Implementation of Endoscopic Minimally Invasive Mitral Valve Replacement Surgery With Automated Suturing Technology.

In the evolving landscape of cardiac surgery, this article explores the potential of minimally invasive mitral valve replacement procedures as a viable alternative to conventional surgical techniques. Leveraging advancements in automated suturing devices and video endoscopy, our work aims to demonstrate that minimally invasive approaches can be applied across a broad spectrum of surgical scenarios. Herein we highlight preoperative diagnostics and operative techniques, with a focus on infra-axillary anterolateral minithoracotomy as the access point. Our technique utilizes technology from LSI SOLUTIONS® (Victor, NY, USA), including the RAM® Device for automated suturing, which has an ergonomic design and safety features. The device's capabilities are further enhanced by the SEW-EASY® Device, the RAM® RING, and the COR-KNOT MINI® Device, which streamline suture management and securement. This work outlines how these technological advancements can mitigate concerns about technical complexity and learning curves, thereby encouraging wider adoption of minimally invasive techniques. Clinical benefits may include reduced surgical trauma, quicker recovery, and cost-effectiveness, making it a compelling option in an era of aggressively promoted transcatheter interventions.

Risk factors, prevention, and therapy of intraluminal stent thrombosis in frozen elephant trunk prostheses-what we know so far.

Intraluminal thrombus formation (ILT) is a recently discovered and highly clinically relevant complication after frozen elephant trunk implantation in cardiovascular surgery. In this phenomenon, a thrombus forms within the lumen of the stent graft component of the frozen elephant trunk prosthesis and puts the patient at risk for downstream embolization with visceral or lower limb ischemia. Incidence of ILT reported in the currently available studies ranges from 6% to 17% of patients after frozen elephant trunk implantation. Adverse thromboembolic events include acute occlusion of the celiac and superior mesenteric arteries, both renal arteries as well as acute lower limb ischemia due to iliac or femoral artery embolization that not infrequently require interventional or open embolectomy. Therefore, the presence of ILT is associated with increased short-term mortality and morbidity. Currently proposed strategies to avoid ILT formation include a more aggressive anticoagulation management, minimization of postoperative coagulation factor application, and even technical optimizations of the stent graft portion itself. If ILT is manifested, the therapeutic strategies tested to date are long-term escalation of anticoagulation and early endovascular extension of the FET stent graft with overstenting of the intraluminal thrombus. The long-term efficiency of these prophylactic and therapeutic measures has yet to be proven. Nonetheless, all surgeons performing the frozen elephant trunk procedure must be aware of the risk of ILT formation to facilitate a timely diagnosis and therapy.

Impact of Intercostal Artery Reinsertion on Neurological Outcome after Thoracoabdominal Aortic Replacement: A 25-Year Single-Center Experience.

BACKGROUND: Intercostal artery reinsertion (ICAR) during thoracoabdominal aortic replacement remains controversial. While some groups recommend the reinsertion of as many arteries as possible, others consider the sacrifice of multiple intercostals practicable. This study investigates the impact of intercostal artery reinsertion or sacrifice on neurological outcomes and long-term survival after thoracoabdominal aortic repair. METHODS: A total of 349 consecutive patients undergoing thoracoabdominal aortic replacement at our institution between 1996 and 2021 were analyzed in a retrospective single-center study. ICAR was performed in 213 patients, while all intercostal arteries were ligated and sacrificed in the remaining cases. The neurological outcome was analyzed regarding temporary and permanent paraplegia or paraparesis. RESULTS: No statistically significant differences were observed between the ICAR and non ICAR groups regarding the cumulative endpoint of transient and permanent spinal cord-related complications (12.2% vs. 11.8%, p = 0.9). Operation, bypass, and cross-clamp times were significantly longer in the ICAR group. Likewise, prolonged mechanical ventilation was more often necessary in the ICAR group (26.4% vs. 16.9%, p = 0.03). Overall long-term survival was similar in both groups in the Kaplan-Meier analysis. CONCLUSION: Omitting ICAR during thoracoabdominal aortic replacement may reduce operation and cross-clamp times and thus minimize the duration of intraoperative spinal cord hypoperfusion.

