those with associated pulmonary hypertension. Given the rarity of this condition, physicians have yet to establish standard treatment guidelines. Most studies published to date are case reports with one or two patients; here, we describe our experience with six cases of large PAAs treated surgically at our institution. METHODS: We identified and retrospectively analyzed clinical data for patients who underwent surgery for PAAs between 2009 and 2017. RESULTS: The average age at surgery was 59.73 years, five patients were females, and 83.3% had baseline hypertension. Systolic murmurs were the most common clinical finding. The average aneurysmal size was 65.0 mm. We repaired the PAA with a woven Dacron graft (22-26 mm) in four patients. We performed concomitant pulmonary valve procedures on five patients: four replacements and one repair. Mean pump and cross-clamp times were 108.5 and 65 minutes. Operative and 30-day mortality was 0%. Average length of stay was 10.5 days. CONCLUSIONS: Postoperative mortality was 0%; all patients showed improvement of symptoms after surgery. These findings confirm that PAA repair has an acceptable risk profile in select patients.

Open repair of descending and thoracoabdominal aortic aneurysms in octogenarians.

OBJECTIVE: Despite improved outcomes for open repair of descending thoracic aneurysm (DTA) and thoracoabdominal aortic aneurysm (TAAA), these operations remain challenging in octogenarians. Patients unsuitable for thoracic endovascular aortic repair require open surgery to avoid catastrophic rupture. We analyzed our results for DTA/TAAA repair in these elderly patients. METHODS: Our institutional aortic database was queried to identify those ≥80 years old and those <80 years old undergoing open DTA/TAAA repair. Logistic and Cox regression analyses were used to account for confounders and to identify predictors of perioperative and long-term outcomes. RESULTS: From 1997 to 2017, there were 783 patients who underwent open repair of DTA or TAAA; 96 (12.3%) were ≥80 years old. Octogenarians were more likely to be female (P = .018), with chronic pulmonary disease (P = .012), severe peripheral vascular disease (P < .001), and hypertension (P = .025). Degenerative aneurysms were more common among octogenarians (P < .001), whereas chronic and acute dissections were more common among those younger than 80 years (P < .001 for both). Operative mortality was 5.6% and was not negatively affected by advanced age (<80 years, 5.7%; ≥80 years, 5.6%; P = .852). Other than an increased incidence of left recurrent nerve palsy in the younger cohort (<80 years, 6.7%; ≥ 80 years, 1.0%; P = .029), there were no significant differences in the incidence of major postoperative complications. Logistic regression modeling showed that age ≥80 years was not predictive of operative mortality or postoperative complications. A greater percentage of octogenarians had aortic reconstruction with a clamp and sew strategy (85.4% vs 61.6%; P < .001), which led to significantly shorter cross-clamp times in this cohort (26.6 minutes vs 30.7 minutes; P < .004). In octogenarians, the incidence of major postoperative adverse events was associated with extent II aneurysms (odds ratio, 2.6; P < .025). Short- and long-term survival was significantly reduced in octogenarians. CONCLUSIONS: In select octogenarians, open repair of DTA/TAAA can be performed with acceptable risk. A simplified surgical approach may provide the best opportunity for a successful outcome.

Editor's Choice - Aortic Re-operation After Replacement of the Proximal Aorta: A Systematic Review and Meta-Analysis.

