Prognostic impact of shock in patients with type A acute aortic syndrome. Results of a nationwide multicenter study.

OBJECTIVE: To evaluate the clinical characteristics, imaging findings, treatment, and prognosis of patients with type A acute aortic syndrome (AAS-A) presenting with shock. To assess the impact of surgery on this patient population. METHODS: The study included 521 patients with A-AAS enrolled in the Spanish Registry of Acute Aortic Syndrome (RESA-III) from January 2018 to December 2019. The RESA-III is a prospective, multicenter registry that contains AAS data from 30 tertiary-care hospitals. Patients were classified into two groups according to their clinical presentation, with or without shock. Shock was defined as persistent systolic blood pressure <80 mmHg despite adequate volume resuscitation. RESULTS: 97 (18.6%) patients with A-AAS presented with shock. Clinical presentation with syncope was much more common in the Shock group (45.4% vs 10.1%, p = 0.001). Patients in the Shock group had more complications at diagnosis and before surgery: cardiac tamponade (36.2% vs 9%, p < 0.001), acute renal failure (28.9% vs 18.2%, p = 0.018), and need for orotracheal intubation (40% vs 9.1%, p < 0.001). There were no significant differences in aortic regurgitation (51.6% vs 46.7%, p = 0.396) between groups. In-hospital mortality was higher among patients with shock (48.5% vs 27.4%, p < 0.001). Surgery was associated with a significant mortality reduction both in patients with and without shock. Surgery had an independent protective effect on mortality (OR 0.03, 95% CI (0.00-0.32)). CONCLUSION: Patients with AAS-A admitted with shock have a heavily increased risk of mortality. Syncope and pericardial effusion at diagnosis are strongly associated with shock. Surgery was independently associated with a mortality reduction in patients with AAS-A and shock.

Simultaneous Transcatheter Mitral and Tricuspid Valve-in-Valve Replacement.

After the popularization of transcatheter aortic valve-in-valve replacement, mitral valve-in-valve is being increasingly performed for failing bioprostheses or annuloplasty rings. In the tricuspid position, despite smaller experience, valve-in-valve is also becoming an alternative to high-risk redo tricuspid surgery. We report the case of a patient with 2 failing mitral and tricuspid bioprostheses who was successfully treated with simultaneous transapical mitral and percutaneous transjugular tricuspid transcatheter valve-in-valve replacements.

Diagnosis, management and mortality in acute aortic syndrome: results of the Spanish Registry of Acute Aortic Syndrome (RESA-II).

BACKGROUND: Recent advances in the diagnosis and treatment of acute aortic syndrome should improve the outcome of this disease. The Spanish Registry of Acute Aortic Syndrome aimed to assess current results in acute aortic syndrome management in a wide cohort of hospitals in the same geographical area. METHODS: From January 2012 to January 2014, 26 tertiary hospitals included 629 consecutive patients with acute aortic syndrome: 73% men, mean age 64.7±14 years (range 22-92), 443 type A (70.4%) and 186 type B (29.6%). RESULTS: Time elapsed between symptom onset and diagnosis was <12 hours in 70.7% of cases and <24 hours in 84.0% (median 5 hours; 25th-75th percentiles, 2.7-15.5 hours). Computed tomography was the first diagnostic technique in 78% of patients and transthoracic echocardiography in 15%. Surgical treatment was indicated in 78.3% of type A acute aortic syndrome. The interval between diagnosis and surgery was 4.8 hours (quartile 1-3, 2.5-11.4 hours). Among the patients with type B acute aortic syndrome, treatment was medical in 116 cases (62.4%), endovascular in 61 (32.8%) and surgical in nine (4.8%). Type A mortality during hospitalisation was 25.1% in patients treated surgically and 68% in those treated medically. Mortality in type B was 13.8% in those with medical treatment, 18.0% with endovascular therapy and 33.0% with surgical treatment. CONCLUSION: Improvements in the diagnosis and treatment of acute aortic syndrome have not resulted in a significant reduction in hospital mortality. The results of this study reflect more overall and less selected information on acute aortic syndrome management and the need for sustained advances in the therapeutic strategy of acute aortic syndrome.

Fístula coronaria gigante entre el tronco coronario izquierdo y vena cava superior complicada de disección coronaria / Giant coronary artery fistula between the left main coronary artery and the superior vena cava complicated by coronary artery dissection

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Spanish Acute Aortic Syndrome Study (RESA). Better diagnosis is not reflected in reduced mortality.

