Veno-arterial extracorporeal membrane oxygenation for post-infarction ventricular septal defect in a low-volume center.

Managing patients with post-ischaemic ventricular septal defects (VSD) and postcardiotomy cardiogenic shock can be extremely challenging in a low-volume cardiac surgery unit. We present a case of a 68-year-old patient who received veno-arterial extracorporeal membrane oxygenation support due to cardiogenic shock after VSD repair. The patient was successfully weaned off support after 86 h. In the postoperative period, mediastinitis occurred, and negative pressure wound therapy was instituted.

Surgeon-Guided Robotic Arm Facilitates LIMA Takedown in MIDCAB Surgery.

Left internal mammary artery (LIMA) to left anterior descending (LAD) coronary artery bypass has been scientifically proven to have the best patency and long-term results in myocardial revascularization. The latest guidelines suggest minimally invasive LIMA to LAD is the optimal therapy for isolated proximal LAD lesions. The start of a minimally invasive direct coronary artery bypass (MIDCAB) program can be quite challenging as robotic surgery demands high starting costs, while normal thoracoscopic techniques have a longer surgeon learning curve. In this article, we describe to the best of our knowledge the first use of surgeon-guided wristed instruments in LIMA harvesting for MIDCAB surgery. It allows for a facilitated LIMA harvest like in robotic surgery with the comfort of a surgeon constantly standing by the patient, allowing for a faster response time in case of an emergency or the need for instrument exchange. These features result in shorter operating times, lower costs compared with robotic surgery, and faster adoption of this technique for centers just starting MIDCAB surgery.

A new viewpoint on endoscopic CABG: technique description and clinical experience.

BACKGROUND: The aim of this paper is to describe a newly developed endoscopic coronary artery bypass graft (Endo-CABG) technique to treat patients with single- and multi-vessel disease and discuss the short-term clinical results in a large patient cohort. This technique avoids a median sternotomy by combining a thoracoscopic technique via three ∼5 mm thoracic ports and a mini-thoracotomy utility 3-4 cm port through the intercostal space. METHODS: From January 2016 to January 2018, data from consecutive patients undergoing an elective Endo-CABG were prospectively entered into a customized database and retrospectively reviewed. Patients scheduled for a combined hybrid intervention were excluded. Conversion rate to sternotomy, incidence of surgical revision and postoperative graft failure, one-month survival, morbidity, and length of stay (LOS) were investigated. Subgroup analyses were performed. RESULTS: A total of 342 patients undergoing an Endo-CABG with one (n = 53) or multiple (n = 289) bypasses were included. No conversion to sternotomy occurred and incidence of surgical revision, graft failure, and 30-day mortality was 7.3%, 1.5%, and 1.8%, respectively. Adverse neurological outcomes were rare: cerebrovascular accident, transient ischemic attack, epilepsy, and postoperative delirium were observed in 0.6%, 0.3%, 0.3%, and 5.3% of patients, respectively. Median intensive care unit and hospital LOS were 2.75 (IQR 1.8 to 3.8) and 8.0 days (IQR 7.0 to 10.0), respectively. Thirty-day mortality in obese patients, diabetics, and octogenarians was 0%, 3.6%, and 5.6%, respectively. EuroSCORE II > 5% was associated with a high 30-day mortality (25%). CONCLUSIONS: Endo-CABG can be considered a safe and effective procedure to treat single- and multi-vessel coronary artery disease. Individual patient selection seems not necessary to apply this technique.

The effect of minimally invasive surgical aortic valve replacement on postoperative pulmonary and skeletal muscle function.