OBJECTIVE/BACKGROUND: The aim was to estimate risk of aortic re-operation, and re-operative morbidity and mortality, following replacement of the proximal aorta for aneurysm or dissection. METHODS: A meta-analysis was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and the Meta-Analysis of Observational Studies in Epidemiology guidelines. A comprehensive literature review was performed to identify all articles reporting aortic re-operation after proximal aortic replacement. The proximal aorta was defined as extending to the origin of the brachiocephalic trunk. The incidence rate for aortic re-operation (IRAR) was calculated, and stratified based on presence/absence of connective tissue disorders, as well as initial surgical indication. Pooled in hospital mortality and post-operative complication rates were estimated. RESULTS: In total, 7821 patients who underwent proximal aortic replacement from 47 studies were included: 8.3% (n = 649) had Marfan syndrome (MS). During a weighted mean follow up of 4.7 ± 0.3 years, 11.5% (n = 903) underwent aortic re-operation. Mean weighted time between initial surgery and re-operation was 5.2 ± 0.2 years. IRAR was 2.4% per person-year (PPY) (confidence interval [CI] 2.1-2.8%). Patients with MFS had a threefold higher IRAR (6.0% PPY, CI 4.1-8.8%) than did patients without a connective tissue disorders (2.3% PPY, CI 1.9-2.7%; p < .001). IRAR was 2.5% PPY (CI 2.1-3.0%) after operation for dissection and 1.3% PPY (CI 0.9-2.0%) after operation for aneurysm (p = .004 for subgroup differences). IRAR proximal and distal to the left subclavian artery was 1.2% PPY (CI 1.0-1.5%) and 1.3% PPY (CI 1.1-1.6%), respectively. The pooled in hospital mortality and complication rates after re-operation were 14.31% (CI 11.28-17.99%) and 18.08% (CI 10.54-29.25%), respectively. On meta-regression, initial operation for dissection was the only significant predictor of aortic re-operation (beta = .030, p = .001). CONCLUSION: Aortic re-operation occurs at a mean rate of 2.4% per person-year in the five years after proximal aortic replacement and is strongly associated with initial operation for dissection.

Nonbacterial Thrombotic Endocarditis Presenting with Leg Pain and a Left Atrial Mass Lesion.

Systemic lupus erythematosus (SLE) is a major cause of nonbacterial thrombotic endocarditis (NBTE) associated with intracardiac sterile vegetations. It is rare for vegetations to present as an atrial tumor. This report describes a 48-year-old female with SLE and antiphospholipid syndrome complicated by recurrent thrombosis on anticoagulation. A large left atrial mass lesion was detected on echocardiography during a work-up for leg burning. Infective endocarditis could not be confirmed, and hence left atrial mass lesion was the most likely diagnosis. The patient was managed surgically and the pathology report revealed fibrin networks in a pattern similar to that of thrombosis, characteristic of NBTE.

The radial artery: Results and technical considerations.

BACKGROUND: The radial artery (RA) is a frequently used conduit for coronary artery bypass graft (CABG). We review the results of the use of the RA in CABG patients and discuss the unique technical considerations when using this conduit. METHODS: A literature search was performed in PubMed through December 2017 on the comparative efficacy of the RA to other conduits and technical considerations for the use of the RA in CABG surgery. RESULTS: When compared to the saphenous vein graft, the RA proved to be superior in graft patency in multiple randomized clinical trials. The RA was associated with better clinical outcomes in observational studies. The debate over the second best arterial conduit remains unresolved between the RA and the right internal thoracic artery. Preoperative evaluation of the patient's coronary anatomy and the quality of the RA is imperative to achieve the best clinical outcome with RA grafting. CONCLUSION: With careful preoperative planning and attention to technical details, the RA is an excellent choice as the second conduit for CABG surgery.

Coronary artery bypass with single versus multiple arterial grafts in women: A meta-analysis.

