Outcomes and Risk Factors Associated with Pericardiectomy in Patients with Constrictive Pericarditis: A Retrospective Study from China.

PURPOSE: Pericardiectomy is the definitive treatment option for constrictive pericarditis and is associated with a high prevalence of morbidity and mortality. However, information on the associated outcomes and risk factors is limited. We aimed to report the mid-term outcomes of pericardiectomy from a single center in China. METHODS: We retrospectively reviewed data collected from patients who underwent pericardiectomy at our institute from April 2018 to January 2023. RESULTS: Eighty-six consecutive patients (average age, 46.1 ± 14.7 years; 68.6 men) underwent pericardiectomy through midline sternotomy. The most common etiology was idiopathic (n = 60, 69.8%), and 82 patients (95.3%) were in the New York Heart Association function class III/IV. In all, 32 (37.2%) patients underwent redo sternotomies, 36 (41.9%) underwent a concomitant procedure, and 39 (45.3%) required cardiopulmonary bypass. The 30-day mortality rate was 5.8%, and the 1-year and 5-year survival rates were 88.3% and 83.5%, respectively. Multivariable analysis revealed that preoperative mitral insufficiency (MI) ≥moderate (hazard ratio [HR], 6.435; 95% confidence interval [CI] [1.655-25.009]; p = 0.007) and partial pericardiectomy (HR, 11.410; 95% CI [3.052-42.663]; p = 0.000) were associated with increased 5-year mortality. CONCLUSION: Pericardiectomy remains a safe operation for constrictive pericarditis with optimal mid-term outcomes.

Long-term results after mitral valve surgery using minimally invasive versus sternotomy approach: a propensity matched comparison of a large single-center series.

BACKGROUND: Mitral valve (MV) surgery has traditionally been performed by conventional sternotomy (CS), but more recently minimally invasive surgery (MIS) has become another treatment option. The aim of this study is to compare short- and long-term results of MV surgery after CS and MIS. METHODS: This study was a retrospective propensity-matched analysis of MV operations between January 2005 and December 2015. RESULTS: Among 1357 patients, 496 underwent CS and 861 MIS. Matching resulted in 422 patients per group. The procedure time was longer with MIS than CS (192 vs. 185 min; p = 0.002) as was cardiopulmonary bypass time (133 vs. 101 min; p < 0.001) and X-clamp time (80 vs. 71 min; p < 0.001). 'Short-term' successful valve repair was higher with MIS (96.0% vs. 76.0%, p < 0.001). Length of hospital stay was shorter in MIS than CS patients (10 vs. 11 days; p = 0.001). There was no difference in the overall 30-day mortality rate. Cardiovascular death was lower after MIS (1.2%) compared with CS (3.8%; OR 0.30; 95%CI 0.11-0.84). The difference did not remain significant after adjustment for procedural differences (aOR 0.40; 95%CI 0.13-1.25). Pacemaker was required less often after MIS (3.3%) than CS (11.2%; aOR 0.31; 95%CI 0.16-0.61), and acute renal failure was less common (2.1% vs. 11.9%; aOR 0.22; 95%CI 0.10-0.48). There were no significant differences with respect to rates of stroke, myocardial infarction or repeat MV surgery. The 7-year survival rate was significantly better after MIS (88.5%) than CS (74.8%; aHR 0.44, 95%CI 0.31-0.64). CONCLUSION: This study demonstrates that good results for MV surgery can be obtained with MIS, achieving a high MV repair rate, low peri-procedural morbidity and mortality, and improved long-term survival.

The Challenges of Using ICD codes to Perform a Comparative Analysis between Patients with Penetrating Cardiac Injuries who Underwent Non-Resuscitative Thoracotomy versus Sternotomy.

