Minimally invasive strategies of surgical coronary artery revascularization for the aging population.

BACKGROUND: The increasing prevalence of elderly or frail patients with severe coronary disease, who are not suitable for interventional coronary revascularization, necessitates the exploration of alternative treatment options. A less invasive approach, such as minimally-invasive off-pump coronary-artery-bypass (MICS-CABG) grafting through mini-thoracotomy, which avoids both extracorporeal circulation and sternotomy, may be more appropriate for this patient population. This study, a retrospective, monocentric analysis, aimed to evaluate the long-term outcomes of these patients. METHODS: The study included 172 patients aged 80 years or older, who underwent MICS-CABG between 2007 and 2018. The patients underwent single, double, or triple-vessel revascularization using the left internal thoracic artery, and in some cases, the radial artery or saphenous vein. Follow-up, mean duration of 50.4±30.8 months, was available for 163 patients (94.7%). RESULTS: The mean age of the patients was 83.2±3.0 years, 77.3% of them were male. The EuroSCORE I additive was 11.0±12.1. There were no conversions to sternotomy or cardiopulmonary-bypass. The postoperative 30-day mortality rate was 2.9%, with 5 deaths. The in-hospital rate of major adverse cardiac and cerebrovascular events was 4.7% (perioperative myocardial infarction 1.2%, perioperative stroke 2.3%, repeat revascularization 1.2%). Acute renal kidney injury, (stage 3 KDOQI or more), occurred in 5 patients (2.9%) and new-onset atrial fibrillation in 6 patients (3.5%). The 1-, 3-, 5- and 8-year actuarial survival rate of the 30-day survivors was 97%, 82%, 73%, and 42%, respectively. CONCLUSIONS: MICS-CABG grafting is associated with excellent early and long-term outcomes in eligible octogenarians.

A propensity matched comparison of robotic vs. traditional minimal access approach for mitral valve repair with concomitant cryoablation.

Background: Atrial fibrillation (AF) occurs frequently in patients with mitral valve disease. Results of cryoablation concomitant with either minimally invasive video-assisted [minimally invasive mitral valve surgery (MIMVS)] or with robotic-assisted (RMV) mitral valve surgery have previously been separately reported. However, there are up-to-date no studies comparing the two procedures in terms of safety, efficacy, and mid-term follow-up. Methods: Between January 2017 and March 2022, 294 patients underwent MIMVS, and 187 patients underwent RMV at our institution. After 1:1 propensity score matching using 22 preoperative variables, the study included 104 patients. Group 1 (MIMVS) included 52 patients operated on between 2017-2022 using a minimally invasive video-assisted right-sided mini-thoracotomy. Group 2 (RMV) included 52 patients operated on between 2019-2021 using a robotic-assisted approach. Early and mid-term outcomes were assessed, including maintenance of sinus rhythm. Follow-up was 100% complete at a median follow-up of 2 years. Results: For the entire propensity matched cohort, the median EuroSCORE II was 3.14 [interquartile range (IQR), 1.93-4.99], the median age was 68 (IQR, 61-74) years, and two thirds of the patients were male. Most (72.1%) underwent mitral valve surgery, and 26.9% had an additional tricuspid procedure. Only four patients underwent mitral valve replacement (3.8%). The majority (87.5%) received a left-sided atrial Maze and 12.5% a bi-atrial Maze. The left atrial appendage was occluded in 72.1% cases. Overall, there were no significant differences between the two propensity matched groups in baseline demographics or intra-operative characteristics. Similarly, there were no significant differences in the post-operative short and mid-term outcomes between the two groups. There were no in-hospital or 30-day deaths. At the mid-term survival was similar between groups, log-rank test P=0.056. Maintenance of sinus rhythm at follow-up was 76%. Conclusions: Mitral or double valve repair with concomitant cryoablation can be safely performed with either a MIMVS or RMV approach. Both methods demonstrated outstanding early and mid-term outcomes.

Aortic regurgitation management: a systematic review of clinical practice guidelines and recommendations.