OBJECTIVE: The study objective was to investigate the impact of multiple arterial grafting on long-term all-cause mortality in women undergoing isolated coronary artery bypass grafting. METHODS: A comprehensive search was performed to identify observational studies reporting outcomes after coronary artery bypass grafting reported by sex and stratified into multiple arterial grafting versus single arterial grafting strategies. Articles were considered for inclusion if they were written in English and were propensity-matched observational studies. Included studies were then pooled in a meta-analysis performed using the generic inverse variance method. The primary outcome was long-term all-cause mortality. Secondary outcomes were operative mortality and spontaneous myocardial infarction. Meta-regression was used to explore the effects of preoperative and intraoperative variables on the primary outcome. RESULTS: A total of 6 studies with 32,793 women (25,714 single arterial grafting and 7079 multiple arterial grafting) were included. Women who received multiple arterial grafting had lower long-term mortality (incidence rate ratio, 0.86; 95% confidence interval, 0.76-0.96; P = .007) and spontaneous myocardial infarction (incidence rate ratio, 0.80; 95% confidence interval, 0.68-0.93; P = .003) compared with women who received single arterial grafting, but the difference in mortality disappeared when including only the 3 largest studies. There was no difference between groups in operative mortality (odds ratio, 0.99; 95% confidence interval, 0.84-1.17; P = .91). Meta-regression did not identify any associations with the incidence rate ratio for long-term mortality. CONCLUSIONS: The use of multiple arterial grafting in women undergoing coronary artery bypass grafting is associated with lower long-term mortality, although the difference is mostly driven by small series. Further studies, including randomized trials, are needed to evaluate the efficacy of multiple arterial grafting in women undergoing coronary artery bypass grafting.

Impact of ascending aortic prosthetic grafts on early postoperative descending aortic biomechanics on cardiac magnetic resonance imaging.

OBJECTIVES: Among patients with ascending thoracic aortic aneurysms, prosthetic graft replacement yields major benefits but risk for recurrent aortic events persists for which mechanism is poorly understood. This pilot study employed cardiac magnetic resonance to test the impact of proximal prosthetic grafts on downstream aortic flow and vascular biomechanics. METHODS: Cardiac magnetic resonance imaging was prospectively performed in patients with thoracic aortic aneurysms undergoing surgical (Dacron) prosthetic graft implantation. Imaging included time resolved (4-dimensional) phase velocity encoded cardiac magnetic resonance for flow quantification and cine-cardiac magnetic resonance for aortic wall distensibility/strain. RESULTS: Twenty-nine patients with thoracic aortic aneurysms undergoing proximal aortic graft replacement were studied; cardiac magnetic resonance was performed pre- [12 (4, 21) days] and postoperatively [6.4 (6.2, 7.2) months]. Postoperatively, flow velocity and wall shear stress increased in the arch and descending aorta (P < 0.05); increases were greatest in hereditary aneurysm patients. Global circumferential strain correlated with wall shear stress (r = 0.60-0.72, P < 0.001); strain increased postoperatively in the native descending and thoraco-abdominal aorta (P < 0.001). Graft-induced changes in biomechanical properties of the distal native ascending aorta were associated with post-surgical changes in descending aortic wall shear stress, as evidenced by correlations (r = -0.39-0.52; P ≤ 0.05) between graft-induced reduction of ascending aortic distensibility and increased distal native aortic wall shear stress following grafting. CONCLUSIONS: Prosthetic graft replacement of the ascending aorta increases downstream aortic wall shear stress and strain. Postoperative increments in descending aortic wall shear stress correlate with reduced ascending aortic distensibility, suggesting that grafts provide a nidus for high energy flow and adverse distal aortic remodelling.

Surgery for Acute Presentation of Thoracoabdominal Aortic Disease.

Thoracoabdominal aortic aneurysms are most commonly asymptomatic until there is either an impending aortic catastrophe or one that has already occurred. While open surgery remains the gold-standard method for repair, modern technology has led to the development of less invasive endovascular devices and techniques. We provide an expert review of open and endovascular therapies for 3 highly lethal thoracoabdominal aortic emergencies in order to highlight expectations for both short- and long-term outcomes in an era of evolving technology and improvements in patient evaluation and postoperative care. Open repair of ruptured thoracoabdominal aortic aneurysms is associated with a dramatic increase in all postoperative complications, even in specialized aortic surgery centers. Mycotic thoracic aortic aneurysms are highly lethal if surgical treatment is not initiated quickly as they have a propensity toward rapid growth and fatal rupture. Thoracic endovascular aortic repair is well-suited for the treatment of acute complicated type B aortic dissection with outcomes superior to open repair in some centers. Acute aortic events associated with thoracoabdominal aneurysms represent technically challenging situations that require rapid diagnosis and treatment to avoid a fatal outcome. Endovascular techniques have evolved as a viable alternative therapy for acute complicated type B aortic dissection or as a bridge to more definitive repair in the setting of infection or rupture.