NEW FINDINGS: What is the central question of this study? How does surgical aortic valve replacement affect cardiopulmonary and muscle function during exercise? What is the main finding and its importance? Early after the surgical replacement of the aortic valve a significant decline in pulmonary function was observed, which was followed by a decline in skeletal muscle function in the subsequent weeks of recovery. These date reiterate, despite restoration of aortic valve function, the need for a tailored rehabilitation programme for the respiratory and peripheral muscular system. ABSTRACT: Suboptimal post-operative improvements in functional capacity are often observed after minimally invasive aortic valve replacement (mini-AVR). It remains to be studied how AVR affects the cardiopulmonary and skeletal muscle function during exercise to explain these clinical observations and to provide a basis for improved/tailored post-operative rehabilitation. Twenty-two patients with severe aortic stenosis (AS) (aortic valve area (AVA) <1.0 cm²) were pre-operatively compared to 22 healthy controls during submaximal constant-workload endurance-type exercise for oxygen uptake ( V̇O2 ), carbon dioxide output ( V̇CO2 ), respiratory gas exchange ratio, expiratory volume ( V̇E ), ventilatory equivalents for O2 ( V̇E / V̇O2 ) and CO2 ( V̇E / V̇CO2 ), respiratory rate (RR), tidal volume (Vt ), heart rate (HR), oxygen pulse ( V̇O2 /HR), blood lactate, Borg ratings of perceived exertion (RPE) and exercise-onset V̇O2 kinetics. These exercise tests were repeated at 5 and 21 days after AVR surgery (n = 14), along with echocardiographic examinations. Respiratory exchange ratio and ventilatory equivalents ( V̇E / V̇O2 and V̇E / V̇CO2 ) were significantly elevated, V̇O2 and V̇O2 /HR were significantly lowered, and exercise-onset V̇O2 kinetics were significantly slower in AS patients vs. healthy controls (P < 0.05). Although the AVA was restored by mini-AVR in AS patients, V̇E / V̇O2 and V̇E / V̇CO2 further worsened significantly within 5 days after surgery, accompanied by elevations in Borg RPE, V̇E and RR, and lowered Vt . At 21 days after mini-AVR, exercise-onset V̇O2 kinetics further slowed significantly (P < 0.05). A decline in pulmonary function was observed early after mini-AVR surgery, which was followed by a decline in skeletal muscle function in the subsequent weeks of recovery. Therefore, a tailored rehabilitation programme should include training modalities for the respiratory and peripheral muscular system.

A comparison between minimized extracorporeal circuits and conventional extracorporeal circuits in patients undergoing aortic valve surgery: is 'minimally invasive extracorporeal circulation' just low prime or closed loop perfusion ?

INTRODUCTION: Even though results have been encouraging, an unequivocal conclusion on the beneficial effect of minimally invasive extracorporeal circulation (MiECC) in patients undergoing aortic valve surgery cannot be derived from previous publications. Long-term outcomes are rarely reported and a significant decrease in operative mortality has not been shown. Most studies have a limited number of patients and are underpowered. They merely report on short-term results of a heterogeneous intraoperative group using different types of ECC system in aortic valve surgery. The aim of the present study was to determine whether MiECC systems are more beneficial than conventional extracorporeal systems (CECC) with regard to mortality, hospital stay and inflammation and with only haemodilution and blood-air interface as differences. METHODS: We retrospectively analysed data regarding mortality, hospital stay and inflammation in patients undergoing isolated aortic valve surgery. Forty patients were divided into two groups based on the type of extracorporeal system used; conventional (n=20) or MiECC (n=20). RESULTS: Perioperative blood product requirements were significantly lower in the MiECC group (MiECC: 0.2±0.5 units vs CECC: 0.9±1.2 units, p=0.004). No differences were seen postoperatively regarding mortality (5% vs 5%, p=0.99), total length of hospital stay (10.6±7.2 days (MiECC) vs 12.1±5.9 days (CECC), p=0.39) or inflammation markers (CRP: MiECC: 7.09±13.62 mg/L vs CECC: 3.4±3.2 mg/L, p=0.89). CONCLUSION: MiECC provides circulatory support that is equally safe and feasible as conventional extracorporeal circuits. No differences in mortality, hospital stay or inflammation markers were observed.

