Less invasive replacement of aortic root, ascending aorta and hemiarch via partial upper sternotomy: a propensity-score-matched comparison with full sternotomy.

OBJECTIVES: Less invasive surgery has emerged as an option for aortic pathologies. The current study compared our experience on early postoperative results of patients with aortic surgery between partial upper sternotomy (PUS) and full sternotomy (FS). METHODS: We performed a retrospective analysis of the data of patients undergoing aortic root surgery with concomitant ascending aorta and hemiarch replacement. Exclusion criteria were type A aortic dissection and other concomitant major cardiac surgery. After propensity score matching, we compared the perioperative outcomes of patients undergoing surgery with PUS versus FS. RESULTS: A total of 161 patients operated on between January 2013 and September 2022 met the inclusion criteria (PUS: n = 22, FS: n = 139). Propensity score matching yielded 22 pairs with a balanced distribution of propensity scores and covariates between the compared groups. There was no evidence that PUS affects cardiopulmonary bypass [108 (67-119) vs 113 (87-148) min, P = 0.154; PUS vs FS] and circulatory arrest duration [9 (7-10) vs 9 (8-13) min, P = 0.264; PUS vs FS]. There was a reduced cross-clamp duration in the PUS group [88 (58-96) vs 92 (71-122) min, P = 0.032]. Cumulative sum charts have shown consistently low cross-clamp and circulatory arrest duration for 2 experienced surgeons who performed 20 of the procedures in the PUS group (10 each). Perioperative mortality and morbidity were low, with no in-hospital mortality in the PUS group [0 vs 1(4.5%), P > 0.999] and absence of strokes in both groups. CONCLUSIONS: In summary, our initial experience suggests that less invasive aortic root, ascending aorta and hemiarch replacement via PUS could be performed in our patient cohort as safely as via full sternotomy. Advantages for the patient are reduced surgical trauma, improved cosmetic results and-presumably-less pain.

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.

Thrombocytopenia after Implantation of the Perceval, Intuity, and Sapien Aortic Valve Prostheses.

BACKGROUND: An increased incidence of thrombocytopenia was reported after implantation of the LivaNova Perceval and the Edwards Sapien aortic valve bioprostheses. Aim of this study is to assess the perioperative platelet count and bleeding complications in three different types of aortic valve bioprostheses intended for high-risk patients, the sutureless LivaNova Perceval, the rapid deployment Edwards Intuity, and the transcatheter Edwards Sapien. METHODS: We performed a retrospective analysis of the perioperative data of patients receiving the Perceval, Intuity, and Sapien aortic valve bioprosthesis. The platelet count was collected preoperatively, at nadir postoperatively, and at discharge. The bioprostheses were compared for between-group differences in platelet count and postoperative bleeding complications. RESULTS: Overall, 37 patients received the Perceval, 42 the Intuity, and 58 the Sapien bioprosthesis. There was no significant between-group difference in the preoperative platelet count [Perceval 203(178-246)G/l, Intuity 214(190-232)G/l, Sapien 201(178-275)G/l, p = 0.800]. There was a significant between-group difference in the postoperative platelet count, both at nadir value [Perceval 57(37-80)G/l, Intuity 91(73-109)G/l, Sapien 126(105-170)G/l, p < 0.0001] and at discharge [Perceval 150(83-257)G/l, Intuity 239(200-343)G/l, Sapien 232(179-284)G/l, p = 0.001]. There was no significant between-group difference regarding red blood cell transfusions (p = 0.242), platelet transfusions (p = 0.656), and rethoracotomy for bleeding (p = 0.847). CONCLUSION: We found a significant platelet count reduction in all three bioprostheses which was more marked in the Perceval group. The platelet count reduction was transient and fully recovered in the Intuity and Sapien groups, whereas the Perceval group showed only a partial platelet count recovery. However, bleeding complications were not different between the three bioprostheses.

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.

Modified transventricular and transaortic mitral valve edge-to-edge repair mimicking MitraClip overcorrection.

Objective: In the current study, we present our mid-term experience with modified edge-to-edge repair technique through a transventricular and transaortic route in patients requiring left ventricular remodeling or aortic root/valve surgery. Methods: From December 2006 through April 2015, 49 high-risk patients (median age: 69 years; median European System for Cardiac Operative Risk Evaluation II: 11.4 [6.54-14.9]) underwent transventricular (N = 7; 14%) or transaortic (N = 42; 86%) edge-to-edge mitral valve repair. The Alfieri stitch technique was modified by MitraClip type overcorrection and solid buttressing behind the posterior leaflet. Indication was grade 2+ functional mitral valve incompetence and dilated or impaired left ventricle (N = 25; 52%), or grade 3+ (N = 22; 45%) and grade 4+ functional mitral valve regurgitation (N = 2; 4%). Surgical procedure included aortic root surgery in 65%, aortic valve replacement with surgical revascularization in 18%, and Dor-plasty with surgical revascularization in 14%. Results: Intraoperative mortality and early neurologic complications were absent in our series. Ninety-day mortality was 12.2% (N = 6). Median clinical and echocardiographic follow-up-time was 50.7 (21.5-44.1) and 39.2 (33.7-44.1) months, respectively. Median postoperative transvalvular gradient was low (2.72 [1.91-4.22] mm Hg) and did not increase during follow-up (P = .268), although peak gradient rose slightly from 7.41 to 8.12 mm Hg (P = .071). The actuarial reoperation free rate at the index valve was 96.8%. Conclusions: Transventricular or transaortic Alfieri mitral repair mimicking mitral clip overcorrection represents a quick and safe technique in the setting of high-risk patients undergoing left ventricular remodeling or aortic root/valve surgery and can be performed with low risk of creating mitral stenosis at midterm. The technique is straightforward, with reliable identification of the center of the valve leaflets being the limitation.

