Excision of Atrial Myxoma Through a Totally Thoracoscopic Approach on the Fibrillating Heart.

Cardiac myxomas are the most common form of primary cardiac neoplasms. Although benign, they can be deleterious by causing embolic events and intracardiac obstruction. After complete surgical resection, the prognosis is excellent. Although isolated case reports performing video-assisted thoracotomy on the arrested heart have been published, median sternotomy with central cannulation remains the standard approach. We herein describe the case of a morbidly obese patient undergoing successful total resection of a left atrial myxoma using a completely thoracoscopic approach on the fibrillating heart.

Long-term outcome after totally thoracoscopic ablation for atrial fibrillation.

INTRODUCTION: Totally thoracoscopic ablation for symptomatic atrial fibrillation (AF) refractory to drug or catheter based therapy is indicated as a Class 2A recommendation according to latest guidelines. Evidence for long-term rhythm control and stroke reduction is limited. The aim of this study was to report on long-term outcome after totally thoracoscopic ablation. METHODS AND RESULTS: In total 82 consecutive patients were included that underwent totally thoracoscopic ablation including left appendage closure (2012-2013). The primary outcome was freedom from atrial arrhythmia recurrence. Secondary outcomes were survival, freedom from cerebrovascular events, freedom from reablation and definite pacemaker implantation. The mean age was 59.9 ± 8.6 years and 71% were male. The mean CHA2 DS2 -VASc score was 1.2 ± 1.0. The overall freedom from atrial arrhythmia was 60% after a mean follow up of 4.0 ± 0.6 years. Freedom from cerebrovascular events was 98.8% after mean follow-up of 4.4 ± 0.3 years and overall survival was 98.8%, with one noncardiac related death. The observed rate of ischemic stroke, hemorrhagic stroke or transient ischemic attack was 0.3 per 100 patient-years. CONCLUSIONS: Totally thoracoscopic ablation is an effective sustainable rhythm control therapy for AF with a reasonable recurrence rate and low stroke rate when performed in dedicated AF centers.

Thoracoscopic ablation for the treatment of atrial fibrillation: a systematic outcome analysis of a multicentre cohort.

AIMS: To perform a systematic outcome analysis in order to provide cardiologists and general pactitioners with more adequate information to guide their decision making regarding rhythm control. Totally thoracoscopic maze (TTmaze) for the treatment of atrial fibrillation (AF) is recommended as a Class 2a indication mainly based on single centre studies including small patient cohorts and inconsistent lesion sets. METHODS AND RESULTS: We studied consecutive patients undergoing TTmaze in three European referral centres (2012-15). Primary outcome was freedom from atrial tachyarrhythmia (ATA). Secondary outcomes were 30-day complications, the composite endpoint of ischaemic stroke, haemorrhagic stroke or transient ischaemic attack (TIA), all-cause mortality, and predictors of ATA recurrence. Four hundred and seventy-five patients were included, with a mean age of 61 ± 9 years and 69.5% male. The mean CHA2DS2-VASc score was 1.7 ± 1.3. The overall freedom from ATA was 68.8% after a mean follow-up period of 20 ± 9 months. Freedom from ATA was 72.7% for paroxysmal AF, 68.9% for persistent AF, and 54.2% for longstanding persistent AF. Multivariate analysis revealed female gender [hazard ratio (HR): 1.87, P = 0.005], in-hospital AF (HR: 1.95, P = 0.040), longer duration of preoperative AF (HR: 1.06, P = 0.003) and mitral regurgitation (HR: 1.84, P = 0.025) as independent predictors of ATA recurrence. Overall 30-day freedom from any complication was 92.4%. Freedom from cerebrovascular events after mean follow-up of 30 ± 16 months was 98.7% and overall survival was 98.3%. The observed rate of ischaemic stroke, haemorrhagic stroke, or TIA was low (0.5 per 100 patient-years). CONCLUSION: Totally thoracoscopic maze is a safe and effective rhythm control therapy.

Minimally Invasive Mitral Valve Surgery With Endoaortic Balloon Requires Cerebral Monitoring.