A 20-Year Experience With Resection of Primary Cardiac Tumors and Metastatic Tumors of the Heart.

BACKGROUND: Cardiac tumors are uncommon, occurring in less than 1% of the population, and are comprised of numerous tumor types. Management of certain tumors types such as sarcoma have evolved and improved in the recent era. We evaluate the outcomes of patients who underwent resection of benign or malignant cardiac tumors with a focused review of cardiac sarcomas. METHODS: Institutional data were reviewed from 1997 to 2017, and 180 patients who underwent tumor resection were identified. Outcomes and survival were examined based on tumor type. RESULTS: Two-thirds of patients (119 of 180) had benign tumors. Of 61 malignant tumors, 23 were sarcomas, 24 were cavoatrial tumors, and 8 were T4 lung tumors. In the sarcoma group, operative mortality was 2 of 23 (9.1%). Neoadjuvant therapy was administered to 8 of 23 patients (34.8%) with R0 resection achieved in 5 of 8 patients (62.5%). R0 resection was successful in 7 of 15 patients (46.7%) without neoadjuvant therapy. Mean survival with neoadjuvant therapy was 2.76 ± 3.85 years versus 1.28 ± 1.31 years without neoadjuvant therapy (p = 0.428). Mean survival with R0 resection was 2.79 ± 4.23 years compared with 1.64 ± 1.63 years without (p = 0.407). In the T4 lung tumor group, operative mortality was zero and R0 resection was achieved in 6 of 8 (75%). The cavoatrial tumors were mostly renal cell carcinoma resected with a mortality of 4.5%. CONCLUSIONS: Cardiac tumors are comprised of diverse tumor types. Indications for, and benefits of, resecting benign tumors and many malignant tumor types are clear, and operative outcomes are generally good. Cardiac sarcomas benefit from neoadjuvant therapy, which improves the rate of complete resection, thus improving survival.

Surgery for chronic type B dissection with aneurysmal degeneration.

PURPOSE: Open repair of descending thoracic or thoracoabdominal aortic aneurysm (TAAA) continues to carry a not insignificant operative risk, even in experienced hands. Over the past three decades, there has been considerable improvement in both the mortality and morbidity associated with these procedures. Herein, we describe our operative results and long-term outcomes in patients with chronic type B aortic dissections. METHODS: Review of the aortic surgical database was conducted to identify all consecutive patients who underwent repair of TAAA for chronic type B dissection from May 1997 to March 2018. The primary end point was operative mortality with secondary end points as the composite of major adverse events as well as each of the individual complications. RESULTS: One hundred and fifty-three patients met inclusion criteria with 54.9% (84/153) having surgery on an elective basis. The mean age was 58.9 years with a majority of male gender-107/153 (69.9%). Eighty-three (54.2%) of the TAAA were extent I, while 36 (23.5%) were extent II and 34 (22.3%) extent III-IV. Operative mortality was 8.5% (13/153) with eight of the deaths in patients who presented with extent II TAAA. On Kaplan-Meier survival analysis, 87.5% (95% confidence interval (CI) 77.9-97.1%) of the elective cohort were alive after 5 years while only 69.9% (CI 55.2-84.6%) of those in need of urgent/emergency intervention survived (p = .039). CONCLUSIONS: In a majority of patients with chronic type B dissections, reproducibly, excellent outcomes can be achieved with relatively low risk of mortality. In the higher risk subsets of patients with extent II TAAA, careful consideration and discussion of expected outcomes will help inform the decision-making process.

Systematic preoperative CT scan is associated with reduced risk of stroke in minimally invasive mitral valve surgery: A meta-analysis.

