Left ventricular assist device implantation and clinical outcomes in the Netherlands.

BACKGROUND: Left ventricular assist device (LVAD) therapy is an established treatment for advanced heart failure with reduced ejection fraction. We evaluated the characteristics and clinical outcomes of patients implanted with an LVAD in the Netherlands. METHODS: Patients implanted with an LVAD in the Netherlands between 2016 and 2020 were included in the analysis. Baseline characteristics entered into this registry, as well as clinical outcomes (death on device, heart transplantation) and major adverse events (device dysfunction, major bleeding, major infection and cerebrovascular event), were evaluated. RESULTS: A total of 430 patients were implanted with an LVAD; mean age was 55 ± 13 years and 27% were female. The initial device strategy was bridge to transplant (BTT) in 50%, destination therapy (DT) in 29% and bridge to decision (BTD) in the remaining 21%. After a follow-up of 17 months, 97 (23%) patients had died during active LVAD support. Survival was 83% at 1 year, 76% at 2 years and 54% at 5 years. Patients implanted with an LVAD as a BTT had better outcomes compared with DT at all time points (1 year 86% vs 72%, 2 years 83% vs 59% and 5 years 58% vs 33%). Major adverse events were frequently observed, most often major infection, major bleeding and cerebrovascular events (0.84, 0.33 and 0.09 per patient-year at risk, respectively) and were similar across device strategies. Patients supported with HeartMate 3 had a lower incidence of major adverse events. CONCLUSIONS: Long-term survival on durable LVAD support in the Netherlands is over 50% after 5 years. Major adverse events, especially infection and bleeding, are still frequently observed, but decreasing with the contemporary use of HeartMate 3 LVAD.

Staged single-port thoracoscopic R2 sympathicotomy as a reproducible, safe and effective treatment option for debilitating severe facial blushing.

OBJECTIVES: Our goal was to investigate the safety, feasibility, success rate, complication rate and side effects of staged single-port thoracoscopic R2 sympathicotomy in the treatment of severe facial blushing. Facial blushing is considered a benign condition; however, severe facial blushing can have a major impact on quality of life. When nonsurgical options such as medication and psychological treatments offer no or insufficient relief, surgical treatment with thoracoscopic sympathicotomy should be considered. METHODS: All patients who underwent a staged thoracoscopic sympathicotomy at level R2 for severe facial blushing between January 2016 and September 2021 were included. Clinical and surgical data were prospectively collected and analysed. RESULTS: A total of 16 patients with low operative risk (American Society of Anesthesiologists class 1) were treated. No major perioperative complications were encountered. One patient experienced postoperative unilateral Horner's syndrome that resolved completely after 1 week. Two patients experienced compensatory hyperhidrosis. The success rate was 100%. One patient experienced a slight recurrence of blushing symptoms after 3 years that did not interfere with their quality of life. All patients were satisfied with the results and had no regrets of having undergone the procedure. CONCLUSIONS: Staged single-port thoracoscopic R2 sympathicotomy is a reproducible, safe and highly effective surgical treatment option with low compensatory hyperhidrosis rates and the potential to significantly improve quality of life in carefully selected patients suffering from severe facial blushing. We would like to increase awareness among healthcare professionals for debilitating facial blushing and suggest timely referral for surgical treatment.

Treatment of resistant Raynaud's phenomenon with single-port thoracoscopic sympathicotomy: One-year follow-up.

OBJECTIVE: Follow-up of patients with treatment-resistant Raynaud's phenomenon (RP) one-year after single-port thoracoscopic sympathicotomy (SPTS). METHODS: Eight patients (six males, two females, median age of 45 years) with treatment-resistant RP underwent left-sided SPTS at the third rib (R3), unilaterally. Questionnaires were taken, and number and duration of RP attacks were reported over a 2-week period. Perfusion was assessed with a cooling and recovery procedure at baseline and one year after SPTS. Furthermore, laser speckle contrast analysis, pulse wave velocity, heart rate variability and nailfold capillary microscopy were performed. RESULTS: One year after SPTS the duration of the attacks of was reduced with 1.9 h in the left hand versus 0.3 h in the right hand. Furthermore, three aspects of the questionnaire showed a significant improvement (role limitations due to physical health (p = 0.017), pain (p = 0.027) and physical functioning (p = 0.025)). The total area under the curve of the total cooling and recovery procedure of the left hand was larger one year after surgery (101 (75-140) at baseline versus 118 (95-190) one year post-operatively, p = 0.012), implying a better perfusion in the fingers. This was mainly due to the improvement during the recovery phase (21 (1-41) at baseline versus 38 (24-43) one year post-operatively, p = 0.028). CONCLUSION: One year after unilateral R3 SPTS the benefit with regard to the majority of outcome variables persisted, though some effects seem to attenuate. Long-term effects and long-term follow-up results will be investigated in an on-going study. CLINICAL TRIAL REGISTRATION NUMBER: NCT02680509.

