Topical Versus Intravenous Tranexamic Acid in Patients Undergoing Cardiac Surgery: The DEPOSITION Randomized Controlled Trial.

BACKGROUND: Although intravenous tranexamic acid is used in cardiac surgery to reduce bleeding and transfusion, topical tranexamic acid results in lower plasma concentrations compared to intravenous tranexamic acid, which may lower the risk of seizures. We aimed to determine whether topical tranexamic acid reduces the risk of in-hospital seizure without increasing the risk of transfusion among cardiac surgery patients. METHODS: We conducted a multicenter, double dummy, blinded, randomized controlled trial of patients recruited by convenience sampling in academic hospitals undergoing cardiac surgery with cardiopulmonary bypass. Between September 17, 2019, and November 28, 2023, a total of 3242 patients from 16 hospitals in 6 countries were randomly assigned (1:1 ratio) to receive either intravenous tranexamic acid (control) through surgery or topical tranexamic acid (treatment) at the end of surgery. The primary outcome was seizure, and the secondary outcome was red blood cell transfusion. After the last planned interim analysis-when 75% of anticipated participants had completed follow up-the Data and Safety Monitoring Board recommended to terminate the trial, and upon unblinding, the Operations Committee stopped the trial for safety. RESULTS: Among 3242 randomized patients (mean age, 66.0 years; 77.7% male), in-hospital seizure occurred in 4 of 1624 patients (0.2%) in the topical group and in 11 of 1628 patients (0.7%) in the intravenous group (absolute risk difference, -0.5%; 95% CI, -0.9 to 0.03; P = .07). Red blood cell transfusion occurred in 570 patients (35.1%) in the topical group and in 433 (26.8%) in the intravenous group (absolute risk difference, 8.3%; 95% CI, 5.2 to 11.5; P = .007). The absolute risk difference in transfusion of ≥4 units of red blood cells in the topical group compared to the intravenous group was 8.2% (95% CI, 3.4 to 12.9). CONCLUSIONS: Among patients having cardiac surgery, topical administration of tranexamic acid resulted in an 8.3% absolute increase in transfusion without reducing the incidence of seizure, compared to intravenous tranexamic acid.

Retrospective cohort analysis of 926 tricuspid valve surgeries: clinical and hemodynamic outcomes with propensity score analysis.

BACKGROUND: The objectives were to describe morbidity and mortality after tricuspid valve (TV) surgery, to compare outcomes after repair versus replacement, and to assess risk factors for mortality and tricuspid regurgitation (TR) recurrence. METHODS: A retrospective cohort study including 926 consecutive cases of TV surgery (792 repairs and 134 replacements) performed at the Montreal Heart Institute was conducted. Median follow-up was 4.3 years (4,657 patient-years). Median age was 62 years (interquartile range 53-69 years), and 72% of patients were women. RESULTS: Operative mortality was 14% (128 patients: 1977-1998 20%, 1999-2008 7%, P < .001). Independent risk factors for operative mortality in the 1999 to 2008 period were hypertension (odds ratio [OR] 6.03, P = .02), daily furosemide dose (by 10 mg) (OR 1.06, P = .05), weight (by 10 kg) (OR 0.36, P < .01), and cardiopulmonary bypass time (by 10 minutes) (OR 1.29, P < .001). Ten-year survival was 49% ± 2% and 38 ± 5% in the repair and replacement groups, respectively (P = .012). At discharge, severity of TR was ≥3/4 in 13% and 2% of patients in the repair and replacement groups, respectively (P = .01). Propensity score analysis showed that tricuspid repair was associated with higher rates of TR ≥3/4 at follow-up compared with replacement (hazard ratio 2.15, P = .02). Forty-eight reoperations (7% of patients at risk) were performed during follow-up (repair group, 6%; replacement group, 15%; P = .01). At last follow-up, New York Heart Association functional class was improved compared with baseline in both groups (P < .001). CONCLUSION: Tricuspid valve surgery is associated with substantial early and late mortalities but with significant functional improvement. Replacement is more effective in early and late corrections of regurgitation, but it does not translate into better survival outcomes.

Triple-valve surgery: clinical results of a three-decade experience.