BACKGROUND: Minimally invasive mitral valve surgery (MIMVS) is performed with increasing frequency. However, patients undergoing MIMVS might be at increased risk of perioperative stroke, mainly due to retrograde aortic embolization during femoral cardio-pulmonary bypass. Pre-operative computed tomography (CT) screening allows visualization of the aorta and femoro-iliac vessels and individualization of the surgical approach. In this meta-analysis, we aim to determine if systematic pre-operative CT screening is associated with decreased incidence of post-operative stroke and other complications following MIMVS. METHODS: A comprehensive review was performed in PubMed (inception-May 2018). Eligible studies included those which reported on MIMVS (mini-thoracotomy, port access or robotic approach) with retrograde arterial perfusion. Studies were separated into two subgroups: systematic pre-operative CT screening (CT-group) and no CT screening (Non-CT). Pooled event rates (PER) for operative mortality, post-operative stroke, perioperative myocardial infarction (MI), and new onset renal failure requiring dialysis were estimated and inter-group comparisons were performed. RESULTS: Data from 57 studies (13,731 patients) were analyzed (19 CT-group, 38 Non-CT). PER for post-operative stroke was 2.0% with a statistically significant difference between the groups (CT-group: 1.5% versus Non-CT: 2.2%, P = 0.03). PER for new dialysis was 1.9%, significantly lower in the CT-group (0.8% versus 2.3% in the Non-CT group, P = 0.02). PER for operative mortality was 1.4% with a trend towards better outcomes in the CT-group (0.8% versus 1.6% in the Non-CT group, P = 0.05). CONCLUSIONS: Systematic pre-operative CT screening is associated with lower risk of post-operative stroke and need for dialysis and a trend toward lower operative mortality after MIMVS.

Lessons learned from Radial Artery Database International ALliance (RADIAL).

Coronary artery bypass graft (CABG) surgery was first performed in the 1960s. As the surgery has evolved, there has been a growing interest in the use of multiple arterial grafts in CABG. Since the re-introduction of the radial artery (RA) to clinical use as a bypass conduit in the 1990s, there have been several randomized controlled trials (RCTs) which have compared saphenous vein graft (SVG) conduits to RA use in CABG. While most trials have shown improved patency of the RA, none of them have been able to demonstrate a survival benefit using the arterial conduit. In this review, we examine the existing RCTs on the subject. We then look at our solution to the decades-old inquiry regarding the RA compared with the SVG. The Radial Artery Database International ALliance (RADIAL) project is an individual patient-level meta-analysis developed to adequately power a study to assess if the RA has superior clinical outcomes compared with the SVG. We describe the process by which this investigation was conducted and the collaboration necessary to achieve success.

Bilateral internal thoracic artery use in coronary bypass surgery: is there a benefit?

PURPOSE: Over the past three decades, there have been a plethora of retrospective observational data and meta-analyses which support the hypothesis of improved clinical outcomes using bilateral internal thoracic arteries (BITA) when compared to saphenous vein grafts (SVGs). However, recently published results have brought this thinking into doubt. We discuss the existing literature on the subject and attempt to clarify the appropriate use of BITA in coronary artery bypass surgery (CABG). METHODS: A review of all existing meta-analyses on BITA was conducted to better understand the utility of BITA in CABG. A review of the largest randomized controlled trials on the subject was then compared to the observational data. RESULTS: In all existing meta-analyses, BITA shows a significant advantage over the use of a single internal thoracic artery (SITA) with SVGs. The two largest randomized controlled trials evaluating BITA failed to show a survival advantage and brought into question the complications associated with BITA. CONCLUSIONS: At present, the use of multiple arterial grafts remains a reasonable choice, particularly in young patients, provided that their use does not increase the operative risk. Further evidence currently being collected may lend a definitive answer in the near future.

Percutaneous coronary intervention versus coronary bypass surgery for unprotected left main disease: a meta-analysis of randomized controlled trials.