Conservative initial postoperative anticoagulation strategy after HeartMate 3 left ventricular assist device implantation.

INTRODUCTION: Although anticoagulation therapy is mandated after implantation of a left ventricular assist device (LVAD), postoperative bleedings and reoperations occur relatively frequently and are associated with worse outcomes. We evaluated the use of a conservative postoperative anticoagulation protocol in patients implanted with a HeartMate 3 (HM3) LVAD. METHODS: In a single-centre retrospective analysis of postoperative outcomes after HM3 LVAD implantation, a standard (old) anticoagulation protocol (i.e. early, full-dose anticoagulation with low-molecular weight heparin and overlapping vitamin K antagonist) was compared with a new conservative anticoagulation protocol (i.e. slow initiation of vitamin K antagonists without overlapping heparin). Main outcomes were changes in international normalised ratio (INR), lactate dehydrogenase (LDH), bleeding and/or tamponade events requiring reoperation, length of stay and adverse events. RESULTS: In total, 73 patients (48 in old vs 25 in new protocol group) were evaluated. Mean age was 56 years (standard deviation 13) and most patients (78%) were males. Changes in INR and LDH in the first 14 days were similar in both groups (p = 0.50 and p = 0.997 for interaction, respectively). Number of bleeding/tamponade events requiring reoperation was lower in the new than in the old protocol group (4% vs 33%, p = 0.005). Postoperative 30-day mortality was similar, and we observed no thromboembolic events. Median (25th-75th percentiles) total length of postoperative hospital stay (27 (25-41) vs 21 (19-27) days, p < 0.001) and length of intensive care unit stay (5 (2-9) vs 2 (2-5) days, p = 0.022) were significantly shorter in the new protocol group. CONCLUSION: These retrospective data suggest that conservative slow initiation of anticoagulation therapy after HM3 LVAD implantation is associated with less bleeding/tamponade events requiring reoperation, a similar safety profile and a shorter duration of stay than the currently advised standard anticoagulation protocol.

Minimally Invasive Sympathicotomy for Palmar Hyperhidrosis and Facial Blushing: Current Status and the Hyperhidrosis Expert Center Approach.

Hyperhidrosis, the medical term for excessive sweating beyond physiological need, is a condition with serious emotional and social consequences for affected patients. Symptoms usually appear in focal areas such as the feet, hands, axillae and face. Non-surgical treatment options such as topical antiperspirants or systemic medications are usually offered as a first step of treatment, although these therapies are often ineffective, especially in severe and intolerable cases of hyperhidrosis. In the treatment algorithm for patients suffering from hyperhidrosis, surgical thoracoscopic sympathicotomy offers a permanent solution, which is particularly effective in the treatment of palmar hyperhidrosis and facial blushing. In this review, we describe the current status of thoracoscopic sympathicotomy for palmar hyperhidrosis and facial blushing. In addition, we share the specific treatment approach, technique and results of our Hyperhidrosis Expert Center. Last, we share recommendations to ensure an effective, reproducible and safe application of single-port thoracoscopic sympathicotomy for palmar hyperhidrosis and facial blushing, based on our extensive experience.

[Sympathicotomy in patients with drug resistant Raynaud's phenomenon]. / Sympathicotomie bij medicatieresistent fenomeen van Raynaud.

Raynaud's phenomenon (RP) is a disorder of the microvasculature which causes poor blood flow to the digits. This disorder is common in young females and may be associated with several underlying connective tissue diseases including systemic sclerosis. Although RP may have a tremendous impact on quality of life, treatment options are limited. Conventional medical treatment mainly consists of vasodilatory drugs, which are not effective in all patients and may induce undesired side effects. The current clinical lesson describes three patients with severe RP who all underwent a novel, minimally invasive, single-port thoracoscopic sympathicotomy (SPTS). Although this procedure seems promising in patients with treatment-resistant RP, as shown with patients A and B, future research has yet to show what the long-term effects are.

Bilateral one-stage single-port sympathicotomy in primary focal hyperhidrosis, a prospective cohort study: treat earlier?

