External stenting for saphenous vein grafts reduces early postoperative graft failure.

OBJECTIVES: Multiple studies have shown that external stenting (ExSt) mitigates the progression of vein graft disease years after coronary artery bypass grafting (CABG). We used computed tomography to evaluate the effect of ExSt on perioperative vein graft patency. METHODS: This study assessed graft patency rates of saphenous vein grafts (SVG) in consecutive patients with isolated coronary artery bypass grafting (CABG) between 2018 and 2021. Logistic regression analyses were conducted to compare the outcomes of supported and non-supported groups at both patient and graft levels, with age, EuroSCORE II, gender, diabetes and arterial grafts as covariates. Subgroup analyses were performed based on different covariates. The goal of the study was to provide valuable insights into the clinical outcomes of SVG in patients having CABG. RESULTS: The study examined a total of 357 patients who met the inclusion criteria and evaluated 572 vein grafts. Of these, 150 patients (205 SVGs) received ExSt, whereas 207 patients (337 SVGs) did not receive ExSt. The study results indicated that the likelihood of overall SVG patency at discharge was higher in the stented group than in the non-stented group, both at the level of the grafts [93.8% vs 87.8%, odds ratio (OR) 2.1; 95% confidence interval (CI) 1.0-4.5; P = 0.05] and at the patient level (90.1% vs 83.5%, OR 1.8; 95% CI 0.9-3.6; P = 0.1). It is worth noting that the difference between the stented and non-stented groups was most significant in the subgroup that received 2 arterial grafts (96.5% vs 89.6%, OR 3.2; 95% CI 1.2-8.4; P = 0.02) and in the subgroup with a higher EuroSCORE II (median >1.1) (98.6% vs 88.6%, OR 8.8; 95% CI 1.1-72.7; P = 0.04). CONCLUSIONS: The ExSt is associated with improved perioperative SVG patency at both the graft and the patient levels. Moreover, SVGs to the right territory and high-risk patients appear to have an advantage using ExSt.

Thirteen Years of Impactful, Minimally Invasive Coronary Surgery: Short- and Long-Term Results for Single and Multi-Vessel Disease.

OBJECTIVES: Minimally invasive coronary surgery (MICS) via lateral thoracotomy is a less invasive alternative to the traditional median full sternotomy approach for coronary surgery. This study investigates its effectiveness for short- and long-term revascularization in cases of single and multi-vessel diseases. METHODS: A thorough examination was performed on the databases of two cardiac surgery programs, focusing on patients who underwent minimally invasive coronary bypass grafting procedures between 2010 and 2023. The study involved patients who underwent either minimally invasive direct coronary artery bypass grafting (MIDCAB) for the revascularization of left anterior descending (LAD) artery stenosis or minimally invasive multi-vessel coronary artery bypass grafting (MICSCABG). Our assessment criteria included in-hospital mortality, long-term mortality, and freedom from reoperations due to failed aortocoronary bypass grafts post-surgery. Additionally, we evaluated significant in-hospital complications as secondary endpoints. RESULTS: A total of 315 consecutive patients were identified between 2010 and 2023 (MIDCAB 271 vs. MICSCABG 44). Conversion to median sternotomy (MS) occurred in eight patients (2.5%). The 30-day all-cause mortality was 1.3% (n = 4). Postoperative AF was the most common complication postoperatively (n = 26, 8.5%). Five patients were reoperated for bleeding (1.6%), and myocardial infarction (MI) happened in four patients (1.3%). The mean follow-up time was six years (±4 years). All-cause mortality was 10.3% (n = 30), with only five (1.7%) patients having a confirmed cardiac cause. The reoperation rate due to graft failure or the progression of aortocoronary disease was 1.4% (n = 4). CONCLUSIONS: Despite the complexity of the MICS approach, the results of our study support the safety and effectiveness of this procedure with low rates of mortality, morbidity, and conversion for both single and multi-vessel bypass surgeries. These results underscore further the necessity to implement such programs to benefit patients.

Navigating the challenges of minimally invasive mitral valve surgery: a risk analysis and learning curve evaluation.

BACKGROUND: This study aimed to report the risk and learning curve analysis of a minimally invasive mitral valve surgery program performed through a right mini-thoracotomy at a single institution. METHODS: From January 2013 through December 2019, 266 consecutive patients underwent minimally invasive mitral valve surgery in our department and were included in the current study. Multiple logistic regression analysis was used for the adverse event outcome. Distribution over time of perioperative complications, defined as clinical endpoints in the Valve Academic Research Consortium-2 (VARC-2) consensus document, as well as CUSUM charts for assessment of cardiopulmonary bypass and aortic cross-clamping duration over time, has been performed for learning curve assessment. RESULTS: Overall incidences of postoperative stroke (1.1%), myocardial infarction (1.1%), and thirty-day mortality (1.5%) were low. The mitral valve reconstruction rate in our series was 95%. Multivariable analysis revealed that concomitant tricuspid valve surgery (OR 4.44; 95%CI 1.61-11.80; p = 0.003) was significantly associated with adverse event outcomes. Despite a trend towards adverse event outcomes in patients with preexisting active mitral valve endocarditis (OR 2.69; 95%CI 0.81-7.87; p = 0.082), mitral valve pathology did not significantly impact postoperative morbidity and mortality. Distribution over time of perioperative complications, defined as clinical endpoints in the VARC-2 consensus document, showed a trend towards an improved complication rate after the initial 65-100 procedures. CONCLUSIONS: Mitral valve surgery via right-sided mini-thoracotomy can be implemented safely with low perioperative morbidity and mortality rates. Careful patient selection regarding isolated mitral valve surgery in the presence of degenerative mitral valve disease may represent a significant safety issue during the learning curve. TRIAL REGISTRATION: The cantonal ethics commission of Zurich approved the study (registration ID 2020-00752, date of approval 24 April 2020).