Compromised Cardiopulmonary Exercise Capacity in Patients Early After Endoscopic Atraumatic Coronary Artery Bypass Graft: Implications for Rehabilitation.

OBJECTIVE: The purpose of this work was to test the hypothesis that cardiopulmonary exercise tolerance is better preserved early after endoscopic atraumatic coronary artery bypass graft (endo-ACAB) surgery versus coronary artery bypass graft (CABG) surgery. DESIGN: Twenty endo-ACAB surgery patients, 20 CABG surgery patients, and 15 healthy subjects executed a maximal cardiopulmonary exercise test, with assessment and comparison of cycling power output, O2 uptake, CO2 output, respiratory gas exchange ratio, end-tidal O2 and CO2 pressures, equivalents for O2 uptake and CO2 output, heart rate, O2 pulse, expiratory volume, tidal volume, respiratory rate, at peak exercise and ventilatory threshold. In patients, forced expiratory volume and forced vital capacity were measured. RESULTS: Oxygen uptake, CO2 output, expiratory and tidal volume, equivalents for O2 uptake and CO2 output, end-tidal O2 and CO2 pressures at peak exercise (matched peak respiratory gas exchange ratio between patient groups), and ventilatory threshold were significantly worse in patients versus healthy controls (P < 0.05; observed power, >0.80). All these parameters, and lung function, were, however, comparable between CABG and endo-ACAB surgery patients (P > 0.10). CONCLUSIONS: Exercise tolerance and ventilatory function during exercise seems, in contrast to expectation, equally compromised early after endo-ACAB surgery as opposed to after CABG surgery. These data may signify the need for exercise-based rehabilitation intervention early after endo-ACAB surgery.

From Bone Marrow to Cardiac Atrial Appendage Stem Cells for Cardiac Repair: A Review.

Traditionally the heart is considered a terminally differentiated organ. However, at the beginning of this century increased mitotic activity was reported in ischemic and idiopathic dilated cardiomyopathy hearts, compared to healthy controls, underscoring the potential of regeneration after injury. Due to the presence of adult stem cells in bone marrow and their purported ability to differentiate into other cell lineages, this cell population was soon estimated to be the most suited candidate for cardiac regeneration. Clinical trials with autologous bone marrow-derived mononuclear cells, using either an intracoronary or direct intramyocardial injection approach consistently showed only minor improvement in global left ventricular ejection fraction. This was explained by their limited cardiomyogenic differentiation potential. To obtain more convincing improvement in cardiac function, based on true myocardial regeneration, the focus of research has shifted towards resident cardiac progenitor cells. Several isolation procedures have been described: the c-kit surface marker was the first to be used, however experimental research has clearly shown that c-kit+ cells only marginally contribute to regeneration post myocardial infarction. Sphere formation was used to isolate the so-called cardiosphere derived cells (CDC), and also in this cell population cardiomyogenic differentiation is a rare event. Recently a new type of stem cells derived from atrial tissue (cardiac atrial stem cells - CASCs) was identified, based on the presence of the enzyme aldehyde dehydrogenase (ALDH). Those cells significantly improve both regional and global LV ejection fraction, based on substantial engraftment and consistent differentiation into mature cardiomyocytes (98%).

Improvement of Atrial and Ventricular Remodeling with Low Atrial Fibrillation Burden after Hybrid Ablation of Persistent Atrial Fibrillation.