BACKGROUND: Primary Focal Hyperhidrosis (PFH) has a detrimental effect on Quality of Life. Repetitive, non-curative symptomatic strategies dominate current treatment of PFH, in spite of the availability of an effective and permanent curative treatment like Endoscopic Thoracic Sympathectomy (ETS). Current surgical optimization may allow for a re-established position of sympathetic modulation in this treatment algorithm. We sought to evaluate the safety, effectiveness, and long-term results of a Bilateral One-stage Single-port Sympathicotomy (BOSS) procedure in PFH patients and to identify subgroups benefitting most. METHODS: Prospective analysis of 163 patients, 35 (21.5%) underwent Rib-3 (R3) BOSS for palmar PFH, 58 (35.6%) R3-R5 BOSS for axillary PFH and 70 (42.9%) R3-R5 BOSS for combined palmar/axillary PFH. Effectiveness was measured using Skindex-29 and the Hyperhidrosis Disease Severity Scale (HDSS). RESULTS: Overall Skindex-29-rating (46.5 ± 14.8 preoperatively vs 20.1 ± 20.6 postoperatively, p < 0.001), and HDSS score (3.71 ± 0.45 preoperatively vs 1.82 ± 0.86 postoperatively, p < 0.001) indicated a significant improvement in health-related quality of life after BOSS. R3 BOSS was superior to R3-R5 BOSS in terms of HDSS score (1.49 vs 1.91 respectively, p = 0.004) and in terms of severe compensatory hyperhidrosis, a frequently reported side-effect (17.1% vs 32.8% respectively, p < 0.001). No major complications occurred. CONCLUSIONS: BOSS is safe, effective, and offers a long-term curative solution in the treatment of PFH. Especially in the palmar PFH subgroup, R3 BOSS treatment results compare favorably to the treatment results of non-curative alternatives published in the current literature. Therefore, R3 BOSS should be offered to all patients with severe PFH, reporting insufficient benefit of treatment options such as oral and/or local agents.

Thoracoscopic sympathicotomy for the treatment of intolerable palmar and axillary hyperhidrosis in children is associated with high recurrence rates.

BACKGROUND: Treatment of palmar and axillary primary focal hyperhidrosis (PFH) in children up to 16 years using thoracoscopic sympathicotomy is supported by scarce evidence. Therefore, this study aimed to summarize the results of our standardized bilateral, one-stage, single-port sympathicotomy (BOSS) in children up to 16 years of age. METHODS: Consecutive children (n = 14) up to 16 years of age undergoing BOSS between October 2011 and June 2015 in our institution were included in this retrospective study. RESULTS: Recurrence of primary hyperhidrosis was noted in seven patients (50.0%), of whom five patients (35.7%) underwent reoperation. Reoperations were associated with placement of additional thoracoscopic ports (n = 1; 12.5%), intraoperative placement of pleural drains (n = 2; 25%), and prolonged air leak (n = 1; 12.5%). Despite the high recurrence and reoperation rates, overall patient satisfaction was high with a median satisfaction score of 7.5 (interquartile range of 1.75; range: 4-9). CONCLUSION: Although the overall patient satisfaction score in our cohort was good, BOSS for the treatment of intolerable palmar and axillary PFH in children up to 16 years of age is associated with a high recurrence and reoperation rate.

Treatment of resistant Raynaud's phenomenon with single-port thoracoscopic sympathicotomy: a novel minimally invasive endoscopic technique.

OBJECTIVE: To assess the minimally invasive single-port thoracoscopic sympathicotomy feasibility and efficacy in patients with treatment-resistant RP. METHODS: Single-port thoracoscopic sympathicotomy was performed unilaterally on the left side in eight patients with RP (six males, two females, with a median age of 45.2 years). Five patients had primary and three had secondary RP. Perfusion effects in the hands were assessed at baseline and after 1 month by using a cooling and recovery procedure, and by using laser speckle contrast analysis. Number and duration of RP attacks were reported over a 2-week period. RESULTS: Patient satisfaction was 100% after surgery. After surgery, a unilateral improvement in perfusion was observed in the left hand compared with the right hand, with cooling and recovery (P = 0.008) and with laser speckle contrast analysis (P = 0.023). In addition, the number and duration of the attacks in the left hand decreased compared with the right hand (both P = 0.028). No serious adverse events occurred in a follow-up period of at least 10 months. CONCLUSION: Single-port thoracoscopic sympathicotomy is feasible and can be effective in improving hand perfusion in patients with RP. However, long-term efficacy needs to be established. CLINICAL TRIAL REGISTRATION NUMBER: NCT02680509.