After induction of anesthesia, an extra right radial artery catheter and cerebral oximetry were placed for minimally invasive mitral valve surgery. An anterolateral minithoracotomy, endoaortic balloon, and left atriotomy allowed visualization of the mitral valve. During the procedure, we observed a drop of the right cerebral oximetry saturation without a drop in right radial artery pressure. We suspected an aberrant right subclavian artery. After the endoaortic balloon was repositioned, right cerebral oximetry recovered. A postoperative computed tomography scan revealed an aberrant right subclavian artery. In this case, bilateral upper extremity arterial pressure monitoring would not have detected cerebral hypoperfusion.

Comparison of Endoaortic and Transthoracic Aortic Clamping in Less-Invasive Mitral Valve Surgery.

BACKGROUND: Less-invasive mitral valve surgery has become a widespread procedure in recent years, although mode of perfusion and aortic clamping are still debated questions. The aim of this study was to compare the results between transthoracic aortic clamping (TTC) and endoaortic clamping (EAC) in a multicenter, retrospective study. METHODS: Data from 3 centers experienced in both TTC and EAC were retrospectively analyzed. Five hundred consecutive patients undergoing less-invasive mitral valve surgery received either TTC (n = 250) or EAC (n = 250). Age, sex, logistic EuroSCORE, ejection fraction, associated procedures, and mitral valve repair rate were similar. A higher incidence of previous cardiac operations was observed in the EAC group (TTC 8.8% versus EAC 16.8%, p = 0.001). RESULTS: Clamping and cardiopulmonary bypass times were comparable between the 2 groups. Reoperation for bleeding (TTC 11.2% versus EAC 3.2%, p < 0.001), conversion to full sternotomy (6 cases in the TTC group), and hospital length of stay (TTC 9 days versus EAC 8 days, p = 0.01) were higher in the TTC group. No differences were found in respiratory failure, renal failure, major vascular complication, stroke, and in-hospital mortality rate. CONCLUSIONS: Despite recent concerns arising about EAC, this large multicenter study shows equivalence in terms of safety and effectiveness of this technique compared with TTC. Reduction in postoperative bleeding was observed in the EAC group despite the higher rate of complex redo cases.

Does a Platelet Transfusion Independently Affect Bleeding and Adverse Outcomes in Cardiac Surgery?

BACKGROUND: Conflicting results have been reported concerning the effect of platelet transfusion on several outcomes. The aim of this study was to assess the independent effect of a single early intraoperative platelet transfusion on bleeding and adverse outcomes in cardiac surgery patients. METHODS: For this observational study, 23,860 cardiac surgery patients were analyzed. Patients who received one early (shortly after cardiopulmonary bypass while still in the operating room) platelet transfusion, and no other transfusions, were defined as the intervention group. By matching the intervention group 1:3 to patients who received no early transfusion with most comparable propensity scores, the reference group was identified. RESULTS: The intervention group comprised 169 patients and the reference group 507. No difference between the groups was observed concerning reinterventions, thromboembolic complications, infections, organ failure, and mortality. However, patients in the intervention group experienced less blood loss and required vasoactive medication 139 of 169 (82%) versus 370 of 507 (74%; odds ratio, 1.65; 95% CI, 1.05 to 2.58), prolonged mechanical ventilation 92 of 169 (54%) versus 226 of 507 (45%; odds ratio, 1.47; 94% CI, 1.03 to 2.11), prolonged intensive care 95 of 169 (56%) versus 240 of 507 (46%; odds ratio, 1.49; 95% CI, 1.04 to 2.12), erythrocytes 75 of 169 (44%) versus 145 of 507 (34%; odds ratio, 1.55; 95% CI, 1.08 to 2.23), plasma 29 of 169 (17%) versus 23 of 507 (7.3%; odds ratio, 2.63; 95% CI, 1.50-4.63), and platelets 72 of 169 (43%) versus 25 of 507 (4.3%; odds ratio, 16.4; 95% CI, 9.3-28.9) more often compared to the reference group. CONCLUSIONS: In this retrospective analysis, cardiac surgery patients receiving platelet transfusion in the operating room experienced less blood loss and more often required vasoactive medication, prolonged ventilation, prolonged intensive care, and blood products postoperatively. However, early platelet transfusion was not associated with reinterventions, thromboembolic complications, infections, organ failure, or mortality.