Prosthesis-Patient Mismatch after Aortic Valve Replacement with the Mosaic Ultra Bioprosthesis.

BACKGROUND: Several studies have reported high rates of prosthesis-patient mismatch (PPM) after aortic valve replacement (AVR) with the Mosaic prosthesis. This work assesses the incidence of PPM after AVR with a modified version of the Mosaic prosthesis, the Mosaic Ultra. METHODS: We performed a retrospective analysis of the data of 532 patients who underwent AVR with implantation of the Mosaic Ultra prosthesis in the period 2007-2016 in our institution. Patients were classified according to their indexed effective orifice area (EOAi) to severe (EOAi < 0.65 cm2/m2), moderate (EOAi 0.65-0.85 cm2/m2), and absent/mild PPM (EOAi > 0.85 cm2/m2). In-hospital postoperative outcomes and the impact of PPM on mean transvalvular pressure gradient after stratification by prosthesis size were assessed. RESULTS: Overall, 3 (0.6%) patients had severe, 92 (17.3%) moderate, and 437 (82.1%) absent/mild PPM. There was a significant difference in PPM proportions (moderate/severe vs absent/mild PPM) across different prosthesis sizes overall (p < 0.0001), observing gradually increasing rates of PPM with decreasing prosthesis sizes. Patients with moderate/severe PPM had higher mean transvalvular pressure gradients (19 [13-25] vs 13 [10-17] mm Hg, p < 0.0001) than patients with absent/mild PPM. There was a significant difference in mean transvalvular pressure gradient between the different aortic valve prosthesis sizes overall (p < 0.0001), observing gradually increasing gradients with decreasing prosthesis sizes. CONCLUSION: Patients undergoing AVR with the smaller sized (19, 21, and 23 mm) Mosaic Ultra aortic valve prostheses exhibit a higher risk for moderate/severe PPM and higher mean aortic transvalvular pressure gradients than patients receiving the larger sized (25, 27, and 29 mm) prostheses.

Conversion from off-pump to on-pump coronary artery bypass grafting: impact of surgeon and anaesthetist experience.

OBJECTIVES: Intraoperative conversion from off-pump to on-pump coronary artery bypass grafting (CABG) is associated with increased postoperative morbidity and mortality. The aim of this study is to assess the impact of surgeon and anaesthetist experience on the conversion rate. METHODS: We performed a retrospective analysis of the data of all patients who underwent planned off-pump CABG in a single centre in 2007-2021, some of whom were non-electively converted to on-pump. Surgeon and anaesthetist experience were assessed by the number of off-pump bypass procedures per year. Multivariable logistic regression analysis was used to assess the impact of surgeon and anaesthetist experience on conversion rate. RESULTS: A total of 2742 patients met the inclusion criteria. Ninety-four (3.4%) patients underwent non-elective conversion to on-pump surgery. Converted patients had significantly higher mortality [11 (11.7%) vs 35 (1.3%), P < 0.0001] in comparison to non-converted patients. Anaesthetist experience was found to be a risk factor for conversion (P = 0.011). Surgeon experience did not significantly affect conversion rate (P = 0.51). Other risk factors for conversion were female gender [odds ratio 2.65 (95% confidence interval 1.65-4.26), P = 0.0001] and left ventricular ejection fraction ≤35% [odds ratio 1.91 (95% confidence interval 1.05-3.49), P = 0.040]. CONCLUSIONS: Conversion from off-pump to on-pump CABG is associated with worse postoperative outcomes. Limited experience of anaesthetists in off-pump bypass surgery is associated with a higher conversion rate.

Isolated Minimally Invasive Mitral Valve Surgery in Octogenarians: Perioperative Outcome.