BACKGROUND: An endoscopic transdiaphragmatic epicardial radiofrequency ablation procedure combined with percutaneous endocardial radiofrequency ablation--a hybrid procedure--is a potentially curative treatment option for patients with persistent atrial fibrillation (AF). Long-term effects of arrhythmia elimination on atrial and ventricular remodeling are not completely understood. Therefore, the aim of our study was to quantify echocardiographic structural and functional changes of the left atrium (LA) and left ventricle (LV) following a hybrid procedure. METHODS AND RESULTS: Thirty-seven consecutive patients with symptomatic drug refractory persistent AF underwent a hybrid procedure to achieve complete pulmonary vein and LA posterior wall electrical isolation. AF burden was measured using an insertable electrocardiographic (ECG) monitor. Patients were divided into responders to ablation and nonresponders according to postoperative AF burden at 12-month follow-up (responder < 0.5% vs nonresponder ≥ 0.5%). Median AF burden was 0.32 (0.04-27.5)% for all patients. In responders (19/37 patients), significant echocardiographic reduction of LA volume index from 47 to 41 mL/m(2) (P < 0.05) and improvement of LA function parameters (LA stiffness from 73.3 to 41.3 [P < 0.05], LA emptying fraction from 21% to 45% [P < 0.05], LA global longitudinal strain from 11.2% to 18.8% [P < 0.5]) was documented. In addition, LV systolic function significantly improved in comparison with nonresponders. CONCLUSION: Hybrid ablation of persistent AF achieved stable sinus rhythm in a significant proportion of patients, as evidenced by continuous ECG monitoring, resulting in important LA and LV reverse remodeling after 12 months.

Restrictive versus Standard Fluid Regimen in Elective Minilaparotomy Abdominal Aortic Repair-Prospective Randomized Controlled Trial.

Objective Elective minilaparotomy abdominal aortic aneurysm (AAA) repair is associated with a significant number of complications involving respiratory, cardiovascular, gastrointestinal, and central nervous systems, with mortality ranging up to 5%. In our study, we tested the hypothesis that intra- and postoperative intravenous restrictive fluid regimen reduces postoperative morbidity and mortality, and improves the outcome of minilaparotomy AAA repair. Methods From March 2009 to July 2013, 60 patients operated due to AAA were included in a prospective randomized controlled trial (RCT). About the administration of fluid during the operation and in the early postoperative period, all the patients were randomized into two groups: the group of standard fluid administration (S-group, 30 patients) and the group of reduced fluid administration (R-group, 30 patients). The verification of the treatment success was measured by the length of intensive care unit (ICU) stay, duration of hospitalization after the procedure, as well as the number and type of postoperative complications and mortality. This prospective RCT was registered in a publicly accessible database ClinicalTrials.gov with unique Identifier ID: NTC01939652. Results Total fluid administration and administration of blood products were significantly lower in R-group as compared with S-group (2,445.5 mL vs. 3308.7 mL, p = 0.004). Though the number of nonlethal complications was significantly lower in R-group (2 vs. 9 patients, p = 0.042), the difference in lethal complications remained nonsignificant (0 vs. 1 patient, p = ns). The average ICU stay (1.2 vs. 1.97 days, p = 0.003) and duration of postoperative hospital stay (4.33 vs. 6.20 days, p = 0.035 for R-group and S-group, respectively) were found to be significantly shorter in R-group. Conclusion Intra- and postoperative restrictive intravenous fluid regimen in patients undergoing minilaparotomy AAA repair significantly reduces postoperative morbidity, and shortens ICU and overall hospital stay. Even though incidence of lethal complication was lower in R-group, the difference did not reach statistical significance. Therefore, we may assume that this study was probably underpowered to estimate the differences in mortality between R- and S-groups. Further multicentric, sufficiently powered RCTs are needed to confirm these findings and to clarify effect of restrictive fluid management on mortality.

Cardiac atrial appendage stem cells engraft and differentiate into cardiomyocytes in vivo: A new tool for cardiac repair after MI.