Single-port videoscopic splanchnotomy for palliation of refractory chronic pancreatitis.

OBJECTIVES: Interrupting the afferent signals that travel through the splanchnic nerves by multiportal thoracoscopic splanchnotomy can offer effective palliation in chronic pancreatitis. However, obtained results weaken after time, possibly necessitating repeat procedures. Given the palliative nature of this procedure, potential for iatrogenic damage should be kept at a minimum. So, in order to minimize invasiveness while optimizing repeatability, we sought to create an easily reproducible single-access port operative strategy. METHODS: Four patients suffering from intractable pain due to chronic pancreatitis for >10 years (12.8 ± 5.9) underwent a single-port unilateral R5-R11 splanchnotomy. RESULTS: Postoperative recovery was uneventful. No operative complications were observed. All 4 patients experienced excellent pain relief with a significant improvement of Visual Analogue Scale pain scores (8.8 ± 1.0 preoperatively to 3.0 ± 1.2 postoperatively, P = 0.003). CONCLUSIONS: We report the first series of single-port video-assisted thoracoscopic surgical (VATS) splanchnotomy for palliation of intractable pain due to chronic pancreatitis. From this small study, single-port VATS splanchnotomy seems to be a safe and effective alternative to multiportal or open procedures.

Long-term survival after mitral valve surgery for post-myocardial infarction papillary muscle rupture.

BACKGROUND: Papillary muscle rupture (PMR) is a rare, but dramatic mechanical complication of myocardial infarction (MI), which can lead to rapid clinical deterioration and death. Immediate surgical intervention is considered the optimal and most rational treatment, despite high risks. In this study we sought to identify overall long-term survival and its predictors for patients who underwent mitral valve surgery for post-MI PMR. METHODS: Fifty consecutive patients (mean age 64.7±10.8 years) underwent mitral valve repair (n=10) or replacement (n=40) for post-MI PMR from January 1990 through May 2014. Clinical data, echocardiographic data, catheterization data, and surgical data were stored in a dedicated database. Follow-up was obtained in June of 2014; mean follow-up was 7.1±6.8 years (range 0.0-22.2 years). Univariate and multivariate Cox proportional hazard regression analyses were performed to identify predictors of long-term survival. Kaplan-Meier curves were compared with the log-rank test. RESULTS: Kaplan-Meier cumulative survival at 1, 5, 10, 15, and 20 years was 71.9±6.4%, 65.1±6.9%, 49.5±7.6%, 36.1±8.0% and 23.7±9.2%, respectively. Univariate and multivariate analyses revealed logistic EuroSCORE≥40% and EuroSCORE II≥25% as strong independent predictors of a lower overall long-term survival. After removal of the EuroSCOREs from the model, preoperative inotropic drug support and mitral valve replacement (MVR) without (partial or complete) preservation of the subvalvular apparatus were independent predictors of a lower overall long-term survival. CONCLUSIONS: Logistic EuroSCORE≥40%, EuroSCORE II≥25%, preoperative inotropic drug support and MVR without (partial or complete) preservation of the subvalvular apparatus are strong independent predictors of a lower overall long-term survival in patients undergoing mitral valve surgery for post-MI PMR. Whenever possible, the subvalvular apparatus should be preserved in these patients.

A new beating-heart off-pump coronary artery bypass grafting training model.

OBJECTIVES: Training models are essential in mastering the skills required for off-pump coronary artery bypass grafting (OPCAB). We describe a new, high-fidelity, effective and reproducible beating-heart OPCAB training model in human cadavers. METHODS: Human cadavers were embalmed according to the 'Thiel method' which allows their long-term and repeated use. The training model was constructed by bilateral ligation of the pulmonary veins, cross-clamping of the aorta, positioning of an intra-aortic balloon pump (IABP) in the left ventricle (LV) through the apex (tightened with pledget-reinforced purse strings) and finally placing of a fluid line in the LV through the left atrial appendage (tightened with a pledget-reinforced purse string). The LV was filled with saline to the desired pressure through the fluid line and the IABP was switched on and set to a desired frequency [usually 60-80 beats per minute (bpm)]. RESULTS: A high-fidelity simulation has known limitations, but a more complex, realistic training environment with an actual beating (human) heart strengthens the entire training exercise and is of incremental value. All types of coronary artery anastomosis can be trained with this model. Training should be performed under the supervision of an experienced OPCAB surgeon and training progress is best evaluated with serial Objective Structured Assessment of Technical Skills (OSATS). A score of at least 48 points on the final OSATS ('good' on all components) is recommended before trainees can start their training on patients. CONCLUSIONS: The entire set-up provides a versatile training model to help develop and improve the skills required to safely perform beating heart OPCAB anastomoses.