BACKGROUND AND AIM OF THE STUDY: Triple-valve disease is a challenge that surgeons face periodically, yet the clinical benefits of triple-valve surgery, in relation to the high operative risk, are not well known. The study aims were to describe the early and late mortality associated with triple-valve surgery, to assess the risk factors, and describe the long-term outcomes. METHODS: A retrospective analysis of 178 consecutive triple-valve surgeries performed at the Montreal Heart Institute between 1977 and 2008 was performed. The median follow up was 5.0 years (inter-quartile range: 1.6 to 9.4 years). RESULTS: Among 170 patients (122 females, 48 males; mean age 60 +/- 11 years), the preoperative NYHA functional class was > or = III/IV in 93% of cases; 61% of the patients had undergone previous cardiac surgery. The operative mortality was 12% between 1999 and 2008, and 25% between 1977 and 1998 (p = 0.033). Independent risk factors between 1999 and 2008 period included tricuspid regurgitation severity (OR = 13.71; p = 0.03) and the presence of a right intraventricular pacemaker lead (OR = 11.25; p = 0.039). Survival rates at five and 10 years were 61 +/- 4% and 38 +/- 5%, respectively. A lower left ventricular ejection fraction at discharge was associated with a poor late survival, independent of patient age and gender (OR = 0.95; p = 0.035). Twenty-three patients (18%) required reoperation during the follow up period, at which time the NYHA functional class was improved compared to baseline (p < 0.001). CONCLUSION: Although triple-valve surgery is associated with substantial operative mortality, this situation has improved significantly over the years. Currently, survivors experience a significant improvement in their cardiac functional capacity, justifying the continued use of triple-valve procedures, though preferably earlier during the course of the disease.

Active clearance vs conventional management of chest tubes after cardiac surgery: a randomized controlled study.

BACKGROUND: Chest tubes are routinely used after cardiac surgery to evacuate shed mediastinal blood. Incomplete chest drainage due to chest tube clogging can lead to retained blood after cardiac surgery. This can include cardiac tamponade, hemothorax, bloody effusions and postoperative atrial fibrillation (POAF). Prior published non randomized studies have demonstrated that active tube clearance (ATC) of chest tubes can reduce retained blood complications prompting the ERAS Cardiac Society guidelines to recommend this modality. OBJECTIVE: A randomized prospective trial to evaluate whether an ATC protocol aimed at improving chest tube patency without breaking the sterile field could efficiently reduce complications related to retained blood after cardiac surgery. METHODS: This was a pragmatic, single-blinded, parallel randomized control trial held from November 2015 to June 2017 including a 30-day post index surgery follow-up. The setting was two academic centers affiliated with the Université de Montréal School of Medicine; the Montreal Heart Institute and the Hôpital du Sacré-Coeur de Montréal. Adult patients admitted for non-emergent coronary bypass grafting and/or valvular heart surgery through median sternotomy, in sinus rhythm for a minimum of 30 days prior to the surgical intervention were eligible for inclusion. In the active tube clearance group (ATC), a 28F PleuraFlow device was positioned within the mediastinum. In the standard drainage group, a conventional chest tube (Teleflex Inc.) was used. Other chest tubes were left at the discretion of the operating surgeon. RESULTS: A total of 520 adult patients undergoing cardiac surgery were randomized to receive either ATC (n = 257) or standard drainage (n = 263). ATC was associated with a 72% reduction in re-exploration for bleeding (5.7% vs 1.6%, p = .01) and an 89% reduction in complete chest tube occlusion (2% vs 19%, p = .01). There was an 18% reduction in POAF between the ATC and control group that was not statistically significant (31% vs 38%, p = .08). CONCLUSIONS AND RELEVANCE: In this RCT, the implementation of active clearance of chest tubes reduced re-exploration and chest tube clogging in patients after cardiac surgery further supporting recommendations to consider this modality postoperatively. TRIAL REGISTRATION: Clinical Trials NCT02808897 . Retrospectively registered 22 June 2016.

Sequential multidetector computed tomography assessments after venous graft treatment solution in coronary artery bypass grafting.