Background: Comparative morbidity after either sternotomy or non-resuscitative thoracotomy in penetrating cardiac injuries (PCI) is unknown. Methods: Retrospective review of adults with PCI who underwent either sternotomy or non-resuscitative thoracotomy using the National Trauma Data Bank 2007-2015. Since there is no unique International Classification of Diseases Procedure Coding System (ICD-PCS) codes assigned for resuscitative vs. non-resuscitative thoracotomy, and both procedures were coded as "thoracotomy", propensity score (PS) methods were applied to avoid inclusion of resuscitative thoracotomy. Results: Despite well PS matching on injury severity score the non-thoracotomy group compared to the sternotomy group had a significantly increased risk of mortality (30 percent vs 8 percent, p<0.0001). The morbidity differed as well-25 percent vs. 12 percent, p=0.0007. Conclusions: The differences in mortality in PCI patients who underwent non-resuscitative thoracotomy vs. sternotomy may be biased by unintentional inclusion of resuscitative thoracotomy. To accurately capture thoracotomy type, separate unique resuscitative and non-resuscitative thoracotomy procedure codes should be created in future revisions of the ICD PCS.

Lower hemisternotomy: infrequently used but versatile.

BACKGROUND: A lower hemisternotomy is an infrequently used approach in cardiac surgery. This single center report evaluates applicability and clinical outcomes of procedures performed through a lower hemisternotomy. METHODS: The institutional database was reviewed. From 2014 to 2019, 55 consecutive patients had undergone minimally invasive procedures through a lower hemisternotomy (median follow-up 34 months). Demographic as well as outcome data were retrieved from our prospectively maintained institutional database. RESULTS: Performed procedures included mitral and tricuspid repairs, aortic valve replacement as well as coronary artery bypass grafting. The median patient age was 72 years. Out of the 55 patients, 55% were male. Predominantly mitral valve procedures (11 isolated, 30 combined) had been performed. Mitral valve procedures (N.=41) consisted of 36 repairs and 5 replacements. Repair rate for degenerative mitral insufficiency was 97.6%. Median EuroScore II was 3.4% (2.1-6.0). Median cross-clamp time was 67 (44-99) min. Median procedural length was 169 (138-201) min. Reoperation rate for bleeding was 1.8%. Major vascular complications occurred in two patients. Freedom from valve related reoperation was 96.1% during follow-up. Thirty-day mortality and overall mortality during follow-up was 3.6% and 10.9%. CONCLUSIONS: In properly selected cases the lower hemisternotomy allows for a variety of cardiac procedures. It permits central aortic cannulation and a direct vision of intracardiac structures and therefore should be kept in mind as an alternative minimally invasive approach.

The incidence and effect of resternotomy following cardiac surgery on morbidity and mortality: a 1-year national audit on behalf of the Association of Cardiothoracic Anaesthesia and Critical Care.

Over 30,000 adult cardiac operations are carried out in the UK annually. A small number of these patients need to return to theatre in the first few days after the initial surgery, but the exact proportion is unknown. The majority of these resternotomies are for bleeding or cardiac tamponade. The Association of Cardiothoracic Anaesthesia and Critical Care carried out a 1-year national audit of resternotomy in 2018. Twenty-three of the 35 centres that were eligible participated. The overall resternotomy rate (95%CI) within the period of admission for the initial operation in these centres was 3.6% (3.37-3.85). The rate varied between centres from 0.69% to 7.6%. Of the 849 patients who required resternotomy, 127 subsequently died, giving a mortality rate (95%CI) of 15.0% (12.7-17.5). In patients who underwent resternotomy, the median (IQR [range]) length of stay on ICU was 5 (2-10 [0-335]) days, and time to tracheal extubation was 20 (12-48 [0-2880]) hours. A total of 89.3% of patients who underwent resternotomy were transfused red cells, with a median (IQR [range]) of 4 (2-7 [1-1144]) units of red blood cells. The rate (95%CI) of needing renal replacement therapy was 23.4% (20.6-26.5). This UK-wide audit has demonstrated that resternotomy after cardiac surgery is associated with prolonged intensive care stay, high rates of blood transfusion, renal replacement therapy and very high mortality. Further research into this area is required to try to improve patient care and outcomes in patients who require resternotomy in the first 24 h after cardiac surgery.