Antibacterial copper-filled TiO2 coating of cardiovascular implants to prevent infective endocarditis-A pilot study.

BACKGROUND: Infective endocarditis (IE) poses a significant health risk, especially in patients with prosthetic heart valves. Despite advances in treatment, mortality rates remain high. This study aims to investigate the antibacterial properties of a copper titanium dioxide (4× Cu-TiO2) coating on cardiovascular implants against Staphylococcus aureus, a common causative agent of IE. METHODS: Titanium oxide carriers functionalized with copper ions were employed as an antibacterial coating for heart and vascular prostheses. The coating's antibacterial efficacy was assessed using S. aureus ATCC 29213. Microscopic evaluations were conducted on both biological and artificial materials. Antibacterial activity was qualitatively assessed via a modified disc diffusion method and quantitatively measured through colony counts in NaCl suspensions. RESULTS: The coating process was successfully applied to all tested cardiovascular prosthetic materials. Qualitative assessments of antibacterial effectiveness revealed an absence of bacterial growth in the area directly beneath the coated valve. Quantitative evaluations showed a significant reduction in bacterial colonization on coated mechanical valves, with 2.95 × 104 CFU per valve, compared to 1.91 × 105 CFU in control valves. CONCLUSIONS: The 4× Cu-TiO2 coating demonstrated promising antibacterial properties against S. aureus, suggesting its potential as an effective strategy for reducing the risk of bacterial colonization of cardiovascular implants. Further studies are needed to assess the longevity of the coating and its efficacy against other pathogens.

Acute right atrial thrombus formation after extracorporeal life support removal during LVAD-implantation.

A 58-year-old male underwent LVAD-Implantation after ECLS explantation. After removal of ECLS (A) transesophageal echocardiography revealed thrombus in the inferior vena cava (B) and right atrium (C). The thrombus was removed with a second pump run including RVAD-Implantation. (D) The diameter of thrombus formations was 6 × 1 cm and 5 × 1.5 cm.

Right Axillary Artery Cannulation for Veno-Arterial Extracorporeal Membrane Oxygenation in Postcardiotomy Patients: A Single-Center Experience.

Background and Objectives: To analyze the patient outcome and complication rate of axillary artery cannulation for veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in patients who could not be weaned from cardiopulmonary bypass after cardiothoracic surgery. Materials and Methods: We analyzed the data of 179 patients who were supported with VA-ECMO with femoral-axillary access (FA VA-ECMO) after cardiothoracic surgery between January 2014 and January 2019 in our department. Patients requiring central aortic cannulation and patients with respiratory failure requiring veno-venous ECMO were excluded. Primary outcomes were in-hospital mortality and 1-year survival rate of patients who were weaned from VA-ECMO support. Secondary outcomes were cannulation-related complications at the axillary site, VA-ECMO-related complications, and systemic complications. Results: In our cohort, 60 (33.5%) patients were female. Mean age was 67.0 ± 10.9 years. Overall, 78 (43.5%) patients were operated upon electively, 37 (20.7%) patients underwent urgent surgery, and 64 (35.8%) patients underwent emergency surgical treatment. Sixty-seven patients (37.4%) were resuscitated preoperatively. The mean duration of VA-ECMO support was 8.4 ± 5.1 days. Weaning from VA-ECMO was successful in 87 (48.6%) patients; 62 (34.6%) patients survived the hospital stay. The 1-year survival rate was 74%. Subclavian bleeding occurred in 24 (13.4%) patients, femoral bleeding in 4 (2.2%) patients, ischemia of the upper limb in 11 (6.1%) patients, intracerebral bleeding in 9 (5%) patients, and stroke in 19 (10.6%) patients. Conclusions: In patients with acute LV dysfunction after cardiothoracic surgery who cannot be weaned from cardiopulmonary bypass, right axillary artery cannulation is a safe and reliable method for VA-ECMO support with an acceptable complication rate.

Expanding the Minimally Invasive Approach towards the Ascending Aorta-A Practical Overview of the Currently Available Techniques.