Predictors of in-hospital mortality after mitral valve surgery for post-myocardial infarction papillary muscle rupture.

BACKGROUND: Papillary muscle rupture (PMR) is a rare, but often life-threatening mechanical complication of myocardial infarction (MI). Immediate surgical intervention is considered the optimal and most rational treatment for acute PMR, but carries high risks. At this point it is not entirely clear which patients are at highest risk. In this study we sought to determine in-hospital mortality and its predictors for patients who underwent mitral valve surgery for post-MI PMR. METHODS: Between January 1990 and December 2012, 48 consecutive patients (mean age 64.9 ± 10.8 years) underwent mitral valve repair (n = 10) or replacement (n = 38) for post-MI PMR. Clinical data, echocardiographic data, catheterization data, and surgical reports were reviewed. Univariate and multivariate logistic regression analyses were performed to identify predictors of in-hospital mortality. RESULTS: Intraoperative mortality was 4.2% and in-hospital mortality was 25.0%. Univariate and multivariate logistic regression analyses revealed the logistic EuroSCORE and EuroSCORE II as independent predictors of in-hospital mortality. Receiver operating characteristics curves showed an optimal cutoff value of 40% for the logistic EuroSCORE (area under the curve 0.85, 95% CI 0.71-1.00, P < 0.001) and of 25% for the EuroSCORE II (area under the curve 0.83, 95% CI 0.68-0.99, P = 0.001). After removal of the EuroSCOREs from the model, complete PMR and intraoperative intra-aortic balloon pump (IABP) requirement were independent predictors of in-hospital mortality. CONCLUSIONS: The logistic EuroSCORE (optimal cutoff ≥ 40%), EuroSCORE II (optimal cutoff ≥ 25%), complete PMR, and intraoperative IABP requirement are strong independent predictors of in-hospital mortality in patients undergoing mitral valve surgery for post-MI PMR. These predictors may aid in surgical decision making and they may help improve the quality of informed consent.

Single-port one-stage bilateral thoracoscopic sympathicotomy for severe hyperhidrosis: prospective analysis of a standardized approach.

BACKGROUND: Primary palmar and/or axillary focal hyperhidrosis is a frequent disorder characterized by excessive sweating beyond physiological needs, often leading to a substantial impairment of quality of life. Over the years several minimally invasive surgical treatments have been described, however results vary, and due to a lack of uniform surgical approach, technique and nomenclature are often difficult to compare. In this prospective study we sought to evaluate the safety and effectiveness of our standardized technique of single-port, one-stage bilateral thoracoscopic sympathicotomy. METHODS: On a prospective basis a hundred consecutive patients with severe or intolerable primary hyperhidrosis underwent one-stage bilateral single-port thoracoscopic sympathicotomy. Primary outcome was measured in pre- vs. post-operative Hyperhidrosis Disease Severity Scale scores. Location and extend of compensatory hyperhidrosis, and satisfaction with the procedure were registered. RESULTS: A significant reduction in mean Hyperhidrosis Disease Severity Scale score (3.69 ± 0.47 preoperatively vs. 1.06 ± 0.34 postoperatively) (p < 0.001) was observed. In 97 (97%) out of the 100 enrolled patients a >80% reduction in sweat production was achieved. Compensatory hyperhidrosis was seen in 27 patients (27%). It was rated as mild by 21 patients (78%) and as moderate by 6 (22%) of these patients. No severe compensatory hyperhidrosis was reported. Major complications, such as intraoperative bleeding, infections, and Horner's syndrome were not observed. CONCLUSIONS: Highly selective sympathicotomy at well-defined levels with a one-stage bilateral single-port transaxillary thoracoscopic approach is a save procedure, with excellent and reproducible immediate results in the treatment of primary palmar and/or axillary hyperhidrosis.

Mitral valve repair for post-myocardial infarction papillary muscle rupture.