INTRODUCTION: Despite the feasibility, safety, and excellent outcomes of mitral valve surgery through a right mini-thoracotomy, there is data paucity about its use in octogenarians. In this study, we assess the outcomes of mitral valve surgery via right mini-thoracotomy in octogenarians. METHODS: We performed a retrospective analysis of the in-hospital perioperative data of 38 octogenarian patients with severe mitral regurgitation undergoing isolated mitral valve surgery via right mini-thoracotomy from 2013 to 2021 in our institution. RESULTS: The median patient age was 82 (81-83) years, and the median EuroSCORE II was 3.1% (2.3-4.9). A total of 19 (50%) patients underwent mitral valve repair. The median cardiopulmonary bypass duration was 78 (54-100) min and the median aortic cross-clamping duration was 57 (40-70) min. Two (5.3%) patients were converted to sternotomy, 1 (2.6%) underwent renal replacement therapy, 5 (13.2%) underwent reexploration for bleeding or tamponade, and 12 (31.6%) underwent permanent pacemaker implantation. The surgical repair success rate was 89.5%, with 2 (10.5%) patients requiring reoperation due to repair failure. No other patients required reoperation on the mitral valve. The median intensive care unit stay was 1 (1-2) day, and the median postoperative stay was 9.5 (8-14) days. There was no perioperative stroke or death. CONCLUSION: Despite a relatively increased risk of pacemaker implantation and reexploration for bleeding, our data support the feasibility of mitral valve surgery via a right mini-thoracotomy in octogenarians, with short ischemic times, low overall in-hospital morbidity, and no mortality. Preferring replacement in mitral diseases with a high risk for repair failure could minimize reoperations in this high-risk subgroup.

Transseptal versus left atrial approach for mitral valve surgery: postoperative need for pacemaker.

OBJECTIVES: Concerns exist about higher rates of pacemaker implantation using the extended superior transseptal approach for mitral valve surgery. This study aims to compare the extended superior transseptal and the left atrial approach regarding the need for pacemaker implantation after mitral valve surgery. METHODS: We performed a retrospective analysis of the data of patients undergoing mitral valve surgery through either a sternotomy and transseptal approach or a mini-thoracotomy and left atrial approach in a single centre in the period January 2010 to May 2021. The primary outcome was the evaluation of the postoperative pacemaker implantation rate. RESULTS: Overall, 677 patients were included, 333 with transseptal and 344 with left atrial approach, and 58 (8.6%) patients underwent pacemaker implantation postoperatively. There was no significant difference in the rate of pacemaker implantation between the 2 groups [overall: 34 (10.2%) vs 24 (7%), P = 0.133; for sinus node dysfunction: 12 (3.6%) vs 9 (2.6%), P = 0.459; for high-degree atrioventricular block: 22 (6.6%) vs 15 (4.4%), P = 0.199; transseptal vs left atrial approach, respectively]. A subgroup analysis of the relative effect of transseptal versus left atrial approach on the rate of postoperative pacemaker implantation revealed mitral replacement as a statistically significant confounder (P = 0.019). The exclusion of patients undergoing concomitant cardiac procedures did not lead to a statistically significant difference in the pacemaker implantation rate between the 2 approaches. CONCLUSIONS: The analysis of the data of these patients shows no significant difference in the rate of permanent pacemaker implantation between the extended superior transseptal and the left atrial approach for mitral valve surgery.

Active clearance of chest tubes after cardiac surgery: a propensity score matched analysis.

AIMS OF THE STUDY: Chest tubes inserted to drain shed mediastinal blood after cardiac surgery often become clogged, limiting their capacity to evacuate blood, and leading to blood retention and retained blood syndrome. The aim of this study was the assessment of the efficacy of an active tube clearance (ATC) system in the reduction of retained blood syndrome after cardiac surgery. METHODS: This study included 2461 adult patients undergoing major cardiac surgery. Patients receiving conventional chest tubes only (n = 1980) were compared with patients receiving an ATC tube in the retrosternal position (n = 481) for interventions caused by retained blood syndrome (re-exploration for bleeding or tamponade and interventions for pleural effusion or pneumothorax), kidney replacement therapy, postoperative atrial fibrillation, sternal infection and chest tube output before and after propensity score matching. RESULTS: Propensity score matching generated 471 patient-pairs balanced for their baseline characteristics. Matched patients with an ATC tube in the retrosternal position had no statistically significant difference in the rate of intervention for retained blood syndrome (33% vs 31%, p = 1), re-exploration because of bleeding or tamponade (2.5% vs 4%, p = 1), intervention for pneumothorax (4.7% vs 4.9%, p = 1) and intervention for pleural effusion (28% vs 28%, p = 1), but had statistically significantly less chest tube output on the first postoperative day (median 480, IQR 316–700 ml vs median 590, IQR 380–905 ml; p <0.0001) and second postoperative day (median 505, IQR 342–800 ml vs median 597, IQR 383–962 ml; p = 0.0012)  in comparison with patients with conventional chest tubes only. CONCLUSION: An ATC tube in the retrosternal position reduced chest tube output but showed no reduction in the rate of intervention for retained blood syndrome. Further research should be performed to test the combination of ATC in the retrosternal and the inferior pericardial space.

Left atrial myxoma: Unusual presentation as a cystic tumor.

Myxomas are the most common cardiac tumors, benign, and usually located in the left atrium. Typically echocardiography reveals a solid tumor, whereas cystic myxomas are rare with only a few cases documented in the literature. We describe the case of a 63-year-old, female patient with an unusual presentation of a left atrial myxoma as a cystic tumor.