Guidelines for the diagnosis and management of aortic regurgitation (AR) contain recommendations that do not always match. We systematically reviewed clinical practice guidelines and summarized similarities and differences in the recommendations as well as gaps in evidence on the management of AR. We searched MEDLINE and Embase (1 January 2011 to 1 September 2021), Google Scholar, and websites of relevant organizations for contemporary guidelines that were rigorously developed as assessed by the Appraisal of Guidelines for Research and Evaluation II tool. Three guidelines met our inclusion criteria. There was consensus on the definition of severe AR and use of echocardiography and of multimodality imaging for diagnosis, with emphasis on comprehensive assessment by the heart valve team to assess suitability and choice of intervention. Surgery is indicated in all symptomatic patients and aortic valve replacement is the cornerstone of treatment. There is consistency in the frequency of follow-up of patients, and safety of non-cardiac surgery in patients without indications for surgery. Discrepancies exist in recommendations for 3D imaging and the use of global longitudinal strain and biomarkers. Cut-offs for left ventricular ejection fraction and size for recommending surgery in severe asymptomatic AR also vary. There are no specific AR cut-offs for high-risk surgery and the role of percutaneous intervention is yet undefined. Recommendations on the treatment of mixed valvular disease are sparse and lack robust prospective data.

Leaflet thrombosis after valve-in-valve transcatheter aortic valve implantation: a case series.

BACKGROUND: Valve-in-valve transcatheter aortic valve implantation (ViV-TAVI) in degenerated surgical aortic valve replacement (SAVR) is an alternative to redo-SAVR. However, reports on leaflet thrombosis following ViV-TAVI are emerging and subclinical thrombosis has gained recent attention. Although the incidence of transcatheter heart valve (THV) thrombosis after TAVI for native aortic valve disease is low, current imaging studies suggest the incidence of subclinical THV thrombosis may be significantly higher. While anticoagulation strategies for THV patients for native aortic stenosis presenting with symptomatic obstructive thrombosis has been described, the optimal management and anticoagulation therapy of patients with THV thrombosis following ViV-TAVI are less evident. CASE SUMMARY: We report a case series of three patients presenting with early and late THV thrombosis after ViV-TAVI. Two patients presented clinically on single antiplatelet therapy and one patient presented with subclinical valve thrombosis whilst taking a non-vitamin K oral anticoagulation agent. DISCUSSION: Leaflet thrombosis after ViV-TAVI is an important cause of THV degeneration and may present subclinically. Imaging modalities such as serial transthoracic echocardiograms and multidetector computerized tomography aid diagnosis and guide management. Patient-individualized risk- vs. -benefit prophylactic post-procedural oral anticoagulation may be indicated.

Successful repositioning of apically tethered transcatheter mitral valve replacement in the off-bypass, beating heart.

A 73-year-old man with severe, symptomatic secondary mitral regurgitation (MR) underwent successful transcatheter mitral valve replacement using the Tendyne™ mitral valve system. The device was deployed from the left ventricular (LV) apex and secured in position by a tether attached to an epicardial pad. Three days postoperatively, the patient developed hemolytic anemia and a paravalvular leak (PVL) associated with indentation of the LV apex. Adjustment of the tether tension and placement of an epicardial disc under the pad resulted in reduction in the PVL, and resolution of the hemolytic anemia.

Cerebral oxygenation monitoring in patients with bilateral carotid stenosis undergoing urgent cardiac surgery: Observational case series.

BACKGROUND: Patients with significant bilateral carotid artery stenosis requiring urgent cardiac surgery have an increased risk of stroke and death. The optimal management strategy remains inconclusive, and the available evidence does not support the superiority of one strategy over another. MATERIALS AND METHODS: A number of noninvasive strategies have been developed for minimizing perioperative stroke including continuous real-time monitoring of cerebral oxygenation with near-infrared spectroscopy (NIRS). The number of patients presenting with this combination (bilateral significant carotid stenosis requiring urgent cardiac surgery) in any single institution will be small and hence there is a lack of large randomized studies. RESULTS: This case series describes our early experience with NIRS in a select group of patients with significant bilateral carotid stenosis undergoing urgent cardiac surgery (n = 8). In contrast to other studies, this series is a single surgeon, single center study, where the entire surgery (both distal ends and proximal ends) was performed during single aortic clamp technique, which effectively removes several confounding variables. NIRS monitoring led to the early recognition of decreased cerebral oxygenation, and corrective steps (increased cardiopulmonary bypass flow, increased pCO 2 , etc.,) were taken. CONCLUSION: The study shows good clinical outcome with the use of NIRS. This is our "work in progress," and we aim to conduct a larger study.