Clinical outcome of acute thoracic aortic syndrome in nonagenarians.

BACKGROUND: Decision-making regarding the operability of thoracic aortic disease in nonagenarian patients remains controversial because outcomes of open surgical repair of the thoracic aorta are unclear. We investigated the surgical and nonsurgical outcomes of acute thoracic aortic syndrome treatment in nonagenarians. METHODS: After evaluating data in our institute from April 2016 to March 2020, we included 10 nonagenarians who needed surgical intervention on the thoracic aorta via a median sternotomy for acute thoracic aortic syndrome. The mean age of the cohort was 91.9 ± 2.1 years. Five patients underwent open surgical repair of the thoracic aorta (surgical group), and 5 refused surgery (nonsurgical group). All patients in the surgical group performed activities of daily living independently, with a mean clinical frailty scale of 3.2 ± 0.4. The surgical group included 4 patients with type A aortic dissection and one with a ruptured thoracic aortic aneurysm. Hemiarch replacement was performed in 3 patients and total arch replacement in 2. The mean follow-up period was 17.8 ± 5.1 months. RESULTS: Hospital mortality rates were 0% in the surgical and 80% in the nonsurgical group. The mean length of hospitalization was 28.4 ± 6.7 days in the surgical group. The 1-year survival rates were 100% in the surgical group and 20% in the nonsurgical group. CONCLUSION: Open surgical repair for acute thoracic aortic syndrome via median sternotomy is a reasonable treatment option even in nonagenarians. Involvement of family members is important for decision-making to devise the optimal treatment strategy (surgical vs. medical).

Is it safe to move away from a full sternotomy for aortic valve replacement?

BACKGROUND: Minimally invasive surgical approaches have gained popularity among patients and surgeons. The aim of this project was to assess the safety of initiating aortic valve replacement via an anterior right thoracotomy program. METHODS: Between May 2015 and May 2019, data of all isolated primary aortic valve replacements were extracted retrospectively from our prospectively collected database and categorized into conventional median sternotomy, hemisternotomy, and anterior right thoracotomy cases. In total, 661 patients underwent isolated primary aortic valve replacement, of whom 429 (65%) had a median sternotomy, 126 (19%) had a hemisternotomy, and 106 (16%) had an anterior right thoracotomy. Preoperative characteristics were similar in each of the three groups. Statistical testing of the surgical groups was undertaken using the chi-square test for categorical variables and one-way analysis of variance with Tukey post-hoc pairwise tests (where appropriate) for continuous variables, to identify differences between pairs of data. RESULTS: Cardiopulmonary bypass and crossclamp times were significantly longer in the anterior right thoracotomy group compared to the hemisternotomy and median sternotomy groups (p < 0.001). Blood loss was significantly less and hospital stay significantly shorter in the hemisternotomy group compared to median sternotomy group but not the anterior right thoracotomy group. Mortality, stroke, renal, gastrointestinal and respiratory complications showed no statistical differences. CONCLUSION: Surgical aortic valve replacement had a very low mortality and morbidity in our experience, and it is safe to start a minimal access program for aortic valve replacement.

Initial Experience with Non-Sternotomy Minimally Invasive Pulmonary Embolectomy with Thoracoscopic Assistance.

The endpoint in emergent management of acute massive pulmonary embolism (PE) has traditionally been with embolectomy through standard median sternotomy. This approach is limited in both exposure and concomitant functional morbidity associated with sternotomy. Herein we describe a novel minimally invasive, thoracoscopically assisted approach to pulmonary embolectomy. This utilizes a small 5-cm left parasternal thoracotomy and femoral cardiopulmonary bypass to conduct thoracoscopically assisted surgical pulmonary embolectomy. This novel minimally invasive approach has been developed and successfully utilized in 3 patients with massive PE at our institution. The assistance of the thoracoscope allowed for complete visualization and clot extraction of the main and segmental pulmonary arteries bilaterally. The use of a non-sternotomy approach sped both functional and pulmonary recovery times and decreased length of stay. These initial data suggest that non-sternotomy minimally invasive surgical pulmonary embolectomy with thoracoscopic assistance is a feasible and safe approach for acute massive PE that may result in enhanced recovery times and decreased hospital length of stay.