Effectiveness of pericardial lavage with or without tranexamic acid in cardiac surgery patients receiving intravenous tranexamic acid: a randomized controlled trial.

OBJECTIVES: Pericardial lavage with saline, with or without tranexamic acid (TA), is still not evidence-based within current clinical practice as a part of a blood conservation strategy in cardiac surgery patients receiving intravenous TA administration. The objective was to determine whether intravenous TA combined with pericardial lavage with saline, with or without TA, reduces blood loss by 25% after cardiac surgery measured in the first 12 h postoperatively. METHODS: In this single-centre, randomized controlled, multiple-armed, parallel study, individual patients were randomly assigned to receive either topical administration of 2 g TA diluted in 200 ml of saline (TA group), 200 ml of saline (placebo group) or no topical administration at all (control group). Eligible participants were all adults aged 18 or older and scheduled for elective cardiac surgery on cardiopulmonary bypass. All patients received 2 g TA intravenously before sternal incision and 2 g TA after cardiopulmonary bypass. The main outcome measure was the 12-h postoperative blood loss. RESULTS: In total, 739 individuals were analysed according to intention-to-treat analyses (TA group, n = 245 patients; placebo group, n = 249 patients; control group, n = 245 patients). There was no difference in the median 12-h postoperative blood loss between the three groups [TA group, 290 (IQR 190-430) ml; placebo group, 290 (IQR 210-440) ml; control group, 300 (IQR 190-450) ml, P= 0.759]. CONCLUSIONS: Pericardial lavage, with or without TA, does not result in a statistically significant difference in the 12-h postoperative blood loss in cardiac surgery patients receiving intravenous TA administration. Pericardial lavage with saline, with or without TA, should not be a part of a blood conservation strategy.

Totally thoracoscopic left atrial Maze: standardized, effective and safe.

OBJECTIVES: The totally thoracoscopic left atrial Maze (TT-Maze) is a relatively new surgical solution for the treatment of atrial fibrillation (AF). The procedure consists of a complete left atrial Maze, which is performed by video-assisted thoracoscopy with the use of radiofrequency ablation. We describe our rhythm results as well as our learning curve experience of the TT-Maze. METHODS: To evaluate the learning curve, all consecutive patients who underwent a TT-Maze and were operated by one surgeon (Bart P. Van Putte) were included in the study. The endpoint of surgery was sinus rhythm with a bidirectional block of the box and pulmonary veins. RESULTS: A total of 83 patients were included. Fifty percent of the patients had paroxysmal AF. The mean indexed left atrial volume was 44 ± 15 ml/m(2) and 38% of the patients had a previous catheter ablation for AF. During a mean follow-up of 10.9 ± 4.9 months, there were no major events. At latest follow-up, 82% of the patients did not have a single registration of AF or other atrial tachyarrhythmias longer than 30 s. Patients without AF were also free from anti-arrhythmic drugs in 90% of the cases, free from coumadins or direct oral anticoagulants in 63% of the cases and free from both in 58% of the cases. CONCLUSIONS: After almost 1-year follow-up, the TT-Maze is proved to be a successful, safe and reproducible strategy for the treatment of all types of AF including patients with enlarged left atria and previously failed catheter ablation.

Endoaortic Clamping Does Not Increase the Risk of Stroke in Minimal Access Mitral Valve Surgery: A Multicenter Experience.