Anemia in cardiac surgery: next target for mortality and morbidity improvement?

OBJECTIVE: To assess the effects of preoperative anemia on outcomes of cardiac surgery and to explore the trend in mortality over an 8-year period. METHODS: During the study period (2005-2012), all 1170 patients undergoing elective or urgent cardiac surgery and classed as anemic were included. A matched group of non-anemic 1170 patients was used as a control group. Postoperative outcomes were compared between the 2 groups. The association between preoperative anemia and postoperative outcomes was analyzed using a logistic regression model. RESULTS: Compared with patients without anemia, the need for airway support (15% vs. 12%, p = 0.05), renal replacement therapy (13% vs. 8%, p < 0.01) and the rate of in-hospital surgical site infection (9% vs. 7%, p = 0.05) were higher in the anemic group. Anemia was associated with greater need for renal replacement therapy (odds ratio = 1.76, confidence interval: 1.21-2.37, p = 0.002) and prolonged (> 7 days) hospital stay (odds ratio = 1.21, confidence interval: 0.97-1.51, p = 0.08). The blood transfusion rate (54% vs. 33%, p < 0.01) and hospital mortality (5.6% vs. 3.5%, p = 0.02) were higher in the anemic group. Over the 8-year period, there was a significant improvement in mortality in the non-anemic group (from 6.5% to 1.6%) but less so in the anemic group (from 6.7% to 4.7%). CONCLUSION: Anemia impacts significantly on morbidity and mortality after cardiac surgery, with less improvement over time compared to patients without anemia. Preoperative correction of anemia, when feasible, could potentially help to improve cardiac surgery outcomes.

National administrative data produces an accurate and stable risk prediction model for short-term and 1-year mortality following cardiac surgery.

OBJECTIVES: Various risk models exist to predict short-term risk-adjusted outcomes after cardiac surgery. Statistical models constructed using clinical registry data usually perform better than those based on administrative datasets. We constructed a procedure-specific risk prediction model based on administrative hospital data for England and we compared its performance with the EuroSCORE (ES) and its variants. METHODS: The Hospital Episode Statistics (HES) risk prediction model was developed using administrative data linked to national mortality statistics register of patients undergoing CABG (35,115), valve surgery (18,353) and combined CABG and valve surgery (8392) from 2008 to 2011 in England and tested using an independent dataset sampled for the financial years 2011-2013. Specific models were constructed to predict mortality within 1-year post discharge. Comparisons with EuroSCORE models were performed on a local cohort of patients (2580) from 2008 to 2013. RESULTS: The discrimination of the HES model demonstrates a good performance for early and up to 1-year following surgery (c-stats: CABG 81.6%, 78.4%; isolated valve 78.6%, 77.8%; CABG & valve 76.4%, 72.0%), respectively. Extended testing in subsequent financial years shows that the models maintained performance outside the development period. Calibration of the HES model demonstrates a small difference (CABG 0.15%; isolated valve 0.39%; CABG & valve 0.63%) between observed and expected mortality rates and delivers a good estimate of risk. Discrimination for the HES model for in-hospital deaths is similar for CABG (logistic ES 79.0%) and combined CABG and valve surgery (logistic ES 71.6%) patients and superior for valve patients (logistic ES 70.9%) compared to the EuroSCORE models. The C-statistics of the EuroSCORE models for longer periods are numerically lower than that of the HES model. CONCLUSION: The national administrative dataset has produced an accurate, stable and clinically useful early and 1-year mortality prediction after cardiac surgery.

Role of topical application of gentamicin containing collagen implants in cardiac surgery.