BACKGROUND: This meta-analysis of randomized controlled trials (RCTs) was aimed at comparing coronary artery bypass grafting (CABG) with percutaneous coronary intervention (PCI) for the treatment of unprotected left main coronary disease. METHODS: All RCTs randomizing patients to any type of PCI with stents vs. CABG for left main disease (LMD) were included. Primary outcome was a composite of follow-up death/myocardial infarction/stroke/repeat revascularization. Secondary outcomes were peri-procedural mortality and the individual components of the primary outcome. Incidence rate ratio (IRR) or odds ratio (OR) and 95% confidence intervals (CIs) were pooled using a generic inverse variance method with random effects model. Subgroup analyses were done based on: (I) type of PCI [bare metal stents (BMS) vs. drug-eluting stents (DES)] and; (II) mean SYNTAX score tertiles. Leave one-out analysis and meta-regression were performed. RESULTS: Six trials were included (4,700 patients; 2,349 PCI and 2,351 CABG). Follow-up ranged from 2.33 to 5 years. PCI was associated with higher risk of follow-up death/myocardial infarction/stroke/repeat revascularization (IRR =1.328, 95% CI, 1.114-1.582, P=0.002) and of repeated revascularization (IRR =1.754, 95% CI, 1.470-2.093, P<0.001). The risk of peri-procedural mortality (OR =0.866, 95% CI, 0.460-1.628, P=0.654), follow-up mortality (IRR =0.947, 95% CI, 0.711-1.262, P=0.712), myocardial infarction (IRR =1.342, 95% CI, 0.827-2.179, P=0.234) and stroke (IRR =0.800, 95% CI, 0.374-1.710, P=0.565) were similar between groups. No differences were found between DES and BMS subgroups. The risk of follow-up death/myocardial infarction/stroke/repeat revascularization with PCI was higher in all SYNTAX tertiles, with a progressive increase from the 1st to the 3rd tertile. At meta-regression, higher mean SYNTAX score was associated with higher risk for the primary outcome in the PCI group (beta =0.02, P=0.05), whereas no association was found with female gender, mean age, or diabetes. CONCLUSIONS: CABG remains the therapy of choice for the treatment of unprotected LMD, especially for patients with a high SYNTAX score.

Totally endoscopic coronary artery bypass surgery: A meta-analysis of the current evidence.

BACKGROUND: Totally endoscopic coronary artery bypass (TECAB) has emerged as an alternative to other minimally invasive techniques. However, limited TECAB results are available to date. The purpose of this systematic review is to examine the existing literature to give an objective estimate of the outcomes of TECAB using a meta-analytical approach. METHODS: A comprehensive online review was performed in Ovid MEDLINE®, Ovid EMBASE and The Cochrane Library from 2000 to July 2017. Eligible studies included single arm TECAB studies as well as comparative studies (TECAB vs minimally invasive direct coronary artery bypass (MIDCAB)). Pooled event rates and odds ratios (ORs) for operative mortality, perioperative myocardial infarction (MI), perioperative stroke, graft patency and repeat revascularization were estimated. Single arm and pairwise comparisons were performed. RESULTS: Seventeen single arm TECAB articles (3721 patients, weighted mean follow-up 3.3years) were included. The pooled event rate was 0.80% (95%CI: 0.60-1.2%) for operative mortality, 2.28% (95%CI: 1.7-3%) for perioperative MI, 1.50% (95%CI: 1.1-2.0%) for perioperative stroke, 2.99% (95%CI: 1.6-5.4%) for repeat revascularization and 94.8% (95%CI: 89.3-97.5%) for early graft patency (weighted mean follow-up 10.1months). On pairwise meta-analysis 376 patients (263 TECAB and 113 MIDCAB) were included. No difference in operative mortality (OR=0.25, 95%CI: 0.02-2.83), perioperative MI (OR=3.09, 95%CI: 0.37-26.12) or perioperative stroke (OR=1.33, 95%CI: 0.17-10.26) was found between the two techniques. CONCLUSIONS: TECAB has an acceptably low operative risk and a good early patency rate. The incidence of perioperative MI requires further investigation. The dearth of data comparing TECAB to open approaches compels the need for future comparative trials.