Less Invasive Approach to Left Ventricular Assist Device Implantation May Improve Survival in High-Risk Patients.

OBJECTIVE: Despite improvement in outcomes after left ventricular assist device (LVAD) implantation over the past 2 decades, high-risk recipients continue to have a prohibitive rate of morbidity and mortality. We hypothesized that a less invasive approach to LVAD implantation would be associated with improved survival compared to a conventional approach in this high-risk cohort. METHODS: All consecutive LVAD recipients (2013 to 2017) that underwent centrifugal LVAD implantation were retrospectively reviewed. Patients were classified as high-risk if INTERMACS 1 or required temporary VAD/venoarterial extracorporeal membrane oxygenation prior to durable VAD implantation. Patients were stratified into 3 groups: left thoracotomy with hemi-sternotomy (LTHS) high-risk, conventional sternotomy (CS) high-risk, and non-high-risk. The primary outcome was 1-year survival. RESULTS: A total of 57 patients (LTHS high-risk: 11, CS high-risk: 12, non-high-risk: 34) were identified. Preoperative right ventricular failure scores, HeartMate-II mortality scores, and end-organ dysfunction were similar between the 2 high-risk groups. While operative time was similar between the 3 groups, cardiopulmonary bypass time was significantly shorter in the LTHS high-risk group compared to other groups. There was a trend toward decreased intensive care unit length of stay and ventilator time in LTHS high-risk compared to CS high-risk patients. Moreover, between these 2 groups, there was a significant decrease in temporary right VAD support (50% vs 0%, P = 0.014), and 1-year survival was significantly higher in the LTHS group (42% vs 91%, P = 0.025). CONCLUSIONS: Less invasive LVAD implantation appears to be associated with improved survival compared to conventional LVAD implantation in high-risk patients.

Impact of Surgical Approach in Double Lung Transplantation: Median Sternotomy vs Clamshell Thoracotomy.

BACKGROUND: Double lung transplantation (DLT) remains the gold standard for end-stage lung disease. Although DLT was historically performed via clamshell thoracotomy, recently the median sternotomy has emerged as a viable alternative. As the ideal surgical approach remains unclear, the aim of our study was to compare the short- and long-term outcomes of these 2 surgical approaches in DLT. METHODS: We retrospectively reviewed 192 consecutive adult patients who underwent primary DLT at our institution between 2012 and 2017 (sternotomy, n = 147; clamshell, n = 45). The impact of each surgical approach on post-transplant morbidity was investigated, and the overall survival probability analyses were performed. RESULTS: There were no significant differences in recipients' baseline and donors' characteristics and bilateral allograft ischemic time. Freedom from primary graft dysfunction, acute rejection episodes, postoperative prolonged ventilator support, tracheostomy, postoperative stroke, and airway dehiscence were comparable between these 2 groups. The duration of cardiopulmonary bypass and operative time were significantly longer in the clamshell thoracotomy group. Postoperative extracorporeal membrane oxygenation usage tended to be more frequent in the clamshell thoracotomy group than the median sternotomy group, despite no statistical significance. Length of hospital and intensive care unit stay were not influenced by the type of incision. There was no significant difference in overall survival between these 2 procedure groups (P = .61, log-rank test). CONCLUSIONS: The median sternotomy approach in DLT decreases operative time and more importantly leads to a shorter duration of cardiopulmonary bypass. The type of surgical approach did not show any statistically significant impact on adult DLT recipients' morbidity and survival.

Long-Term Outcomes of Right Minithoracotomy Versus Hemisternotomy for Mitral Valve Repair.