INTRODUCTION AND OBJECTIVES: Because acute aortic syndrome (AAS) is associated with high mortality, early diagnosis and treatment are vital. The aim of the Spanish Acute Aortic Syndrome Study (RESA) was to investigate the effectiveness of current treatment of AAS in a broad range of tertiary care hospitals in Spain. METHODS: Between January 2005 and December 2007, 24 tertiary care hospitals reported data on 519 patients with AAS (78% male, mean age 61 +/- 13 years, range 20-92 years): 357 had type-A AAS and 162 had type B. RESULTS: The time delay between symptom onset and diagnosis was <24 hours in 67% of cases and >72 hours in 11%. Some 80% of patients with type-A AAS were treated surgically. The interval between diagnosis and surgery was <24 hours in 90% of cases. In patients with type-B AAS, 34% received invasive treatment: 11% had surgery and 23% underwent endovascular procedures. Mortality during hospitalization in patients with type-A disease was 33% in those treated surgically and 71% in those treated medically. Mortality in patients with type-B disease was 17% with medical treatment, 27% with endovascular treatment and 50% with surgical treatment. CONCLUSIONS: Despite significant advances in the diagnosis of AAS, in-hospital mortality remains high. The findings of this study are representative of a broad range of unselected patients undergoing treatment for the disease and support the need for continuing improvements in therapeutic approaches to AAS.

[Axillary artery cannulation with a Dacron graft for surgery of the aortic arch and ascending aorta]. / Canulación axilar mediante prótesis de Dacron en cirugía del arco y la aorta ascendente.

Cannulation of the axillary artery is one possible means of establishing cardiopulmonary bypass during surgery of the ascending aorta and aortic arch. Use of a Dacron graft for cannulation has a number of advantages. In this article, we report our experience with this technique in seven consecutive patients in whom we performed an ascending aorta replacement. The associated procedures involved were aortic root reconstruction using David's procedure in two patients, the Bentall procedure in one, the hemi-arch technique in two, the complete arch and elephant trunk technique in one, aortic valve repair in one, and Valsalva sinus reconstruction in one. Circulatory arrest with antegrade cerebral perfusion was carried out in three cases. There was no in-hospital mortality, and there were no vascular or infectious complications related to axillary access. One patient presented with transient paresthesia of the brachial plexus. In all cases, cardiopulmonary bypass flow was adequate.

Canulación axilar mediante prótesis de Dacron en cirugía del arco y la aorta ascendente / Axillary artery cannulation with a Dacron graft for surgery of the aortic arch and ascending aorta

La canulación de las arterias axilares para instaurar la circulación extracorpórea es una alternativa en la cirugía del arco y la aorta ascendente. Su canulación mediante una prótesis de Dacron presenta ciertas ventajas. En el presente trabajo comunicamos nuestra experiencia con esta técnica en 7 pacientes consecutivos. En todos se realizó un recambio de la aorta ascendente. Se asociaron los siguientes procedimientos: reconstrucción de la raíz aórtica según técnica de David en 2 pacientes, intervención de Bentall en uno, hemiarco en dos, arco completo y trompa de elefante en uno, resuspensión de velos aórticos en uno y reconstrucción de senos de Valsalva en uno. Se realizó parada circulatoria con perfusión anterógrada en 3 casos. La mortalidad hospitalaria fue nula. No hubo complicaciones vasculares ni infecciosas del abordaje axilar. Un paciente presentó una parestesia transitoria por afección del plexo braquial. El flujo de la circulación extracorpórea fue adecuado en todos los casos

Cannulation of the axillary artery is one possible means of establishing cardiopulmonary bypass during surgery of the ascending aorta and aortic arch. Use of a Dacron graft for cannulation has a number of advantages. In this article, we report our experience with this technique in seven consecutive patients in whom we performed an ascending aorta replacement. The associated procedures involved were aortic root reconstruction using David's procedure in two patients, the Bentall procedure in one, the hemi-arch technique in two, the complete arch and elephant trunk technique in one, aortic valve repair in one, and Valsalva sinus reconstruction in one. Circulatory arrest with antegrade cerebral perfusion was carried out in three cases. There was no in-hospital mortality, and there were no vascular or infectious complications related to axillary access. One patient presented with transient paresthesia of the brachial plexus. In all cases, cardiopulmonary bypass flow was adequate