OBJECTIVES: To assess the effect of DuraGraft (Somahlution Inc, Jupiter, Fla), an intraoperative graft treatment, on saphenous vein grafts in patients undergoing isolated coronary artery bypass grafting. METHODS: Within patients, 2 saphenous vein grafts were randomized to DuraGraft or heparinized saline. Multidetector computed tomography angiography at 1, 3, and 12 months assessed change in wall thickness (primary end point at 3 months), lumen diameter, and maximum narrowing for the whole graft and the proximal 5-cm segment. Safety end points included graft occlusion, death, myocardial infarction, and repeat revascularization. RESULTS: At 3 months, no significant changes were observed between DuraGraft- and saline-treated grafts (125 each) for wall thickness, lumen diameter, and maximum narrowing. At 12 months, DuraGraft-treated grafts demonstrated smaller mean wall thickness, overall (0.12 ± 0.06 vs 0.20 ± 0.31 mm; P = .02) and in the proximal segment (0.11 ± 0.03 vs 0.21 ± 0.33 mm; P = .01). Changes in wall thickness were greater in the proximal segment of saline-treated grafts (0.09 ± 0.29 vs 0.00 ± 0.03 mm; P = .04). Increase in maximum graft narrowing was larger in the proximal segment in the saline-treated grafts (4.7% ± 12.7% vs 0.2% ± 3.8%; P = .01). Nine DuraGraft and 11 saline grafts had occluded or thrombosed. One myocardial infarction was associated with a saline graft occlusion. No deaths or revascularizations were observed. CONCLUSIONS: DuraGraft demonstrated a favorable effect on wall thickness at 12 months, particularly in the proximal segment. Longer-term follow-up in larger studies is needed to evaluate the effect on clinical outcomes.

The endovascular coronary sinus catheter in minimally invasive mitral and tricuspid valve surgery: a case series.

OBJECTIVES: To determine the safety and efficacy of a standardized approach to the use of an endovascular coronary sinus (CS) catheter during minimally invasive cardiac surgery. DESIGN: Case series. SETTING: University hospital. PARTICIPANTS: Patients undergoing mitral and/or tricuspid valve surgery using a minimally invasive cardiac surgery approach. INTERVENTIONS: An endovascular CS catheter was placed to enable the administration of retrograde cardioplegia using transesophageal echocardiography (TEE), fluoroscopy, and CS pressure measurements. MEASUREMENTS AND MAIN RESULTS: Data were collected from 96 patient records. A total of 95 (99.0%) endovascular coronary sinus catheters were positioned. The mean time to insert the catheter into the sinus ostium under TEE guidance was 6.3 ± 8.4 minutes. Confirmation of adequate positioning with fluoroscopy took an average of 9.1 ± 10.6 minutes for a mean total procedure time of 16.1 ± 14.1 minutes. Successful positioning, as defined by the ability to generate a perfusion pressure in the CS greater than 30 mmHg during surgery, was achieved in 87.5% of cases. During positioning, ventricularization of the CS pressure curve was observed in 86.0% of cases. The presence of ventricularization was associated with an increase in positioning success (odds ratio = 15.8; 95% confidence interval, 3.713-67.239). One patient developed extravasation of contrast agent after CS catheter placement, without evidence of CS rupture. CONCLUSIONS: Endovascular CS catheter insertion can be performed with a high rate of success for positioning and a low complication rate. During positioning, obtaining ventricularization is associated with an increased success rate.

Mini Right Anterior Thoracotomy Approach Versus Sternotomy for Resection of Intracardiac Myxoma.

OBJECTIVE: The standard approach in treating cardiac myxoma is the median full sternotomy. After recent advances in surgical techniques, the mini right anterior thoracotomy has emerged as an alternative method. METHODS: We performed a retrospective study to compare the clinical outcomes of the mini right anterior thoracotomy approach with those of the sternotomy approach for resection of cardiac myxoma at the Montreal Heart Institute. There were 20 patients treated using a mini right anterior thoracotomy (4-5 cm) and 23 patients were treated using a median sternotomy. RESULTS: No early mortalities were found in either group. Although the cardiopulmonary bypass time and aorta cross-clamp time were not significantly different between the two groups (64.3 mn ± 18 and 37.2 mn ± 15 vs 54.3 mn ± 25 and 37.20 mn ± 2), preoperative blood loss (106 mn ± 95 vs 338 mn ± 270) was significantly less in the mini right anterior thoracotomy group. The intensive care unit and hospital stay (1.65 days ± 1.2 and 5.70 days ± 3) were shorter with the mini right anterior thoracotomy approach. CONCLUSIONS: A minimally invasive surgery through mini right anterior thoracotomy is a good alternative technique for treating cardiac myxoma. Despite the small size of the experience, there is a clear diminution in preoperative blood loss and an interesting trend toward a shorter intensive care unit and hospital stay.