OBJECTIVE: Minimally invasive mitral valve repair has been increasingly adopted. Right minithoracotomy (RT) and lower hemisternotomy (HS) have each been associated with improved short-term outcomes; however, these approaches have not been directly compared to each other. The aim of this study was to compare long-term survival and durability of 2 minimally invasive approaches to mitral repair. METHODS: We retrospectively identified all isolated mitral repairs performed via RT or HS between October 1997 and June 2018; 100 RT cases and 719 HS cases were included. Outcomes of interest were postoperative complications, long-term survival, and freedom from mitral reoperation. A Cox proportional hazard model was used to compare RT and HS to a reference cohort of full-sternotomy cases. Total observation time was 9,901 patient-years and mean follow-up time was 12.2 years. RESULTS: Mean age was 58±12 years in the RT group and 56±13 years in the HS group (P = 0.2). The RT group had longer bypass (143 minutes vs. 112 minutes; P < 0.001) and cross-clamp times (99 minutes vs. 78 minutes; P < 0.001) compared with the HS group. There were no differences in operative mortality or 30-day outcomes. Survival at 5, 10, and 15 years was 99% (96-100), 92% (85-100), and 69% (30-100) in the RT group and 98% (97-99), 92% (90-94), and 89% (86-92) for HS (P < 0.9). There were no differences in risk-adjusted survival between RT, HS and full sternotomy. No long-term mitral reoperations occurred in the RT group and 8 (1%) occurred in the HS group (P < 0.50). CONCLUSIONS: Minimally invasive mitral valve repair can be performed safely through RT or HS with excellent survival and durability at 15 years.

Impact of redo sternotomy on proximal aortic repair: Does previous aortic repair affect outcomes?

PURPOSE: Proximal aortic repair (AoR) in the setting of previous sternotomy may be associated with greater risk than primary repair. Our objective was to determine whether redo sternotomy increases the risk of adverse outcomes following proximal aortic surgery. METHODS: We reviewed all proximal AoRs from 1991 to 2014. Outcomes were compared between first-time AoR (non-redo = 1305) and redo AoRs, which were further classified into 3 categories: (1) previous acute type A aortic dissection (AAD) repair (redo-AAD = 146, 8.3%); (2) previous proximal aneurysm repair (redo-aneurysm = 165, 9.4%); and (3) previous cardiac (non-aortic) sternotomy (redo-cardiac = 145, 8.2%). Data were analyzed by contingency tables and multiple regression. RESULTS: In total, 456 of 1761 (25.9%) proximal AoRs had redo sternotomy. Aortic redos (redo-AAD and redo-cardiac) had significantly more connective tissue disorders (P < .001). On presentation, AAD was least common in aortic redos followed by cardiac redos (redo-cardiac) versus non-redos (5% vs 28% vs 31%, P < .001). At reoperation, 190 underwent ascending + hemiarch (21% redo-AAD, 50% redo-aneurysm, 53% redo-cardiac), 140 total arch (64% redo-AAD, 15% redo-aneurysm, 15% redo-cardiac), 110 elephant trunk (52% redo-AAD, 12% redo-aneurysm, 11% redo-cardiac), 159 AVR (36% redo-AAD, 42% redo-aneurysm, 25% redo-cardiac), and 100 aortic root (34% redo-AAD, 22% redo-aneurysm, 10% redo-cardiac). Except for pulmonary, redo sternotomy did not increase risk of postoperative complications. Thirty-day mortality after redo sternotomy was 14%-the greatest among cardiac redos. Over a median follow-up of 13 years, non-redos had significantly greater long-term survival (P < .001). Coronary artery disease was a significant predictor of mortality (P < .001). After adjustment for coronary artery disease, cardiac redos had the greatest long-term mortality risk (hazard ratio, 1.43, P < .005). Previous AoR did not significantly add risk above redo sternotomy alone (P = .734). CONCLUSIONS: Redo sternotomy is associated with increased risk for short- and long-term mortality after proximal aortic repair. Despite need for extensive repair, previous proximal aortic (for aneurysm or AAD) repair did not add further risk above that attributable to redo sternotomy.

Minimally Invasive Redo-Aortic Valve Replacement: Reduced Operative Times as Compared to Full Sternotomy.