Minimally invasive techniques have gained immense importance in cardiovascular surgery. While minimal access strategies for coronary and mitral valve surgery are already widely accepted and often used as standard approaches, the application of minimally invasive techniques is currently expanded towards more complex operations of the ascending aorta as well. In this new and developing field, various techniques have been established and reported ranging from upper hemisternotomy approaches, which allow even extensive operations of the ascending aorta to be performed through a minimally invasive access to sternal sparing thoracotomy strategies, which completely avoid sternal trauma during ascending aorta replacements. All of these techniques place high demands on patient selection, preoperative planning, and practical surgical implementation. Application of these strategies is currently limited to high-volume centers and highly experienced surgeons. This narrative review gives an overview of the currently available techniques with a special focus on the practical execution as well as the advantages and disadvantages of the currently available techniques. The first results demonstrate the practicability and safety of minimally invasive techniques for replacement of the ascending aorta in a well-selected patient population. With success and complication rates comparable to classic full sternotomy, the proof of concept for minimally invasive replacement of the ascending aorta is now achieved.

Hemoadsorption in LVAD Surgery: Suitable in Theory?

The incidence of patients with heart failure is growing steadily, particularly due to advancements in medical therapy [...].

Myocardial Function after Coronary Artery Bypass Grafting in Patients with Preoperative Preserved Left Ventricular Ejection Fraction-The Role of the Left Ventricular Longitudinal Strain.

Background and Objectives: The role of coronary artery bypass grafting (CABG) on postoperative left ventricular (LV) function in patients with preoperatively preserved left ventricular ejection fraction (LVEF) is still being discussed and only a few studies address this question. This study aimed to assess LV function after CABG in patients with preoperatively preserved LVEF using left ventricular longitudinal strain assessed by 2D speckle tracking imaging (STI). Materials and Methods: Fifty-nine consecutive adult patients with coronary artery disease (CAD) referred for a first-time elective CABG surgery were enrolled in the final analysis of this prospective single-center clinical study. Transthoracic echocardiography (TTE), with conventional measures and STI measures, was performed within 1 week before CABG as well as 4 months after surgery. Patients were divided into groups based on their preoperative global longitudinal strain (GLS) value. Differences in systolic and diastolic parameters between groups were analyzed. Results: Preoperative GLS was reduced (GLS < -17%) in 39% of the patients. Parameters of systolic LV function were significantly reduced in this group of patients compared to the patient group with GLS% ≥ -17%. In both groups, 4 months after CABG there was a decline in LVEF but statistically significant only in the group with GLS% ≥ -17% (p = 0.035). In patients with reduced GLS, there was a statistically significant postoperative improvement (p = 0.004). In patients with preoperative normal GLS, there was not a significant change in any strain parameters after CABG. There was an improvement in diastolic function parameters measured by Tissue Doppler Imaging (TDI) in both groups. Conclusions: There is improvement in LV systolic and diastolic function after CABG in patients with preserved preoperative LVEF measured by STI and TDI. GLS might be more sensitive and effective than LVEF for monitoring improvements in myocardial function after CABG surgery in patients with preserved LVEF.

Management of Coronary Artery Disease in CADASIL Patients: Review of Current Literature.

Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is the most common heritable form of vascular dementia in adults. It is well-established that CADASIL results in neurocognitive dysfunction and mood disturbance. There is also cumulative evidence that CADASIL patients are more susceptible to ischemic heart disease. The aim of this study is to review the current literature regarding the incidence of coronary artery disease in CADASIL patients with a focus on the various management options and the clinical challenges associated with each of these treatment strategies. We conducted a literature search using Cochrane, MEDLINE, and EMBASE for papers that reported the occurrence of coronary artery disease in patients with CADASIL. We supplemented the search with a manual search in Google Scholar. Only case reports, case series, and original articles were included. The search resulted in six reports indicating the association between coronary artery disease and CADASIL and its management. Evidence suggests that extracranial manifestations of CADASIL may include coronary artery disease, presenting as a more extensive burden of disease in younger patients. Surgical and percutaneous revascularization strategies are feasible, but the incidence of peri-procedural stroke remains significant and should be weighed against the potential benefit derived from either of these strategies. A multidisciplinary approach to therapy, with perspectives from neurologists, cardiologists, and cardiac surgeons, is needed to provide the appropriate treatment to the CADASIL patient with severe coronary artery disease. Future studies should be directed toward the development of targeted therapies that may help with the early detection and prevention of disease progress in these patients.