DuraGraft vascular conduit preservation solution in patients undergoing coronary artery bypass grafting: rationale and design of a within-patient randomised multicentre trial.

Introduction: Saphenous vein grafts (SVGs) remain the most often used conduits in coronary artery bypass grafting (CABG). However, they are prone to vein graft disease (VGD) during follow-up, which may compromise clinical outcomes. Injury to the SVG endothelium during harvesting and storage promotes neointimal hyperplasia that can advance to atherosclerosis characterised by SVG failure. This trial investigates the potential benefit of DuraGraft, a novel, one-time intraoperative graft treatment developed to efficiently protect the structural and functional integrity of the vascular endothelium, on the development and progression of VGD in CABG patients. Methods and analysis: This ongoing prospective randomised, double-blinded multicentre trial (NCT02272582/NCT02774824) includes patients undergoing isolated CABG requiring at least two SVGs. It compares the impact of DuraGraft, a novel treatment against VGD versus the standard-of-care (SOC; heparinised saline) using a within-patient randomisation (with one SVG treated with DuraGraft and the other treated with SOC). Besides clinical assessments, patients undergo longitudinal 64-slice or better multidetector CT (MDCT) angiography of paired grafts (within each patient) at 4-6 weeks, 3 months and 12 months. Primary endpoints will be the magnitude of change in mean wall thickness and lumen diameter (stenosis) of paired grafts, at 3 and 12 months, respectively. Besides the evaluation of overall safety, longitudinal assessment of each graft (secondary endpoint) is performed in order to obtain insight into graft behaviour after CABG. Enrolment of 119 patients was successfully completed, and analysis of MDCT angiography follow-up is ongoing with the completed analysis becoming available by end of first quarter of 2018. Ethics and dissemination: The regional ethics committees have approved the trial. Results will be submitted for publication. Clinical trial identifier: NCT02272582 and NCT02774824.

Tricuspidation of quadricuspid aortic valve: case reports.

Quadricuspid aortic valve in adulthood is a rare pathology which often leads to aortic valve regurgitation that requires surgical treatment. Herein are described two patients with severe regurgitation on a quadricuspid aortic valve and with dilated left ventricle, who where successfully repaired using a technique of tricuspidation of the valve at the level of the abnormal commissure. In each patient, the repair was stabilized and leaflet coaptation increased by subcommissural annuloplasty stitches at the level of the three commissures. After one year and six months' follow up, respectively, both patients presented with trivial aortic regurgitation and good mobility of the three leaflets.

Is the Future of Coronary Arterial Revascularization a Hybrid Approach?: The Canadian Experience Across Three Centers.

OBJECTIVE: Hybrid coronary revascularization offers and combines the advantages of both surgical and percutaneous revascularization and eliminates at the same time the disadvantages of both procedures. The objective of this study was to assess graft and stent patency at 6 months, rate of bleeding, intensive care unit and hospital stay, rate of reintervention, and long-term clinical follow-up. METHODS: From March 2004 to November 2015, a total of 203 patients underwent robotic-assisted minimally invasive direct coronary artery bypass graft of the left internal thoracic artery to the left anterior descending artery and PCI of a non-left anterior descending vessel in a single or two stage, at three different centers. Patients underwent 6-month angiographic follow-up. The mean ± SD clinical follow-up was 77.82 ± 41.4 months. RESULTS: Successful hybrid coronary revascularization occurred in 196 of the 203 patients. One hundred forty-six patients underwent simultaneous surgical and percutaneous intervention. Nineteen patients underwent PCI before surgery, and 38 patient underwent PCI after surgery. No in-hospital mortality occurred. The mean ± SD ICU stay was 1 ± 1 days and the mean ± SD hospital stay was 5 ± 2 days. Only 13.3% of the patients required a blood transfusion. Six-month angiographic follow-up has been performed in the 95 patients, and it demonstrated a left internal thoracic artery anastomotic patency of 97.9% and stent patency of 92.6%. A total of 77.8 ± 41.4-month clinical follow-up demonstrated 95.1% survival, 92.6% freedom from angina, and 90.7% freedom from any form of coronary revascularization. CONCLUSIONS: Hybrid coronary revascularization seems to be a promising and safe revascularization strategy. It provides selected patients with an alternative, functionally complete revascularization with minimal surgical trauma and good long-term clinical outcomes.