Factores preoperatorios predictores de morbimortalidad. Mayor en la cirugía coronaria sin el uso de la circulación extracorpórea. Presentación del Canalejo Score / No disponible

Objetivos: Este es un estudio cooperativo entre el “Hospital Juan Canalejo” in A Coruña, Galicia España y el Cardiocentro “Ernesto Ché Guevara” de Villa Clara, Cuba. Este trabajo fue realizado con el objetivo de conocer cuáles son los factores de riesgo predictores de morbimortalidad mayor en los pacientes revascularizados sin el uso de la circulación extracorpórea (OPCABG) y mostrar un informe sobre la construcción del Canalejo Score. Método: De enero de 1997 a diciembre del 2002, un total de 762 pacientes fueron sometidos a cirugía de revascularización miocárdica sin el uso de la circulación extracorpórea en el servicio de cirugía cardiaca del Complejo hospitalario Juan Canalejo de A Coruña, Galicia, España. Fallecieron 25 pacientes lo que representa un 3,3% de total y presentaron complicaciones mayores 61 pacientes (8% del total de pacientes). Las variables estudiadas en cada paciente fueron recogidas de forma estudiadas en cada paciente fueron recogidas de forma prospectiva en la base de datos Apolo del servicio de cirugía cardiaca de nuestro Hospital. Para determinar las variables predictoras de presencia de eventos de interés se realizó un análisis de regresión logística utilizando como variable dependiente las complicaciones mayores y como covariables las variables que en el análisis univariado estuviesen asociadas a dichas variables o fuesen clínicamente o quirúrgicamente relevantes. Con dichas variables y teniendo en cuenta el coeficiente de regresión se calculó el score. (Canalejo score). La precisión y el poder discriminante del modelo fueron evaluados con curvas ROC. El Canalejo score fue validado en un total de 200 pacientes, de ellos 16 son fallecidos y 22 son complicaciones mayores que fueron sometidos a OPCABG durante el año 2004 en el Cardiocentro “Ernesto Ché Guevara” de Villa Clara, Cuba. Resultados y conclusiones. Las variables que modifican significativamente el riesgo de tener complicaciones mayores son: la insuficiencia renal, la arteriopatía periférica, la resucitación cardiopulmonar, la enfermedad del tronco de la arteria coronaria izquierda más los tres vasos coronarios con lesiones significativas, el antecedente de accidente cerebrovascular con secuelas, la inestabilidad hemodinámica y la fracción de eyección. El área bajo la curva con la probabilidad del modelo para predecir complicaciones mayores fue del 80% (AU)

Objective: This a cooperative study between “Juan Canalejo Hospital” in A Coruña, Galicia, Spain and “Ernesto Ché Guevara” heart Institute in Cuba. The aim of this study is to know the risk factors to predict greater morbidity in patients that underwent coronary artery bypass grafting surgery without extracorporeal circulation (OPCABG) and show the preliminary report about how we built the Canalejo score. Methods: Between January 1, 1997 and December 30, 2002, 762 patients underwent OPCABG in the cardiac service of Juan Canalejo Hospital in A Coruña, Galicia, Spain, Twenty five patients (3,3%) died in the first month postoperative and Sixty one patients (8%) had greater morbidity. The variables that were investigated in each patient were collected in prospect form in the Apolo database. To know the preoperative risk factors to predict greater morbidity a multivariate logistic regression analysis were developed. The Canalejo score was built with the variables to reach statistic significant in the logistic regression analysis. The Canalejo score was built with the variables to reach statistic significant in the logistic regression analysis. The weight of each variable into de score was calculated according the coefficient? In the logistic regression analysis. The weight of each variable into the score was calculated according the coefficient? In the logistic regression analysis. The accuracy of the model was assessed with ROC curve. The Canalejo score was validated in200 patients that underwent OPCABG in “Ernesto Ché Guevara” Heart Institute in Villa Clara, Cuba. Results and conclusions: The risk factors that results significant (p=0,05) in the morbidity logistic regression analysis were: ejection fraction, renal failure, peripheral vascular disease, preoperative cardiopulmonary resuscitation, left main trunk disease associated with significant stenosis in the three coronary vessel, preoperative hemodynamic instability, and history of cerebrovascular disease with sequel. The Canalejo score show an area under the ROC curve of 0,80 (80%) (AU)

[Preoperative risk evaluation in beating-heart coronary artery bypass surgery]. / Evaluación preoperatoria del riesgo en la cirugía coronaria sin circulación extracorpórea.