Incidental Finding of Subannular Perfused Aortic Root Abscess.

An 83-year-old female presented with aortic valve stenosis requiring surgery, which was diagnosed with a transthoracic echocardiography three years ago. However, the patient declined the surgery at that time due to personal reasons. Three years later she presented again with signs of dizziness and weakness and progression of the aortic valve stenosis. Cardiac catheterization and a computed tomography scan were performed before the planned surgery. Surprisingly, a huge subannular perfused abscess hole around the aortic root companying a pericardial effusion was revealed. The patient underwent an urgent aortic root replacement with a tissue valve and an aortic ascending replacement without any complications. Intraoperative inspection confirmed an active aortic root and valve endocarditis.

Patients with Pulmonary Metastases from Head and Neck Cancer Benefit from Pulmonary Metastasectomy, A Systematic Review.

Background and Objectives: The incidence of distant metastases in patients with head and neck cancer (HNC) is approximately 10%. Pulmonary metastases are the most frequent distant location, with an incidence of 70-85%. The standard treatment options are chemo-, immuno- and radiotherapy. Despite a benefit for long-term survival for patients with isolated pulmonary metastases, pulmonary metastasectomy (PM) is not the treatment of choice. Furthermore, many otorhinolaryngologists are not sufficiently familiar with the concept of PM. This work reviews the recent studies of pulmonary metastatic HNC and the results after pulmonary metastasectomy. Materials and Methods: PubMed, Medline, Embase, and the Cochrane library were checked for the case series' of patients undergoing metastasectomy with pulmonary metastases published since 1 January 2000. Results: We included the data of 15 studies of patients undergoing PM. The 5-year survival rates varied from 21% to 59%, with median survival from 10 to 77 months after PM. We could not identify one specific prognostic factor for long-term survival after surgery. However, at least most studies stated that PM should be planned if a complete (R0) resection is possible. Conclusions: PM showed reliable results and is supposedly the treatment of choice for patients with isolated pulmonary metastases. Patients not suitable for surgery may benefit from other non-surgical therapy. Every HNC patient with pulmonary metastases should be discussed in the multidisciplinary tumor board to optimize the therapy and the outcome.

Minimally invasive aortic valve replacement with an expandable bioprosthesis after LVAD implantation as redo surgery.

Left Ventricular Assist Device (LVAD) is currently implanted not only as a bridge to transplant or recovery but also as destination therapy. One factor, affecting the device performance and treatment adequacy negatively is the development of aortic valve insufficiency (AI) after the implantation. Herein, we introduce a minimally invasive partial sternotomy aortic valve replacement with an expandable bio-prosthesis in a 74-year-old LVAD patient with severe AI.

Long-Term Follow-Up of Survivors of Extracorporeal Life Support Therapy for Cardiogenic Shock: Are They Really Survivors?

Background and Objectives: Cardiogenic shock (CS) is a medical emergency associated with a high mortality rate. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has become an accepted therapy for CS. Despite widely available data for short-term survival rates, there are only limited data available regarding long-term outcomes following successful VA-ECMO therapy. Materials and Methods: We analyzed the demographics, past medical history, adverse events, and outcomes of survivors who received VA-ECMO support for CS at our center from January 2012 to December 2019. Post-cardiotomy cases were excluded. Results: A total of 578 VA-ECMO implantations on 564 consecutive patients due to CS were identified during the study period. Successful weaning was achieved in 207 (36.7%) patients. Among the survivors, 126 (63%) patients received VA-ECMO therapy without preceding cardiac surgery during their current admission. A follow-up exceeding 12 (mean: 36 ± 20.9) months was available in a total of 55 (43.7%) survivors. The mean VA-ECMO perfusion time was 10.9 (±7.7) days with a mean intensive care unit (ICU) stay of 38.2 (±29.9) days and a mean hospital stay of 49.9 (±30.5) days. A total of 3 deaths were recorded during long-term follow-up (mean survival of 26 ± 5.3 months). Conclusions: Despite the high mortality associated with VA-ECMO therapy, a long-term follow-up with an acceptably low rate of negative cardiac events can be achieved in many survivors. We observed an acceptable low rate of new cardiac events. Further evaluation, including a quality-of-life assessment and a close follow-up for rarer complications in these patients, is needed to elucidate the longer-term outcomes for survivors of invasive VA-ECMO therapy.