Ejection Fraction Recovery after Coronary Artery Bypass Grafting for Ischemic Cardiomyopathy.

BACKGROUND: Controversy exists about left ventricular systolic function recovery after coronary artery bypass grafting in patients with ischemic cardiomyopathy. The aim of this study is to evaluate the temporal evolvement of left ventricular systolic function after coronary artery bypass surgery in patients with ischemic cardiomyopathy. PATIENTS AND METHODS: A total of 50 patients with coronary artery disease and left ventricular ejection fraction (LVEF) ≤35% underwent isolated coronary artery bypass grafting in a single center in the period 2017 to 2019. We performed a retrospective analysis of the echocardiographic and clinical follow-up data at 3 months and 1 year postoperatively. RESULTS: Median LVEF preoperatively was 25% (20-33%), mean patient age was 66 ± 8.2 years, 33 (66%) patients were operated off-pump, and 22 (44%) procedures were non-elective. There was no in-hospital myocardial infarction, stroke, and repeat revascularization. Three (6%) patients underwent re-exploration for bleeding or tamponade. In-hospital mortality was 8% and 1-year mortality was 12%. At 1 year postoperatively, there was no repeat revascularization, no myocardial infarction, 1 (2.6%) patient had a transient ischemic attack, and 10 (20%) patients required an implantable defibrillator. There was a statistically significant median ejection fraction increase at 3 months (15% [5-22%], p < 0.0001) and 1 year (23% [13-25%], p < 0.0001) postoperatively, with an absolute increase ≥10% in 32 (74.4%) and 30 (78.9%) patients at 3 months and 1 year, respectively. CONCLUSION: Patients with ischemic cardiomyopathy undergoing coronary artery bypass surgery show continuous recovery of left ventricular systolic function in the first postoperative year.

Impact of postoperative hypothermia on outcomes after off-pump coronary artery bypass grafting.

BACKGROUND: Even though the physiological derangements caused by hypothermia are well described, there is no consensus about its impact on postoperative outcomes. The aim of this study is to assess the effect of postoperative hypothermia on outcomes after off-pump coronary artery bypass surgery. METHODS: A total of 1979 patients undergoing isolated off-pump coronary artery bypass surgery in a single center in the period 2007-2018 were classified according to their axillary temperature measurement at intensive care unit admission postoperatively to either hypothermic (<36°C) or normothermic (≥36°C). Between-group differences on baseline characteristics and postoperative outcomes were assessed before and after propensity score matching. RESULTS: Data analysis showed that 582 patients (29.4%) were hypothermic (median temperature 35.5°C) and 1397 patients (70.6%) were normothermic (median temperature 36.4°C). Using propensity score matching, 567 patient pairs were created. Patients with hypothermia exhibited a higher rate of postoperative transfusion of at least three red cell concentrate units (14.3% vs 9%, p = 0.005), a longer intubation duration (median duration, 6 vs 5 h, p < 0.0001), and a longer intensive care unit stay (median stay, 1.6 vs 1.3 days, p = 0.008). There was no difference in reoperation for bleeding, renal replacement therapy, infections, and mortality between the two groups. CONCLUSIONS: Even though associated with a higher blood transfusion requirement and a slightly longer intensive care unit stay, mild postoperative hypothermia was not associated with a higher morbidity and mortality.

Aortic Root Replacement with Reimplantation of the Aortic Valve: A Low-Volume Center Experience.

BACKGROUND: Most data after root replacement with reimplantation of the aortic valve originate from high-volume centers. This raises concerns about the generalizability of these data and the reproducibility of this complex procedure. Aim of this study is to assess the perioperative and midterm outcomes of this procedure in a low-volume center. METHODS: We performed a retrospective analysis of the data of 72 patients, who underwent root replacement with reimplantation of the aortic valve in a single center between 2011 and 2020. Time to event analysis was performed with Kaplan-Meier curves. Longitudinal analysis of serial echocardiographic data was performed with a mixed-effects ordinal logistic regression model. RESULTS: In-hospital mortality was 1.4%, with absence of any neurological events during the perioperative period. At midterm follow-up, two further patients died. Overall survival rates at 1 and 5 years were 98.5% (95% confidence interval [CI]: 97-100%) and 96.3% (95% CI: 93.8-98.8%), respectively. During follow-up, five patients (6.9%) required reoperation on the aortic valve. The incidence of moderate and severe aortic regurgitation at 5 years was 6.6% (95% CI: 2.4-13.6%) and 0.6% (95% CI: 0.1-3.2%), respectively. Mild aortic regurgitation at hospital discharge (p < 0.001) and cusp plication (p = 0.0121) were associated with a higher incidence of moderate or severe aortic regurgitation at follow-up. CONCLUSION: Reimplantation of the aortic valve is safe and feasible even in a low-volume center. Mortality, freedom from reoperation, and incidence of moderate or severe aortic regurgitation at follow-up are comparable to those of high-volume centers.

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.

First in Switzerland: concomitant off-pump transapical transcatheter aortic valve implantation and mitral valve reconstruction with the NeoChord system.

Old and polymorbid patients with multivalvular heart disease comprise a special patient group, with high perioperative morbidity and mortality. We report the case of an 80-year-old, female, polymorbid patient with severe mitral valve regurgitation and moderate to severe aortic valve stenosis. This is the first case in Switzerland of a concomitant transapical transcatheter aortic valve implantation and mitral valve reconstruction with the NeoChord system, on a beating heart and with a minimally invasive approach through a left anterolateral thoracotomy. This case emphasises the possibility of a low-risk minimally invasive procedure on this high-risk patient-group and shows the importance of interdisciplinary discussion and cooperation in heart teams for optimal patient treatment.