OBJECTIVES: Increasing experience with minimally invasive cardiac (MIC) aortic valve (AV) replacement makes AV reoperations (rAVR) an appealing alternative to conventional redo surgery. The aim of the study was to compare the perioperative outcome after isolated MIC versus full-sternotomy (FS) rAVR. METHODS: We retrospectively analyzed data of 116 patients from three centers who underwent rAVR by using a FS (n = 70, 60.3%) or a partial upper sternotomy approach (n = 46, 39.7%). Both groups were compared in terms of 30-day mortality by using binary-logistic regression models. Further the EuroSCORE II was used to adjust for preoperative conditions in a multivariable model. Perioperative times and complications were compared between the two groups. RESULTS: There was no statistically significant difference in perioperative mortality between FS (n = 5, 7.1%) and MIC (n = 1, 2.2%) rAVR in the original population (odds ratio [OR] 3.462, 95% confidence interval [CI] 0.391-30,635, p = 0.264) and after adjusting for EuroSCORE II (OR 2.759, 95% CI 0.298-25.567, p = 0.372). Cardiopulmonary bypass- (115.5 minutes vs. 137.5 minutes, p = 0.070) and cross-clamp times (69.0 minutes vs. 81.0 minutes, p = 0.028) were reduced in the MIC group. There was a lower prevalence of postoperative renal failure requiring renal replacement therapy (RRT) in the MIC group 0 and 8.6% (p = 0.041), respectively. No differences were detected between the groups regarding postoperative complications. CONCLUSION: MIC rAVR is associated with reduced cardiopulmonary and cross-clamp times as well as the need for RRT as compared with FS. MIC-rAVR seems to be a viable option in surgical candidates for AV reoperations.

Fibrin-Coated Collagen Fleece Seems to Prevent Sternal Instability after Cardiac Surgery: A Matched Pair Data Analysis.

BACKGROUND: To examine if fibrin-coated collagen fleece (Tachosil) interferes with bone and wound healing when it is used on the cut surface of the sternum after median sternotomy. METHODS: A total of 25 patients with osteoporotic sternal disorders were treated with fibrin-coated collagen fleece at the cut surface of the sternum after median sternotomy (therapy group). We compared the occurrence of impaired wound healing and sternal instability, reoperation rate, and 30-day mortality with a control group of 25 case-matched patients. After matching for age, gender, and risk factors for sternal instability (diabetes mellitus, osteoporosis, body mass index, nicotine consumption), both groups were comparable. RESULTS: Sternal instability occurred in one (4%) patient in the study group and in five (20%) patients in the control group. Impaired wound healing occurred in one (4%) patient in the therapy group and two (8%) patients in the control group. Reoperation was necessary in four (16%) patients in the therapy group and 6 (24%) patients in the control group. The 30-day mortality occurred in six (24%) patients in the therapy group and four (16%) patients in the control group. CONCLUSIONS: The use of fibrin-coated collagen fleece on the cut surface of the sternum in patients with osteoporosis does not impair bone and wound healing. Furthermore, it seems to result in less sternal instability. A larger prospective study is necessary to verify the results of this explorative study.

Surgical repair of cervical aortic arch: An alternative classification scheme based on experience in 35 patients.