Intraventricular Bronchogenic Cyst: A Rare Congenital Anomaly.

Intracardiac bronchogenic cyst is a rare congenital anomaly. This tumor is usually found in the mediastinum (12% to 18% of all primary mediastinal masses) or in the lung parenchyma (15% to 30% of them). Although rare, it should be included in the differential diagnosis of intracardiac tumors. Complete resection is recommended for diagnosis and for therapeutic reasons. We present here a rare case of an intracardiac left ventricular bronchogenic cyst in an asymptomatic 41-year-old woman.

A rare case of a carcinoid myocardial mass.

Right-sided valvular disease is characteristic of the carcinoid syndrome. In contrast, myocardial involvement is unusual. We present a case of an asymptomatic patient who had a myocardial carcinoid tumor discovered during surgery for coronary artery disease. The clinical presentation, diagnostic tests and modalities, and outcomes after surgery are discussed in this case report.

Preoperative vascular imaging for predicting intraoperative modification of peripheral arterial cannulation during minimally invasive mitral valve surgery.

OBJECTIVE: Minimally invasive mitral valve surgery using peripheral cannulation for cardiopulmonary bypass (CBP) is increasingly prevalent. Although conceptually straightforward, peripheral CBP involves challenges and risks specific to this method of perfusion. The utility of preoperative vascular imaging in predicting these technical challenges and preventing vascular complications was studied. METHODS: We performed a retrospective analysis of 73 consecutive patients undergoing minimally invasive mitral valve surgery using femorofemoral CBP with intraluminal aortic occlusion balloon catheter. All patients underwent preoperative computed tomography angiogram or magnetic resonance angiography to study the iliofemoral axes. RESULTS: None of the patients operated with this technique was found to have arterial stenoses. Patients with a femoral artery diameter of less than 7.3 mm needed bilateral or side-graft arterial cannulation significantly more frequently than patients with larger femoral arteries (46.2% vs 9.1%, P = 0.001). There was a trend toward more frequent modification of arterial cannulation strategy in patients with body surface area less than 1.7 m compared with larger patients (body surface area, 1.7-2.0) (26.3% vs 8.3%, P = 0.07). Patients needing high CBP flow rate (>5 L/min) were no more likely to need dual arterial cannulation (18.2% vs 19.1%, P = 0.68). No patient experienced a vascular complication. CONCLUSIONS: This preliminary study suggests that preoperative vascular imaging and patient evaluation may predict difficulties with femoral cannulation and perfusion, which can lead to better preoperative planning and potentially prevent vascular complications. Further data will be accumulated and analyzed to confirm these findings.

Very high repair rate using minimally invasive surgery for the treatment of degenerative mitral insufficiency.

BACKGROUND: Minimally invasive mitral valve surgery (MIMVS) is an established alternative to median sternotomy for mitral valve repair. However, this technique has yet to gain widespread adoption, partly because of concerns that this approach might yield lower repair rates or repairs that are less durable than those performed through a sternotomy. The purpose of this study was to report our inaugural experience with MIMVS, with a focus on mitral valve repair rate and midterm outcomes. METHODS: Between May 2006 and April 2012, minimally invasive mitral valve repair was attempted in 200 consecutive patients with degenerative mitral disease. The approach used was a 4- to 5-cm right anterolateral minithoracotomy with femorofemoral cannulation for cardiopulmonary bypass. Mean follow-up was 2.9 ± 1.8 years, and follow-up was 99% complete. RESULTS: The mitral valve was successfully repaired in all but 2 patients, yielding a repair rate of 99%. Hospital mortality occurred in 2 patients (1%). Intraoperative conversion to sternotomy was necessary in 12 patients (6%), including 1 of the 2 unsuccessful repairs. Mean cardiopulmonary bypass and aortic cross-clamp times were 130.8 ± 41.3 minutes and 104.8 ± 35.6 minutes, respectively. Median hospital stay was 5 days. The 5-year survival and freedom from reoperation were 97.9% ± 1.5% and 98.1% ± 1.3%, respectively. CONCLUSIONS: A very high repair rate can be achieved using MIMVS for the treatment of degenerative mitral regurgitation, including during the learning phase. Midterm survival and freedom from valve-related reoperation are excellent. MIMVS is a safe and effective alternative to mitral valve repair through a sternotomy.