OBJECTIVES: Papillary muscle rupture (PMR) is a rare, but serious mechanical complication of myocardial infarction (MI). Although mitral valve replacement is usually the preferred treatment for this condition, mitral valve repair may offer an improved outcome. In this study, we sought to determine the outcome of mitral valve repair for post-MI PMR and to provide a systematic review of the literature on this topic. METHODS: Between January 1990 and December 2010, 9 consecutive patients (mean age 63.5 ± 14.2 years) underwent mitral valve repair for partial post-MI PMR. Clinical data, echocardiographic data, catheterization data and surgical reports were reviewed. Follow-up was obtained in December of 2012 and it was complete; the mean follow-up was 8.7 ± 6.1 (range 0.2-18.8 years). RESULTS: Intraoperative and in-hospital mortality were 0%. Intraoperative repair failure rate was 11.1% (n = 1). Freedom from Grade 3+ or 4+ mitral regurgitation and from reoperation at 1, 5, 10 and 15 years was 87.5 ± 11.7%. Estimated 1-, 5-, 10- and 15-year survival rates were 100, 83.3 ± 15.2, 66.7 ± 19.2 and 44.4 ± 22.2%, respectively. There were 3 late deaths, and 2 were cardiac-related. All late survivors were in New York Heart Association Class I or II. No predictors of long-term survival could be identified. CONCLUSIONS: Mitral valve repair for partial or incomplete post-MI PMR is reliable and provides good short- and long-term results, provided established repair techniques are used and adjacent tissue is not friable. PMR type and adjacent tissue quality ultimately determine the feasibility and durability of repair.

Mitral valve repair and redo repair for mitral regurgitation in a heart transplant recipient.

A 37-year-old man with end-stage idiopathic dilated cardiomyopathy underwent an orthotopic heart transplant followed by a reoperation with mitral annuloplasty for severe mitral regurgitation. Shortly thereafter, he developed severe tricuspid regurgitation and severe recurrent mitral regurgitation due to annuloplasty ring dehiscence. The dehisced annuloplasty ring was refixated, followed by tricuspid annuloplasty through a right anterolateral thoracotomy. After four years of follow-up, there are no signs of recurrent mitral or tricupid regurgitation and the patient remains in NYHA class II. Pushing the envelope on conventional surgical procedures in marginal donor hearts (both before and after transplantation) may not only improve the patient's functional status and reduce the need for retransplantation, but it may ultimately alleviate the chronic shortage of donor hearts.

PulseCath(R) as a right ventricular assist device.

The PulseCath(®) is a pulsatile pump that offers a circulatory support up to 3 l/min. The PulseCath(®) is indicated for patients who require a higher degree of support than that offered by the intra-aortic balloon pump. We describe the first two cases of the use of the PulseCath(®) as a temporary support for the right ventricle after insertion through the pulmonary artery trunk. Two patients developed an acute right ventricular failure with severe hemodynamic instability after cardiac surgery. The PulseCath(®) was chosen to assist the right ventricle. An immediate improvement of hemodynamic parameters was observed in both cases. In the first patient an irreversible metabolic unbalance, already present prior to PulseCath(®) insertion, led to multi-organ failure and eventually to death. In the second case the early utilization of PulseCath(®) led to a complete recovery of the right ventricle and the patient was discharged in good clinical condition. Besides the technical feasibility, this report would suggest that a correct timing is the key to success for the PulseCath(®) as a right ventricular assist device.

The relation between volume and outcome of coronary interventions: a systematic review and meta-analysis.

AIMS: Although various studies reported better outcomes in centres performing a high volume of procedures of coronary artery bypass grafting (CABG) or percutaneous coronary interventions (PCIs), it is unclear how strong this relation is and whether it pertains to today's practice. METHODS AND RESULTS: Medline, Embase, and conference reports were searched for studies reporting the effect of high volume of CABG or PCI on in-hospital mortality, adjusted for differences in case-mix. Of 140 potentially relevant papers, 15 were included, 2 of which reported data on both CABG and PCI. Meta-analysis of 10 studies on PCI, comprising 1 322 342 patients in 1746 hospitals, indicated an odds ratio (OR) of in-hospital mortality for patients treated in a high-volume hospital of 0.87 (95% confidence interval (CI) 0.83-0.91) compared to those treated in a low-volume hospital. The 7 CABG studies taken together, comprising 1 470 990 patients in 2040 hospitals, also revealed a significant effect of high volume (OR 0.85; CI 0.79-0.92). A differential effect for specific cut-off points could not be identified. Meta-regression did not show notable changes in the effect size over the years. CONCLUSIONS: Patients undergoing CABG or PCI in a high-volume hospital exhibit lower in-hospital mortality than those treated at low-volume hospitals. Our meta-analysis does not support the view that this relation has attenuated over time.