BACKGROUND: Some controversy exists regarding the safety of endoaortic balloon clamping in minimal access isolated mitral valve surgery (MIMVS). The aim of this European multicenter study was to analyze the results in 10 experienced centers and compare the outcomes with published data. METHODS: The most recent 50 consecutive MIMVS cases from 10 European surgeons who had performed at least 100 procedures were prospectively collected and retrospectively analyzed. All procedures were performed through right minithoracotomy with femoral cannulation and endoaortic balloon occlusion. In-hospital and 30-day outcomes were studied. Mortality and stroke rates were compared with published median sternotomy and MIMVS outcomes. RESULTS: Mean age was 63.2 ± 12.5 years, 289 (57.8%) were male, mean logistic European system for cardiac operative risk evaluation was 6.1 ± 6.2, and 53 (10.6%) procedures had cardiac reoperations. Concomitant procedures were performed in 126 (25.9%) cases. Three patients (0.6%) required conversion to full sternotomy. Ten patients (2.0%) necessitated endoaortic balloon clamping conversion (8 to external clamping), and re-exploration for bleeding was necessary in 24 (4.8%) cases. Mean aortic cross-clamp and cardiopulmonary bypass times were 85.6 ± 30.1 and 129.5 ± 40.2 min, respectively, and were significantly longer for concomitant procedures (p < 0.001). There were no aortic dissections and no deep venous thromboses. Operative mortality (none neurologic) and major stroke occurred in 7 (1.4%) and 4 (0.8%) patients, respectively. These rates compared favorably with the published literature on isolated primary mitral valve surgery (MVS) through sternotomy or minithoracotomy (mortality rates 0.2% to 11.6%, stroke rates 0.6% to 4.4%). CONCLUSIONS: Once procedural proficiency is acquired, endoaortic balloon clamping in MIMVS is a safe and effective technique. Despite the fact that this patient cohort also includes combined and redo procedures, the observed mortality and stroke rate compared favorably with the existing literature on primary isolated mitral valve surgery irrespective of the approach.

Comparing the endo-aortic balloon and the external aortic clamp in minimally invasive mitral valve surgery.

OBJECTIVES: The aim of this study was to assess the differences in perioperative outcomes and complications between the endo-aortic balloon (EAB) and the external aortic clamp (EAC) during primary elective minimally invasive mitral valve surgery (MIMVS) in a single referral centre by one surgeon. Primary outcomes were cardiopulmonary bypass time (CPB), cross-clamp time (CX) and occurrence of postoperative cerebrovascular accidents (CVAs). Secondary outcomes were other perioperative parameters and complications. METHODS: We retrospectively analysed 340 consecutive patients who underwent MIMVS for mitral regurgitation (MR), mitral stenosis or combined regurgitation/stenosis between November 2010 and March 2014 in a single referral centre. In total, 221 patients who underwent an isolated mitral valve repair or isolated mitral valve replacement or repair/replacement combined with an atrial fibrillation (AF)-ablation procedure were included. Patients who had previous cardiac surgery or concomitant tricuspid valve surgery, myxoma or atrial septal defect closure surgery were excluded. RESULTS: A total of 57 patients (Group A) underwent MIMVS using the EAC and 164 patients (Group B) were operated using an EAB. Preoperative variables showed a significant difference in poor left ventricular function (LVF, P = 0.18) and moderate LVF (P = 0.019). No significant differences were found in CPB-time, cross-clamp time or postoperative CVA. Furthermore, no significant differences were found in complications, 30-day mortality or postoperative echocardiographical MR gradation. Hospital stay, however, was prolonged in Group A (P = 0.001) and maximum troponin T levels were significantly lower in Group B (P = 0.014). In Group B however, 10 procedures were converted (6%) from EAB to EAC. CONCLUSIONS: There is no difference in use between the EAB and the EAC in terms of CPB-time and cross-clamp time, complications or MR gradation at discharge. Use of the EAC showed significantly higher postoperative levels of troponin T, implying more myocardial damage, compared with the EAB. In 6% of the cases however, patients were converted from the EAB to the EAC.

Defining indications for selective chest radiography in the first 24 hours after cardiac surgery.