INTRODUCTION AND OBJECTIVES: Operative risk stratification scales for use in cardiac surgery have been developed for patients who undergo procedures using extracorporeal circulation. The aims of the present study were to investigate the use of six preoperative risk stratification scales in patients undergoing beating-heart surgery and to identify risk factors for major complications and mortality in our group of patients who underwent revascularization using this approach. PATIENTS AND METHOD: Between January 1997 and December 2002, we performed 762 coronary artery bypass operations on the beating heart; 61 patients suffered major complications (8%) and 25 died (3.3%). Risk factors for major complications and death were identified using logistic regression analysis of prospectively collected data. The following risk scores were calculated for each patient: Parsonnet 95, Parsonnet 97, Euroscore, Cleveland, Ontario, and French. Receiver operating characteristic curves were used to compare the ability of each scale to predict mortality and major complications. RESULTS: In our patient group, the preoperative variables associated with increased risk were: need for cardiopulmonary resuscitation, renal dysfunction, peripheral vasculopathy, and the presence of severe left main coronary artery disease, three-vessel disease, or an impaired ejection fraction. CONCLUSIONS: Mortality and major complications were best predicted by the Parsonnet 95 and Euroscore scales.

Evaluación preoperatoria del riesgo en la cirugía coronaria sin circulación extracorpórea / Preoperative risk evaluation in beating-heart coronary artery bypass surgery

Introducción y objetivos. Los modelos de estratificación del riesgo quirúrgico en cirugía cardíaca han sido elaborados a partir de pacientes intervenidos con circulación extracorpórea. El objetivo del presente estudio es valorar cómo se comportan 6 modelos de riesgo preoperatorio en pacientes intervenidos sin circulación extracorpórea, así como conocer cuáles son los factores de riesgo predictores de complicaciones mayores y mortalidad en nuestros pacientes revascularizados mediante dicha técnica.Pacientes y método. Entre enero de 1997 y diciembre de 2002 se realizó cirugía de revascularización miocárdica sin el uso de circulación extracorpórea en un total de 762 pacientes consecutivos; de ellos, 61 (8%) presentaron complicaciones mayores y 25 (3,3%) murieron. A partir de variables recogidas de forma prospectiva, se calcularon mediante un análisis de regresión logística los factores predictores para complicaciones mayores y mortalidad. En cada uno de los pacientes se calcularon las escalas de riesgo Parsonnet 95, Parsonnet 97, Euroscore, Cleveland, Ontario y Francesa. Mediante curvas ROC se comparó la capacidad de cada una de las escalas para predecir la mortalidad y la presencia de complicaciones mayores.Resultados. En nuestra serie, las variables preoperatorias que aumentan significativamente el riesgo fueron: la resucitación cardiopulmonar, la presencia de insuficiencia renal, la arteriopatía periférica, la presencia de enfermedad coronaria severa de tronco izquierdo en más de 3 vasos y la fracción de eyección deprimida.Conclusiones. Las escalas de riesgo que mejor predicen la mortalidad y la presencia de complicaciones mayores fueron Parsonnet 95 y Euroscore

Introduction and objectives. Operative risk stratification scales for use in cardiac surgery have been developed for patients who undergo procedures using extracorporeal circulation. The aims of the present study were to investigate the use of six preoperative risk stratification scales in patients undergoing beating-heart surgery and to identify risk factors for major complications and mortality in our group of patients who underwent revascularization using this approach.Patients and method. Between January 1997 and December 2002, we performed 762 coronary artery bypass operations on the beating heart; 61 patients suffered major complications (8%) and 25 died (3.3%). Risk factors for major complications and death were identified using logistic regression analysis of prospectively collected data. The following risk scores were calculated for each patient: Parsonnet 95, Parsonnet 97, Euroscore, Cleveland, Ontario, and French. Receiver operating characteristic curves were used to compare the ability of each scale to predict mortality and major complications.Results. In our patient group, the preoperative variables associated with increased risk were: need for cardiopulmonary resuscitation, renal dysfunction, peripheral vasculopathy, and the presence of severe left main coronary artery disease, three-vessel disease, or an impaired ejection fraction.Conclusions. Mortality and major complications were best predicted by the Parsonnet 95 and Euroscore scales