Surgery for infective endocarditis following low-intermediate risk transcatheter aortic valve replacement-a multicentre experience.

OBJECTIVES: With the expansion of transcatheter aortic valve replacement (TAVR) into intermediate and low risk, the number of TAVR procedures is bound to rise and along with it the number of cases of infective endocarditis following TAVR (TIE). The aim of this study was to review a multicentre experience of patients undergoing surgical intervention for TIE and to analyse the underlying indications and operative results. METHODS: We retrospectively identified and analysed 69 patients who underwent cardiac surgery due to TIE at 9 cardiac surgical departments across Germany. The primary outcome was operative mortality, 6-month and 1-year survival. RESULTS: Median age was 78 years (72-81) and 48(69.6%) were male. The median time to surgical aortic valve replacement was 14 months (5-24) after TAVR, with 32 patients (46.4%) being diagnosed with early TIE. Cardiac reoperations were performed in 17% of patients and 33% underwent concomitant mitral valve surgery. The main causative organisms were: Enterococcus faecalis (31.9%), coagulase-negative Staphylococcus spp. (26.1%), Methicillin-sensitive Staphylococcus aureus (15.9%) and viridians group streptococci (14.5%). Extracorporeal life support was required in 2 patients (2.9%) for a median duration of 3 days. Postoperative adverse cerebrovascular events were observed in 13 patients (18.9%). Postoperatively, 9 patients (13.0%) required a pacemaker and 33 patients (47.8%) needed temporary renal replacement therapy. Survival to discharge was 88.4% and survival at 6 months and 1 year was found to be 68% and 53%, respectively. CONCLUSIONS: Our results suggest that TIE can be treated according to the guidelines for prosthetic valve endocarditis, namely with early surgery. Surgery for TIE is associated with acceptable morbidity and mortality rates. Surgery should be discussed liberally as a treatment option in patients with TIE by the 'endocarditis team' in referral centres.

The role of the ADVanced Organ Support (ADVOS) system in critically ill patients with multiple organ failure.

BACKGROUND: Multi-organ failure characterized by acute kidney injury, liver dysfunction, and respiratory failure is a complex condition associated with high mortality, for which multiple individual support devices may be simultaneously required. This review aims to appraise the current evidence for the ADVanced Organ Support (ADVOS) system, a novel device integrating liver, lung, and kidney support with blood detoxification. METHODS: We performed a literature review of the PubMed database to identify human and animal studies evaluating the ADVOS system. RESULTS: In porcine models of acute liver injury and small clinical studies in humans, ADVOS significantly enhanced the elimination of water-soluble and protein-bound toxins and metabolites, including creatinine, ammonia, blood urea nitrogen, and lactate. Cardiovascular parameters (mean arterial pressure, cerebral perfusion pressure, and cardiac index) and renal function were improved. ADVOS clears carbon dioxide (CO2 ) effectively with rapid correction of pH abnormalities, achieving normalization of CO2 , and bicarbonate levels. In patients with COVID-19 infection, ADVOS enables rapid correction of acid-base disturbance and respiratory acidosis. ADVOS therapy reduces mortality in multi-organ failure and has been shown to be safe with minimal adverse events. CONCLUSIONS: From the small observational studies analyzed, ADVOS demonstrates excellent detoxification of water-soluble and protein-bound substances. In particular, ADVOS permits the correction of metabolic and respiratory acidosis through the fluid-based direct removal of acid and CO2 . ADVOS is associated with significant improvements in hemodynamic and biochemical parameters, a trend toward improved survival in multi-organ failure, and is well-tolerated. Larger randomized trials are now necessary to further validate these encouraging results.

Off-pump coronary artery bypass grafting for patients with severely reduced ventricular function-A justified strategy?