OBJECTIVE: Cervical aortic arch (CAA) is rare and difficult to repair. Clinical experience is limited. We report the surgical techniques and midterm outcomes in 35 patients with CAA based on an alternative classification scheme. METHODS: Of 35 patients with CAA, 30 (85.7%) had left-sided aortic arch and 5 had (14.3%) right-sided aortic arch (all 5 had a vascular ring). Mean age was 34.2 ± 13.1 years, 23 were female (65.7%), and 18 were asymptomatic (51.4%). Surgical access and procedure were chosen according to an alternative classification scheme that is based on the presence or absence of vascular ring and relationship of descending aorta to the side of the aortic arch. In the left-sided aortic arch group, aortic arch reconstruction though median sternotomy was performed in 15 patients, and distal arch and descending thoracic aortic replacement via left thoracotomy in 15 patients. In the right-sided aortic arch group, ascending-to-descending aortic bypass was done via median sternotomy in 2 patients and right thoracotomy in 1, and distal arch and descending thoracic aortic replacement via right thoracotomy in 2 patients. RESULTS: Neither death nor spinal cord injury occurred. Left recurrent laryngeal nerve injury, prolonged ventilation, and reexploration for bleeding occurred in 1 each. In 11 patients with coarctation, the upper-lower limb gradient decreased significantly postoperatively (from 34.0 ± 12.7 to 10.2 ± 2.7 mm Hg; P < .01). The diseased aortic segment was excluded in 34 patients, except 1 with residual aneurysm in the proximal descending thoracic aorta. Follow-up was complete in 100% at mean 4.4 ± 2.0 years. No late death, limb ischemia, or stroke occurred. Endovascular repair was performed in 1 patient, and ascending aortic dilation occurred in 1 patient. The residual aorta remained nondilated in 33 patients. Aortic grafts were patent in 100%, with no anastomotic leak or pseudoaneurysm. At 6 years, the incidences of death, aortic events, and event-free survival were 0%, 6.5%, and 93.5%, respectively. CONCLUSIONS: Open repair of CAA can achieve favorable early and midterm outcomes. Surgical accesses and procedures should be chosen based on type of CAA, anatomic variations and associated anomalies. Our alternative categorization scheme of CAA is intuitive and comprehensive, which may facilitate classification and surgical decision making.

Propensity-Matched Comparison of Two Different Access Modes for Minimally Invasive Mitral Valve Surgery.

Mitral valve surgery is being performed routinely using minimally invasive operative techniques. We aimed comparing perioperative and long-term outcomes of minimally invasive mitral valve surgery using 2 different surgical approaches, partial upper sternotomy (PUS) vs right anterolateral minithoracotomy (RAT). From January 1998 through December 2015, 1006 patients underwent mitral valve surgery using a minimally invasive access in our institution. Logistic regression analysis was used to identify covariates among 18 patient variables including the type of mitral valve surgery. Using the significant regression coefficients, each patient's propensity score was calculated, allowing selectively matched subgroups of 243 patients each. Results are based on the matched cohorts between the 2 groups. The PUS approach was performed by 8 surgeons whereas the RAT approach by 2. PUS led to slightly longer duration of the cross-clamp time (100 ± 28 vs 88 ± 26 minutes, P < 0.001) whereas ventilation time (9 ± 37 vs 11 ± 66 hours, P < 0.001) was shorter in PUS than in RAT group. Besides the number of pacemaker implants (PUS: 6.6% vs RAT: 0.4, P = 0.0005) and postoperative chest tube drainage amount at 24 hours (PUS: 556 ± 557 mL/24 h vs RAT: 716 ± 580 mL/24 h, P < 0.001) no differences between the 2 groups regarding further perioperative outcome were observed. Long-term survival and freedom from mitral valve reintervention were comparable between the 2 groups at 6- and 8 years' follow-up. Minimally invasive mitral valve surgery can be performed safely using a PUS or RAT approach without any differences regarding perioperative and long-term morbidity and mortality. Although the RAT approach may be cosmetically more appealing in female patients, PUS may facilitate both safe performance of mitral valve surgery and resident training.

Intrathoracic complications associated with trans-femoral transcatheter aortic valve replacement: Implications for emergency surgical preparedness.