Comparative study of cyclosporine and tacrolimus vs newer immunosuppressants mycophenolate mofetil and rapamycin on coronary endothelial function.

BACKGROUND: Endothelial dysfunction contributes to the development of intimal hyperplasia in transplanted hearts by decreasing the protective effects of endothelial-derived nitric oxide. Immunosuppressive drugs may increase the dysfunction caused by rejection and further accelerate the development of graft coronary vasculopathy. This study compares the effect of cyclosporine and tacrolimus vs two newer immunosuppressive drugs, mycophenolate mofetil and rapamycin, on coronary endothelial function. METHODS: An in vitro model of drug incubation in Krebs-bicarbonate solution (4(o)C, 48 hours) using porcine epicardial coronary arteries was developed. Coronary endothelial function studies were performed in organ chamber experiments after incubation with cyclosporine (10(-4), 10(-7) mol/liter), tacrolimus (10(-4), 10(-7) mol/liter), mycophenolate mofetil (10(-4), 10(-7) mol/liter), rapamycin (10(-7), 10(-11) mol/liter), and their vehicles to assess effects on G-protein-mediated vasorelaxations leading to the release of nitric oxide. RESULTS: Exposure to cyclosporine and mycophenolate mofetil was associated with a dose-dependent decrease in endothelium-dependent relaxations to serotonin (an agonist that binds to 5-HT1D receptors coupled to Gi-protein) but no impairment of relaxations to bradykinin (an agonist that binds to B2 receptors coupled to Gq-proteins). Exposure to tacrolimus and rapamycin caused severe impairment of relaxations to serotonin and a lesser one to bradykinin. We observed alterations of relaxations to the calcium ionophore A23187 after exposure to mycophenolate mofetil and rapamycin. Exposure to rapamycin and mycophenolate mofetil vehicles impaired relaxation to all agonists. CONCLUSIONS: These results suggest that cyclosporine and mycophenolate mofetil induce a dysfunction of the vasorelaxing properties of the endothelium that may lead to a decrease in the protective effects of nitric oxide on the vascular wall but that these drugs still have a more favorable vascular profile than do tacrolimus and rapamycin. Decreased endothelial function after mycophenolate mofetil and rapamycin exposure could be caused by their vehicles.

Randomized trial comparing off-pump to on-pump coronary artery bypass grafting in high-risk patients.

OBJECTIVE: The subset of patients most likely to benefit from off-pump coronary artery bypass grafting (CABG) remains a controversial issue, but the technique has been proposed to decrease postoperative mortality and morbidity. Th e objective of this study was to compare off-pump to onpump CABG in patients with known risk factors for mortality and morbidity. METHODS: Between October 2001 and September 2002, 65 high-risk patients were prospectively randomized to undergo off-pump or o n-pump CABG. Recruited patients had at least 3 of the following criteria: age greater than 65 years, high blood pressure, diabetes, serum creatinine greater than 133 mol/L, left ventricular ejection fraction lower than 45%, chronic pulmonary diseas e, unstable angina, congestive heart failure, repeat CABG, anemia, and carotid atherosclerosis. Hospital mortality and morbidity were the primary end-points of the study. RESULTS: Six patients (9%) crossed over from the original randomized group. Twenty-eight patients averaging 70 +/- 8 years of age underwent 3 +/- 1 grafts off pump, and 37 patients averaging 70 +/- 6 years of age underwent 3.4 +/- 1 grafts on pump. Revascularization was considered complete in 21 (7 5 %) of off-pump patients compared to 33 (89%) of onpump patients (P =.1). There were no hospital deaths in off-pump patients, and 2 patients (5%) undergoing onpump CABG died early following surgery (P =.2). Two offpump (7%) compared to 11 on-pump (30%) of patients presented composite end-points including death, neurological injury, renal failure, respiratory failure, and operative myocardial infarction after CABG (P =.02). CONCLUSION: The present study suggests that off-pump CABG, when technically feasible, significantly reduces morbidity following surgery in a group of high-risk patients.