Sternal wound infections (SWI) continue to be a major cause of concern after cardiac surgery. It leads to prolonged hospital stay and increased morbidity, mortality and increased hospital costs. Prophylactic systemic antibiotics have been used to prevent surgical site infection (SSI). However, prolonged postoperative use of systemic antibiotics can lead to emergence of resistant organisms. Gentamycin Containing Collagen Implants (GCCI) when used during sternotomy closure produces high local antibiotic concentrations in the wound with a low serum concentration. There is evidence that the concentration of gentamicin in the mediastinal fluid reaches levels high enough to be effective against bacteria that are considered resistant to gentamycin and other antibiotics.However, questions have been raised about the safety and efficacy of GCCI. There were concerns whether GCCI can lead to systemic absorption with renal impairment and whether use of topical antibiotics can lead to emergence of antimicrobial resistance.We, hereby, review the literature on GCCI (Collatamp) and take the opportunity to appraise the scientific community about their role in cardiac surgery. Several recent studies have supported their clinical effectiveness. They should be used in dry condition and should not be soaked in saline even for a short period prior to use. However, for GCCI to become part of routine practice in cardiac surgery further large randomised studies are required. As the incidence of sternal wound infection is low in the specialty of cardiac surgery, for any study to be sufficiently powered to address this issue, multicenter studies might be the way forward.Based on the evidence presented in this manuscript it is recommended GCCI (Collatamp) can be a cost effective adjunct for prevention of sternal wound infection. They can also be used for treatment of Deep Sternal Wound Infection.

Continuity of care by cardiothoracic nurse practitioners: impact on outcome.

OBJECTIVES: There have been recent reports on increased mortality in British National Health Service hospitals during weekends. This study aimed to assess the impact on patient care following the introduction of nurse practitioner cover for the cardiothoracic ward, including weekends. METHODS: Prospectively collected and validated data of patients operated on from January 2005 to October 2011 were analyzed. The patients were grouped according to era: before (n = 2385) and after (n = 3910) the introduction of nurse practitioners in October 2007. RESULTS: There were no significant differences in preoperative patient characteristics such as age, logistic EuroSCORE, sex, smoking, and extracardiac vascular problems. There were more patients from an Asian background (p < 0.01), more with noninsulin-dependent diabetes (p < 0.01), and more requiring urgent cardiac surgery (p < 0.01) in the later era. Following the introduction of nurse practitioner grade, there was a decrease in the rate of cardiac intensive care unit readmission from 2.6% to 1.9% (p = 0.05) and length of hospital stay from 10 to 8 days (p < 0.01). There was a significant improvement in overall survival after cardiac surgery from 96.5% to 98.0% (p < 0.01). Logistic regression analysis confirmed that the presence of nurse practitioners on the ward was the strongest predictor of survival with an odds ratio of 1.9 (95% confidence interval: 1.23-3.01). CONCLUSION: The introduction of the nurse practitioner grade to provide continuity in patient care including at weekends has been confirmed to improve patient outcomes including survival after cardiac surgery.

How does the 'Heart Team' decision get enacted for patients with coronary artery disease?

OBJECTIVES: A heart team approach has been recommended for managing patients with coronary artery disease. Although this seems to be a new concept, we have been developing such a practice for over 8 years. In this report, the enactment of the heart team decision is reviewed and possible improvement is discussed. DESIGN: Review of 1000 heart team decisions over a 1-year period for patients with coronary artery disease. These decisions were recorded contemporaneously at the time of the team discussion. Thereafter, patient's notes were reviewed 6 months following the heart team meeting to assess whether the decision was enacted and, if not, what were the reasons for aberration. RESULTS: The heart team decision was enacted in 95.5% of patients. The reasons for aberration in the remaining 45 patients included patient's choice (refusal), unrecognised comorbidities at the time of the heart team discussion, change in patient's clinical condition requiring urgent intervention and death while awaiting procedure, among others. CONCLUSIONS: The decision of a well set-up heartteam meeting is carried out for most patients. Aberration is uncommon and usually due to unknown factors at the time of the discussion. The heart team approach ensures that patients receive best available care (most likely evidence-based), and demonstrates transparency.