BACKGROUND: Intrathoracic complications (ITC) requiring emergency surgical intervention occur during transcatheter aortic valve replacement (TAVR). OBJECTIVES: Characterize the incidence, outcomes and predictors of ITC in a large cohort of transfemoral (TF) TAVR cases over a 5 year period. METHODS: Retrospective registry and chart review of all nonclinical trial TF-TAVR patients from seven centers within one hospital system from 2012-2016. ITC were defined as cardiac perforation, new or worsening pericardial effusion/tamponade, annular rupture, thoracic aortic injury, aortic valve dislodgement, and coronary artery occlusion. Procedural and 30-day outcomes and 1-year mortality were compared between ITC and no ITC patients. Multivariable logistic regression was used to identify predictors of ITC. RESULTS: Over the study period, 1,581 patients had TF-TAVR and 68 ITC occurred in 46 patients (2.9%). The most common ITCs were pericardial effusion/tamponade (59%), cardiac perforation (33%), and valve dislodgement (33%). ITC rate did not decline over time (rate (95% confidence interval) for 2012 = 0% (0-8.8%), 2013 = 1.3% (0-7.2%), 2014 = 4.4% (2.2-8.0%), 2015 = 3.5% (2.0-5.6%), and 2016 = 2.4% (1.5-3.8%)). ITC patients had worse 1-year survival (ITC: 60.7% (45.1-73.1%), no ITC: 88.7% (87.0-90.3%); p < .001). The majority of ITC patient deaths occurred within the first 30 days. Multivariable models to predict ITC were not successful. CONCLUSIONS: ITC did not decline over time in our cohort. Predictors of ITC could not be identified. While these events are rare, they are associated with worse procedural outcomes and mortality. Heart teams should continue to be prepared for emergency intervention.

Is the era of bilateral internal thoracic artery grafting coming for diabetic patients? An updated meta-analysis.

OBJECTIVE: Because of an increased risk of sternal wound complications, the use of bilateral internal thoracic artery grafting in diabetic patients remains controversial. The objective of the present meta-analysis is to compare the safety and efficacy of single internal thoracic artery and bilateral internal thoracic artery grafting in the diabetic population. METHODS: Four electronic databases, including PubMed, the Cochrane Library, Embase, and ISI Web of Knowledge, were comprehensively searched. Prospective randomized trials or observational studies comparing single internal thoracic artery and bilateral internal thoracic artery were considered eligible for the current study. RESULTS: A literature search yielded 1 randomized controlled trial and 17 observational studies (129,871 diabetic patients: 124,233 single internal thoracic arteries and 5638 bilateral internal thoracic arteries). Pooled analysis demonstrated overall incidence of deep sternal wound infection in the bilateral internal thoracic artery grafting group was significantly higher than in the single internal thoracic artery grafting group (3.26% for bilateral internal thoracic artery vs 1.70% for single internal thoracic artery). No significant difference was found between both groups in terms of risk of deep sternal wound infection when the skeletonized harvesting technique was adopted. Furthermore, in-hospital mortality was comparable between both groups (2.80% for bilateral internal thoracic artery vs 2.36% for single internal thoracic artery). However, compared with single internal thoracic artery grafting, bilateral internal thoracic artery grafting could confer a lower risk for long-term overall mortality (hazard ratio, 1.41; 95% confidence interval, 1.18-1.67; P < .001; I2 = 63%) and cardiac mortality (hazard ratio, 3.15; 95% confidence interval, 2.23-4.46; P < .001; I2 = 0%). CONCLUSIONS: Compared with single internal thoracic artery grafting, bilateral internal thoracic artery grafting is associated with enhanced long-term survival among diabetic patients. Skeletonization of bilateral internal thoracic artery is not associated with an increased risk of deep sternal wound infection. Therefore, surgeons should be encouraged to adopt bilateral internal thoracic artery grafting in a skeletonized manner more routinely in diabetic patients.

[Wound infections following open heart surgery - review].

Wound infections are common complications after open heart surgery, both in the sternotomy and vein harvest wound. Fortunately, most of these infections are superficial and respond to minor wound debridement and antibiotics, however, 1-3% of patients develop deep sternal wound infection with mediastinis; an infection that can be fatal. Late infections with sternocutaneous fistulas are encountered less often, but also represent a complex surgical problem. The vein harvest site is the most common site for wound infections after cardiac surgery and these infections result in significant patient morbidity and increases health-care costs. This evidence-based review covers etiology, risk factors, prevention and treatment of wound infections following open heart surgery with special focus on advances in treatment, especially negative-pressure wound therapy.