Excellent outcomes for transcatheter aortic valve replacement within 1 year of opening a low-volume centre and consideration of requirements.

BACKGROUND: After the approval of transcatheter aortic valve replacement (TAVR) for high-risk or inoperable patients with severe aortic stenosis (AS), many low- and moderate-volume TAVR programs were initiated. Contemporary outcomes from these newly initiated centres remain unknown. METHODS: In March 2013, our institution was authorized by the Québec Ministry of Health to perform 30 TAVR procedures. After thorough clinical screening and imaging evaluation, suitable patients underwent transfemoral TAVR with the balloon-expandable SAPIEN XT (Edwards Lifesciences, Irvine, CA) transcatheter heart valve (THV). In-hospital and 30-day outcomes were prospectively collected and reported according to Valve Academic Research Consortium 2 guidelines. RESULTS: From April 2013 to January 2014, 30 consecutive high-risk (n = 16 [53.3%]) or inoperable (n = 14 [46.7%]) patients (mean age, 84.6 years; mean Society of Thoracic Surgery score, 7) with symptomatic severe AS underwent transfemoral TAVR. No catastrophic intraprocedural complications such as annulus rupture, valve embolization, aortic dissection, or coronary occlusion occurred, and there were no deaths at 30 days. Disabling stroke occurred in 1 (3.3%) patient 48 hours after THV implantation. Major vascular complications and major bleeding occurred in 1 (3.3%) patient. No moderate or severe paravalvular leak was observed. The median length of stay was 2 (1-3) days, with 8 (26.7%) patients discharged within 24 hours after the procedure. CONCLUSIONS: Excellent outcomes can be achieved in newly initiated relatively low-volume centres, which compares favorably to previously published large series. Important considerations include appropriate team training, rigorous patient screening, use of multimodality imaging techniques, a heart team approach, constant integration of lessons learned from larger published experiences, and maintaining a recommended minimum volume of 25 cases per year.

Minimally invasive mitral valve surgery: influence of aortic clamping technique on early outcomes.

BACKGROUND: Several methods of aortic clamping have been described for minimally invasive mitral valve surgery (MIMVS). The aim of this study was to compare the endoaortic balloon occlusion technique with the transthoracic clamp approach in terms of perioperative outcomes. METHODS: Between May 2006 and October 2011, a total of 259 patients underwent MIMVS through a 4 to 5 cm right anterolateral minithoracotomy. In 243 (93.8%) of these, the aorta was clamped using either the endoaortic balloon occlusion technique (endoballoon, n = 140) or the transthoracic clamp technique (transthoracic, n = 103). RESULTS: Patients in the endoballoon group had significantly longer operating time (4.3 ± 1.0 hours vs 3.2 ± 0.8 hours, p < 0.001), cardiopulmonary bypass time (143 ± 44 minutes vs 111 ± 29 minutes , p < 0.001), and cross-clamp time (114 ± 38 minutes vs 86 ± 23 minutes , p < 0.001). Perioperative blood loss was higher in the endoballoon group (287 ± 239 mL vs 213 ± 189 mL, p = 0.008) as was the mean postoperative creatinine kinase-MB level (36 ± 44 µg/L vs 26 ± 12 µg/L, p = 0.011). The repair rate was 99% or greater in both groups (p = 0.99). All patients left the operating room with no or trivial residual mitral regurgitation on transesophageal echocardiographic evaluation. In the endoballoon group there was 1 stroke (1%) and 5 myocardial infarctions (4%), compared with 2 strokes (2%) in the transthoracic group (p = not significant). There were 4 cases of postoperative cardiogenic shock, all of which occurred in the endoballoon group (p = 0.14). In-hospital mortality occurred in 2 patients from each group (p = 0.99). CONCLUSIONS: Minimally invasive mitral valve surgery can be performed successfully using either the endoaortic balloon technique or the transthoracic clamp approach. However, the transthoracic technique results in shorter operation time, less perioperative bleeding and better myocardial protection.