Evaluación preoperatoria del riesgo en la cirugía coronaria sin circulación extracorpórea / Preoperative assessment of risks: coronary bypass surgery

Los modelos de estratificación del riesgo quirúrgico en cirugía cardiaca han sido elaborados a partir de pacientes intervenidos con circulación extracorpórea. El objetivo del presente estudio es valorar como se comportan 6 modelos de riesgo preoperatorio en pacientes intervenidos sin circulación extracorpórea, así como conocer cuáles son los factores de riesgo predictores de complicaciones mayores y mortalidad en nuestros pacientes revascularizados mediante dicha técnica. Entre nero de 1997 y diciembre de 2002 se realizó cirugía de revascularización miocárdica sin el uso de circulación estracorpórea en un total de 762 pacientes consecutivos; de ellos, 61 (8 por ciento)presentaron complicaciones mayores y 25 (3,3 por ciento) murieron. A partir de variables recogidas de forma prospectiva, se calcularon mediante un análisis de regresión logística los factores predictores para complicaciones mayores y mortalidad. En cada uno de los pacientes se calcularon las escalas de riesgo Parsonnet 97, Euroscore, Cleveland, Ontario y Francesa. Mediante curvas ROC se comparó la capacidad de cada una de las escalas para predecir la mortalidad y la presencia de complicaciones mayores. En nuestra serie, las variables preoperatorias que aumentan significativamente el riesgo fueron:reanimación cardiopulmonar, la presencia de insuficiencia renal, la arteriopatía periférica, la presencia de enfermedad coronaria severa de tronco izquierdo en más de 3 vasos y la fracción de eyección deprimida. Las escalas de riesgo que mejor predicen la mortalidad y la presencia de complicaciones mayores fueron Parsonnet 95 y Euroscore(AU)

Valor de 6 escalas de riesgo para predecir mortalidad en la cirugía coronaria sin circulación extracorpórea / Value of six risk stratification models in cardiac surgery to predict mortality in coronary artery bypass grafting surgery without extracorporeal circulation

Objetivo: Los modelos de estratificación del riesgo quirúrgico en cirugía cardíaca han sido elaborados a partir de pacientes intervenidos con el uso de la circulación extracorpórea. Con el presente trabajo nos proponemos ver como se comportan 6 modelos de riesgo preoperatorio en pacientes intervenidos sin circulación extracorpórea (CEC). Método: En el período comprendido entre enero de 1997 y diciembre del 2002, 762 pacientes fueron sometidos a cirugía de revascularización miocárdica sin el uso de la circulación extracorpórea (OPCABG) por el servicio de cirugía cardíaca del Complejo Hospitalario Juan Canalejo de A Coruña, Galicia, España. Hubo 25 fallecidos lo que representa un 3,3% de mortalidad. Los datos correspondientes a cada paciente fueron recogidos de forma prospectiva en la base de datos Apolo del servicio de cirugía cardíaca. A cada uno de los pacientes le fueron calculados los siguientes scores de riesgo (Parsonnet 95, Parsonnet 97, Euroscore, Cleveland Clinic, Ontario y Francés). La comparación de diferentes escores para predecir mortalidad, se realizó por medio de curvas ROC. Resultados: Todos los scores mostraron diferencias estadísticamente significativas (p≤0,05) entre los vivos y los muertos. La probabilidad de muerte según los diferentes scores analizados no es lineal, sino que aumenta proporcionalmente con el incremento del valor del score. El score que mejor predice la mortalidad en nuestra serie es el Parsonnet 95, con un área bajo la curva del 90%, seguido del Euroscore y el Parsonnet 97 con un área bajo la curva del 86% y 82% Conclusión: Estos resultados nos permiten conocer que scores de riesgo que fueron diseñados con pacientes que fueron sometidos a cirugía cardíaca usando la CEC, pueden ser usados en los pacientes que serán sometidos a OPCABG (AU)