Incidence, risk factors, and prognostic impact of re-exploration for bleeding after cardiac surgery: A retrospective cohort study.

BACKGROUND: Postoperative re-exploration for bleeding (RB) is a frequent complication following cardiac surgery. We aim to assess incidence, risk factors, and prognostic significance of RB in a large cohort of cardiac patients. MATERIALS AND METHODS: We reviewed prospectively collected data for all patients who underwent cardiac surgery at our institution from 2007 to 2015. Logistic regression analysis was used to identify independent predictors of RB and specific outcomes. Propensity matching using a 1:1-ratio compared outcomes of patients who had RB with patients who did not. RESULTS: During the study period, 7381 patients underwent cardiac operations. Of them, 189 (2.6%) underwent RB. RB was an independent predictor of in-hospital mortality (Odds Ratio (OR):2.62 Confidence Interval (CI):1.38-4.96; p = 0.003), major adverse events (OR:3.94, CI:2.79-5.62; p < 0.001), gastrointestinal events (OR:3.54 CI:1.73-7.24), renal failure (OR:2.44, CI:1.23-4.82), prolonged ventilation (OR:3.83, CI:2.60-5.62, p < 0.001), and sepsis (OR:2.50, CI:1.03-6.04, p = 0.043). Preoperative shock (OR:3.68, CI:1.66-8.13; p = 0.001), congestive heart failure (OR:1.70 CI:1.24-2.32; p = 0.001), and urgent and emergent status (OR:2.27, CI:1.65-3.12 and OR:3.57, CI:1.89-6.75; p < 0.001 for both) were predictors of RB operative mortality. Operative mortality, incidence of major adverse events, gastrointestinal events, and respiratory failure were all significantly higher in the propensity matched RB group (p = 0.050, p < 0.001, p = 0.046, and p < 0.001 respectively). CONCLUSIONS: RB significantly increases in-hospital mortality and morbidity after cardiac surgery.

Posterior Left pericardiotomy for the prevention of postoperative Atrial fibrillation after Cardiac Surgery (PALACS): study protocol for a randomized controlled trial.

BACKGROUND: Postoperative atrial fibrillation (POAF) is a common complication following cardiac surgery. POAF is associated with increased morbidity and hospital costs. We herein describe the protocol for a randomized controlled trial to determine if performing a posterior left pericardiotomy prevents POAF after cardiac surgery. METHODS/DESIGN: All patients submitted to cardiac surgery at our institution will be screened for inclusion into the study. The study will consist of two parallel arms with random allocation between groups to either receive a posterior left pericardiotomy or serve as a control. Masking will be done in a single-blinded fashion to the patient. Patients will be continuously monitored postoperatively for the occurrence of atrial fibrillation until discharge. At the follow-up clinic visit (15-30 days after surgery), the primary endpoint (atrial fibrillation) and other secondary endpoints, such as pleural or pericardial effusion, will be assessed. A total sample size of 350 subjects will be recruited. DISCUSSION: POAF is associated with increased morbidity, prolonged hospital stay, and increased costs after cardiac surgery. Several strategies aimed at reducing the incidence of POAF have been investigated, including beta-blockers, amiodarone, and statins, all with suboptimal results. Posterior left pericardiotomy has been associated with a reduction of POAF in previous series. However, these studies had limited sample sizes and suboptimal methodology, so that the efficacy of posterior pericardiotomy in preventing POAF remains to be definitively proven. Our randomized trial aims to determine the effect of a posterior left pericardiotomy on the incidence of POAF. TRIAL REGISTRATION: ClinicalTrials.gov, ID: NCT02875405 , protocol record 1502015867. Registered on July 2016.