BACKGROUND AND AIM: Low ejection fraction (EF) has been identified as a main risk factor for perioperative complications and mortality after coronary artery bypass grafting (CABG). The purpose of this study was to compare the efficacy and early as well as midterm outcomes of off-pump CABG (OPCAB) and conventional CABG (ONCAB) surgery in patients with reduced EF. METHODS: We performed a retrospective review of patient demographics, preoperative risk factors, operative and postoperative outcomes of patients with left ventricular EF (LV-EF) ≤35%, who underwent CABG at our institution between January 2015 and December 2017. Propensity score and multivariate logistic regression analysis were used to compare risk adjusted outcomes between groups. RESULTS: Overall, 111 consecutive CABG-patients with LV-EF ≤ 35% underwent either ONCAB (46 patients, 41.4%) or OPCAB surgery (65 patients, 58.6%). There was no difference in early mortality (5% vs. 7.5%, p = .64) between groups. After propensity score matching, OPCAB-patients required significantly less re-sternotomies for bleeding (20% vs. 2.5%, p = .03) and consequently received significantly less blood transfusions (57.5% vs. 32.5%, p = .03). Fewer OPCAB-patients experienced low cardiac output syndrome (22.5% vs. 42.5%, p = .06) and suffered from postoperative delirium (22.5% vs. 42.5%, p = .06). There were no differences in completeness of revascularization between groups (median 1 (1.0-1.33; 1.0-1.33) OPCAB versus median 1 (1-1.33; 0.67-2) ONCAB, p = .95). Survival after 6 months, one year and three years was similar for ONCAB- and OPCAB-patients (ONCAB 92.3%, 89.4%, and 89.4% vs. OPCAB 89.8%, 85.7%, and 82.1%; p = .403). More ONCAB-patients needed a coronary re-intervention during follow-up (8.6% vs. 2.3%, p = .402). CONCLUSION: OPCAB-surgery is a safe and effective option for patients with reduced EF. Furthermore, it does not come at the expense of less complete revascularization or increased coronary re-intervention during early follow-up.

Quality of Life Following Urgent LVAD Implantation for ECMO Therapy in Cardiogenic Shock: A Long-Term Follow-Up.

Background and Objectives: Over the past decade, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has developed into a mainstream treatment for refractory cardiogenic shock (CS) to maximal conservative management. Successful weaning of VA-ECMO may not be possible, and bridging with further mechanical circulatory support (MCS), such as urgent implantation of a left ventricular assist device (LVAD), may represent the only means to sustain the patient haemodynamically. In the recovery phase, many survivors are not suitably prepared physically or psychologically for the novel issues encountered during daily life with an LVAD. Materials and Methods: A retrospective analysis of our institutional database between 2012 and 2019 was performed to identify patients treated with VA-ECMO for CS who underwent urgent LVAD implantation whilst on MCS. Post-cardiotomy cases were excluded. QoL was assessed prospectively during a routine follow-up visit using the EuroQol-5 dimensions-5 level (EQ-5D-5L) and the Patient Health Questionnaire (PHQ-9) surveys. Results: Among 126 in-hospital survivors of VA-ECMO therapy due to cardiogenic shock without prior cardiac surgery, 31 (24.6%) urgent LVAD recipients were identified. In 11 (36.7%) cases, cardiopulmonary resuscitation (CPR) was performed (median 10, range 1-60 min) before initiation of VA-ECMO, and in 5 (16.7%) cases, MCS was established under CPR. Mean age at LVAD implantation was 51.7 (+/-14) years and surgery was performed after a mean 12.1 (+/-8) days of VA-ECMO support. During follow-up of 46.9 (+/-25.5) months, there were 10 deaths after 20.4 (+/-12.1) months of LVAD support. Analysis of QoL questionnaires returned a mean EQ-5D-5L score of 66% (+/-21) of societal valuation for Germany and a mean PHQ-9 score of 5.7 (+/-5) corresponding to mild depression severity. When compared with 49 elective LVAD recipients without prior VA-ECMO therapy, there was no significant difference in QoL results. Conclusions: Patients requiring urgent LVAD implantation under VA-ECMO support due to CS are associated with comparable quality of life without a significant difference from elective LVAD recipients. Close follow-up is required to oversee patient rehabilitation after successful initial treatment.