Objective: The risk stratification models have been developed in patients that underwent cardiac surgery using cardiopulmonary bypass and cardioplegic arrest. The aim of this study is to know how predict mortality six risk scores in patients that underwent coronary artery bypass grafting surgery without extracorporeal circulation (OPCABG). Methods: Between January 1, 1997 and December 30, 2002, 762 patients were submitted to OPCABG in the cardiac service of Juan Canalejo Hospital in A Coruña, Galicia, Spain. Twenty five patients (3,3%) died in the first month postoperative. The dates for each patient were collected in cardiac service Apolo database and were calculated the following risk scores: Parsonnet 95, Parsonnet 97, Euroscore, Cleveland Clinic, Ontario and Frances. The comparisons between different scores were made by ROC curves. Results: All risk scores showed statistic significant (p≤ 0,05) between alive and dead patients. The probability of dead is not lineal, but it is increase proportionality with the risk score value. The best score to predict mortality was Parsonnet 95 with an area under the ROC curve of 90%. Other scores that show a good value of ROC curve were Euroscore (0, 86) and Parsonnet 97 (0, 82). Conclusion: These results permit us to know that risk scores which were developed in patients that underwent cardiac surgery with cardiopulmonary bypass (CEC), can be used in patients that will undergo OPCABG (AU)

Endocavitary patch repair for a left ventricular pseudoaneurysm: an alternative approach.

We present a case of postinfarction posterolateral left ventricular wall pseudoaneurysm with severe mitral regurgitation and poor left ventricular function. The patient had New York Heart Association (NYHA) class IV heart failure at the time of surgery, which was performed on an emergency basis. The surgical approach included coronary revascularization, surgical posterior mitral leaflet detachment with patch closure of the pseudoaneurysm neck from inside of the left ventricular cavity followed by mitral valve reconstruction, and subsequent implantation of a mitral annuloplasty ring.

Valor de 6 escalas de riesgo para predecir mortalidad en la cirugía coronaria sin circulación extracorpórea / Value of 6 risk scores for predicting mortality in coronary bypass surgery

Los modelos de estratificación del riesgo quirúrgico en cirugia cardíaca han sido elaborados a partir de pacientes intervenidos con el uso de la circulación extracorpórea. Con el presente trabajo nos proponemos ver como se comportan 6 modelos de riesgo preoperatorio en pacientes intervenidos sin circulación extracorpórea. En el período comprendido entre enero de 1997 y diciembre del 2002, 762 pacientes fueron sometidos a cirugía de revascularización miocárdica sin el uso de la circulación extracorpórea (OPCABG) por el servicio de cirugía cardíaca del Complejo Hospitalario Juan Canalejo de A Coruña, Galicia, España. Hubo 25 fallecidos lo que representa un 3,3 por ciento de mortalidad. Los datos correspondientes a cada paciente fueron recogidos de forma prospectiva en la base de datos Apolo del Servicio de Cirugía Cardíaca. A cada uno de los pacientes le fueron calculados los siguientes scores de riesgo(Parsonnet 95, Parsonnet 97, Euroscore, Cleveland Clinic, Ontario y Francés). La comparación de diferentes escores para predecir mortalidad, se realizó por medio de curvas ROC(AU)

Off-pump total arterial revascularization: our experience.

BACKGROUND AND AIM: Off-pump coronary artery bypass grafting with both the internal thoracic arteries, such as the Tector technique, can reduce the morbidity associated with extracorporeal circulation and aortic cross-clamp. The aim of the present study is to describe our experience and the results obtained. METHODS: From April 1998 to December 2003, the off-pump Tector technique was performed on 743 patients, of whom 621 were male (83.5%), with a mean age of 65.3 +/- 9.5 years (23-90). Preoperative risk factors were diabetes mellitus in 29.5% and peripheral vasculopathy in 14.7% of the patients. Angiography showed left main disease in 25.6% and triple-vessel disease in 50.3% of the patients, with a mean ejection fraction of 60%+/- 13% (23-88). Both the internal thoracic arteries were harvested using the skeletonization technique and were anastomosed as "Y" or "T" grafts. Intraoperative graft patency was checked using a Doppler flowmeter. RESULTS: A total of 2028 distal anastomoses were performed, the average being 2.7 (1 to 5) per patient. At least three distal anastomoses were undertaken in 62% of the patients. Postoperative complications included atrial fibrillation in 40 patients (5.4%), myocardial infarction in 24 (3.2%), mediastinitis and reoperation for bleeding in 7 (0.9%) and stroke in 3 (0.4%). Twenty-four patients (3.2%) died in the first month postoperatively. CONCLUSIONS: The off-pump Tector technique appears to be safe, showing a low surgical morbidity.