OBJECTIVE: In the intensive-care unit (ICU), chest radiographs (CXRs) are frequently obtained routinely for postoperative cardiac surgery patients, despite the fact that the efficacy of routine CXRs is known to be low. We investigated the efficacy and safety of CXRs performed after cardiac surgery for specified indications only. METHODS: In this observational cohort study, we prospectively included all patients who underwent conventional major cardiac surgery by median sternotomy in the year 2012. On-demand CXRs could be obtained during the first postoperative period for specified indications only. A routine control CXR was performed on the morning of the first postoperative day for all patients who had not undergone a CXR before that time. The diagnostic and therapeutic efficacy values were calculated for all CXRs. Differences were tested using Fisher's exact test or χ(2) analysis. RESULTS: A total of 1102 consecutive cardiac surgery patients were included in this study. The diagnostic efficacy of CXRs for major abnormalities was higher for the postoperative on-demand CXRs (n = 301; 27%) than for the routine CXRs taken the morning after surgery (n = 801; 73%) (6.6% vs 2.7%, P = .004). The therapeutic efficacy was higher for the on-demand CXRs, whereas the need for intervention after the next-morning, routine CXRs was limited to 5 patients (4.0% vs 0.6%, P < .001). None of these patients experienced a major adverse event. CONCLUSIONS: Defining clear indications for selective CXRs after cardiac surgery is effective and seems to be safe. This approach may significantly reduce the total number of CXRs performed, and will increase their efficacy.

The value of routine chest radiographs after minimally invasive cardiac surgery: an observational cohort study.

BACKGROUND: Chest radiographs (CXRs) are obtained frequently in postoperative cardiac surgery patients. The diagnostic and therapeutic efficacy of routine CXRs is known to be low and the discussion regarding the safety of abandoning these CXRs after cardiac surgery is still ongoing. We investigated the value of routine CXRs directly after minimally invasive cardiac surgery. METHODS: We prospectively included all patients who underwent minimally invasive cardiac surgery by port access, ministernotomy or bilateral video-assisted thoracoscopy (VATS) in the year 2012. A direct postoperative CXR was performed on all patients at ICU arrival. All CXR findings were noted, including whether they led to an intervention or not. The results were compared to the postoperative CXR results in patients who underwent conventional cardiac surgery by full median sternotomy over the same period. MAIN RESULTS: A total of 249 consecutive patients were included. Most of these patients underwent valve surgery, rhythm surgery or a combination of both. The diagnostic efficacy for minor findings was highest in the port access and bilateral VATS groups (56% and 63% versus 28% and 45%) (p < 0.005). The diagnostic efficacy for major findings was also higher in these groups (8.9% and 11% versus 4.3% and 3.8%) (p = 0.010). The need for an intervention was most common after minimally invasive surgery by port access, although this difference was not statistically significant (p = 0.056). CONCLUSIONS: The diagnostic efficacy of routine CXRs performed after minimally invasive cardiac surgery by port access or bilateral VATS is higher than the efficacy of CXRs performed after conventional cardiac surgery. A routine CXR after these procedures should still be considered.

Tolerance of intraoperative hemoglobin decrease during cardiac surgery.

BACKGROUND: It has been suggested that a decrease of at least 50% from the preoperative hemoglobin (Hb) level during cardiac surgery is associated with adverse outcomes even if the absolute Hb level remains above the commonly used transfusion threshold of 7.0 g/dL. In this study the relation between intraoperative Hb decline of at least 50% and a composite endpoint was analyzed. STUDY DESIGN AND METHODS: This single-center study comprised 11,508 patients who underwent cardiac surgery and had normal preoperative Hb levels (12.0-16.0 g/dL in women, 13.0-18.0 g/dL in men) between January 2001 and December 2011. Logistic regression modeling was used. The composite endpoint comprised in-hospital mortality, stroke, myocardial infarction, and renal failure. RESULTS: Patients whose Hb did not decrease at least 50% and remained above 7 g/dL were used as reference (n = 9672). A total of 363 (3.2%) patients had an intraoperative Hb of less than 7 g/dL during surgery but a Hb decrease of less than 50%; 876 patients (7.4%) showed both a nadir Hb less than 7 g/dL and a Hb decrease of at least 50%, while 597 (5.2%) had a Hb decrease of at least 50% and a nadir Hb of at least 7 g/dL. In this last group the incidence of the composite endpoint was higher than in patients in the reference group (adjusted odds ratio, 1.27; 95% confidence interval, 1.14-1.41). CONCLUSIONS: Our findings show that a decrease of at least 50% from baseline Hb during cardiac surgery is associated with adverse outcomes, even if the absolute Hb level remains higher than the commonly used transfusion threshold of 7.0 g/dL.