BACKGROUND: This study assessed whether autologous transplantation of cardiac atrial appendage stem cells (CASCs) preserves cardiac function after myocardial infarction (MI) in a minipig model. METHODS AND RESULTS: CASCs were isolated from right atrial appendages of Göttingen minipigs based on high aldehyde dehydrogenase activity and expanded. MI was induced by a 2h snare ligation of the left anterior descending coronary artery. Upon reperfusion, CASCs were intramyocardially injected under NOGA guidance (MI-CASC, n=10). Non-transplanted pigs (MI, n=8) received sham treatment. 3D electromechanical mapping (EMM) and cardiac MRI were performed to assess left ventricular (LV) function. MI pigs developed LV dilatation at 2 months (2M), while in the MI-CASC group volumes remained stable. Global LV ejection fraction decreased by 16 ± 8% in MI animals vs 3 ± 10% in MI-CASC animals and regional wall thickening in border areas was better preserved in the MI-CASC group. EMM showed decreased viability and wall motion in the LV for both groups POST-MI, whereas at 2M these parameters only improved in the MI-CASC. Substantial cell retention was accompanied by cardiomyogenic differentiation in 98±1% of the transplanted CASCs, which functionally integrated. Second harmonic generation microscopy confirmed the formation of mature sarcomeres in transplanted CASCs. Absence of cardiac arrhythmias indicated the safety of CASC transplantation. CONCLUSION: CASCs preserve cardiac function by extensive engraftment and cardiomyogenic differentiation. Our data indicate the enormous potential of CASCs in myocardial repair.

European experience of the convergent atrial fibrillation procedure: multicenter outcomes in consecutive patients.

BACKGROUND: The objective of this collaborative, multicenter, European effort was to evaluate the outcomes of the convergent procedure for the treatment of persistent and long-standing persistent atrial fibrillation (AF) in consecutive patients at 4 European centers. METHODS: Outcomes of consecutive patients, undergoing the convergent procedure at 4 European centers, were evaluated in this study. Epicardial ablation was performed before endocardial ablation. Convergent procedure outcomes were recorded by interrogation of implanted loop recorders or Holter monitors. Rhythm status and required interventions (antiarrhythmic drugs, cardioversions, and repeat ablations) were quantified 6 and 12 months after the procedure. Outcomes, monitoring type, and patient baseline characteristics were analyzed and reported. RESULTS: Seventy-three consecutive patients presenting with persistent AF (30.1%) or long-standing persistent AF (69.9%) underwent the convergent procedure between January 2010 and December 2011. At 6 months, 82% (56/68) were in sinus rhythm. At 12 months, 80% (53/66) were in sinus rhythm; single-procedure maintenance of sinus rhythm without postblanking period interventions was 76% (50/66); 52% (34/66) were in sinus rhythm and not receiving antiarrhythmic drugs. CONCLUSIONS: This multicenter European collaborative effort demonstrated that the convergent procedure is a safe and efficacious treatment option for persistent and long-standing persistent AF.

Elective reconstruction of the ascending aorta for aneurysmal disease restores normal life expectancy. An analysis of risk factors for early and late mortality.

OBJECTIVE: We investigated the survival of patients who had undergone elective reconstruction of the ascending aorta for degenerative aneurysms. The long-term survival was compared to an age- and sex-matched case-control population. An analysis of risk factors, influencing survival was made. METHODS AND RESULTS: From May 1998 to January 2012, 72 patients underwent elective reconstruction of the ascending aorta for degenerative disease at the department of Cardiothoracic Surgery of the Jessa Hospital, Hasselt, Belgium. Sixty patients were treated with Bentall procedures, whereas 12 received valve-sparing procedures. The average age of the patient group was 65.5 years (range 24-80), with 64% males. Thirty-day mortality was 9.7% (consistent with calculated Euroscore II: 9.2%). The long-term survival was 80.9% at 3, 5 and 10 years. No deaths occurred between 3 and 10 years postoperatively. In an age- and sex case-matched Belgian population, 3-, 5- and 10-year survival were 95.7%, 94.7% and 85.2%, respectively. Long-term survival was not significantly different between both groups. Poor NYHA class at the time of surgery (P = 0.041) and COPD (P = 0.028) had a significant impact on global survival. Valve-sparing operations provide similar long-term survival, avoiding thrombo-embolic complications. CONCLUSIONS: Reconstruction of the ascending aorta for degenerative aneurysmal disease restores normal life expectancy, compared with an age- and sex-matched case-control population. Early mortality is consistent with the Euroscore II risk calculation. Whereas late survival progressively declines in the average population, it remains constant in the treated group after 3 years. COPD and poor functional class significantly impair survival. Valve-sparing procedures confer a similar long-term survival as valve replacement.