Association of perioperative troponin and atrial fibrillation after coronary artery bypass grafting.

OBJECTIVES: Prediction of atrial fibrillation (AF) after coronary artery bypass grafting (CABG) may lead to preventive or early treatment and improved outcome. We investigated the association of serial perioperative cardiac troponin T (cTNT) measurements with postoperative AF in patients undergoing CABG. METHODS: In a retrospective analysis of prospectively collected data, 3148 patients undergoing elective CABG were evaluated. cTNT values were routinely determined before the start of surgery (cTNT0), at arrival on the intensive care unit (cTNT1) and 8-12 h later (cTNT2). Measurement of cTNT was continued until the peak value was reached. The development of AF during hospital stay was scored. The association between cTNT (cTNT0, cTNT1, cTNT2 and cTNTmax in first 48 h) and AF was calculated in univariable and multivariable analysis. RESULTS: AF occurred in 1080 (34%) patients. cTNT0, cTNT2 and cTNTmax were significantly and positively associated with postoperative AF (P < 0.001) in a univariable analysis, whereas a trend was seen for cTNT1 (P = 0.051). Advanced age, inotropic support and postoperative infection were independently associated with postoperative AF after logistic regression analysis, but cTNT was not. Categorizing patients by inotropic support into categories of inotropic support duration (none, <48 h, >48 h), the mean cTNT values were significantly higher among patients with AF in each category (all P < 0.001). Perioperative cTNT was significantly higher in patients with postoperative complications, longer hospital stay and reduced in-hospital survival. CONCLUSIONS: Perioperative cTNT is univariably associated with postoperative AF after CABG, but not independently. Further, no clinically useful cut-off point for preventive or early treatment could be identified. Both perioperative cTNT and postoperative AF are associated with negative outcome and prolonged hospital stay.

Left bundle-branch block induced by transcatheter aortic valve implantation increases risk of death.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is a novel therapy for treatment of severe aortic stenosis. Although 30% to 50% of patients develop new left bundle-branch block (LBBB), its effect on clinical outcome is unclear. METHODS AND RESULTS: Data were collected in a multicenter registry encompassing TAVI patients from 2005 until 2010. The all-cause mortality rate at follow-up was compared between patients who did and did not develop new LBBB. Of 679 patients analyzed, 387 (57.0%) underwent TAVI with the Medtronic CoreValve System and 292 (43.0%) with the Edwards SAPIEN valve. A total of 233 patients (34.3%) developed new LBBB. Median follow-up was 449.5 (interquartile range, 174-834) days in patients with and 450 (interquartile range, 253-725) days in patients without LBBB (P=0.90). All-cause mortality was 37.8% (n=88) in patients with LBBB and 24.0% (n=107) in patients without LBBB (P=0.002). By multivariate regression analysis, independent predictors of all-cause mortality were TAVI-induced LBBB (hazard ratio [HR], 1.54; confidence interval [CI], 1.12-2.10), chronic obstructive lung disease (HR, 1.56; CI, 1.15-2.10), female sex (HR, 1.39; CI, 1.04-1.85), left ventricular ejection fraction ≤50% (HR, 1.38; CI, 1.02-1.86), and baseline creatinine (HR, 1.32; CI, 1.19-1.43). LBBB was more frequent after implantation of the Medtronic CoreValve System than after Edwards SAPIEN implantation (51.1% and 12.0%, respectively; P<0.001), but device type did not influence the mortality risk of TAVI-induced LBBB. CONCLUSIONS: All-cause mortality after TAVI is higher in patients who develop LBBB than in patients who do not. TAVI-induced LBBB is an independent predictor of mortality.