The cardiac atrial appendage stem cell: a new and promising candidate for myocardial repair.

AIMS: Considerable shortcomings in the treatment of myocardial infarction (MI) still exist and therefore mortality remains high. Cardiac stem cell (CSC) therapy is a promising approach for myocardial repair. However, identification and isolation of candidate CSCs is mainly based on the presence or absence of certain cell surface markers, which suffers from some drawbacks. In order to find a more specific and reliable identification and isolation method, we investigated whether CSCs can be isolated based on the high expression of aldehyde dehydrogenase (ALDH). METHODS AND RESULTS: An ALDH(+) stem cell population, the cardiac atrial appendage stem cells (CASCs), was isolated from human atrial appendages. CASCs possess a unique phenotype that is clearly different from c-kit(+) CSCs but that seems more related to the recently described cardiac colony-forming-unit fibroblasts. Based on immunophenotype and in vitro differentiation studies, we suggest that CASCs are an intrinsic stem cell population and are not mobilized from bone marrow or peripheral blood. Indeed, they possess a clonogenicity of 16% and express pluripotency-associated genes. Furthermore, compared with cardiosphere-derived cells, CASCs possess an enhanced cardiac differentiation capacity. Indeed, differentiated cells express the most important cardiac-specific genes, produce troponin T proteins, and have an electrophysiological behaviour similar to that of adult cardiomyocytes (CMs). Transplanting CASCs in the minipig MI model resulted in extensive cardiomyogenic differentiation without teratoma formation. CONCLUSION: We have identified a new human CSC population able to differentiate into functional CMs. This opens interesting perspectives for cell therapy in patients with ischaemic heart disease.

Low rate of atrial fibrillation recurrence verified by implantable loop recorder monitoring following a convergent epicardial and endocardial ablation of atrial fibrillation.

OBJECTIVE: Evaluate long-term outcomes in patients undergoing the Convergent procedure (CP) for the treatment of atrial fibrillation (AF). BACKGROUND: The CP provides a multidisciplinary approach, combining endoscopic creation of epicardial linear lesions followed by endocardial mapping and ablation and targets persistent and longstanding persistent AF patients who are at increased risk of heart failure, stroke, and mortality. METHODS: Outcomes from a prospective nonrandomized study were recorded for consecutive patients by interrogation of implanted Reveal monitors. Rhythm status and AF burden were quantified 6-24 months postprocedure, and compared relative to AF type, gender, age, body mass index, left atrial size, left ventricular ejection fraction, and congestive heart failure, hypertension, age >75 years, age between 65 and 74 years, stroke/TIA/TE, vascular disease (previous MI, peripheral arterial disease or aortic plaque), diabetes mellitus, female (CHA(2) DS(2) VASc). RESULTS: A total of 50 patients were enrolled with 94% having persistent or longstanding persistent AF. There were 2 atrioesophageal fistulas reported. In one patient, the fistula resulted in death at 33 days postprocedure; in the second, the fistula was surgically repaired but patient died 8 months postprocedure from a CVI. After CP, 95% of patients were in sinus rhythm at 6-month follow-up; 88% at 12 months; and 87% at 24 months. The median AF burden recorded with Reveal XT monitors was 0.0%, 0.1%, and 0.1% at 6, 12, and 24 months with 81%, 81%, and 87% of patients reporting a burden less than 3%, respectively. CONCLUSION: Using 24 × 7 continuous loop recording, the CP demonstrated success in treating persistent and longstanding persistent AF patients. Endocardial mapping and catheter ablation with diagnostic confirmation of procedural success complemented the endoscopic creation of epicardial linear lesions in restoring sinus rhythm.