Anatomic Patterns of Renal Arterial Sympathetic Innervation: New Aspects for Renal Denervation.

AIMS: Initial studies of catheter-based renal arterial sympathetic denervation to lower blood pressure in resistant hypertensive patients renewed interest in the sympathetic nervous system's role in the pathogenesis of hypertension. However, the SYMPLICITY HTN-3 study failed to meet its prespecified blood pressure lowering efficacy endpoint. To date, only a limited number of studies have described the microanatomy of renal nerves, of which, only two involve humans. METHODS AND RESULTS: Renal arteries were harvested from 15 cadavers from the Klinikum Osnabruck and Schuchtermann Klinik, Bad Rothenfelde. Each artery was divided longitudinally in equal thirds (proximal, middle, and distal), with each section then divided into equal superior, inferior, anterior, and posterior quadrants, which were then stained. Segments containing no renal nerves were given a score value = 0, 1-2 nerves with diameter <300 µm a score = 1; 3-4 nerves or nerve diameter 300-599 µm a score = 2, and >4 nerves or nerve diameter ≥600 µm a score = 3. A total of 22 renal arteries (9 right-sided, 13 left-sided) were suitable for examination. Overall, 691 sections of 5 mm thickness were prepared. Right renal arteries had significantly higher mean innervation grade (1.56 ± 0.85) compared to left renal arteries (1.09 ± 0.87) (P < 0.001). Medial (1.30 ± 0.59) and distal (1.39 ± 0.62) innervation was higher than the proximal (1.17 ± 0.55) segments (p < 0.001). When divided in quadrants, the anterior (1.52 ± 0.96) and superior (1.71 ± 0.89) segments were more innervated compared to posterior (0.96 ± 0.72) and inferior (0.90 ± 0.68) segments (P < 0.001). CONCLUSIONS: That the right renal artery has significantly higher innervation scores than the left. The anterior and superior quadrants of the renal arteries scored higher in innervation than the posterior and inferior quadrants did. The distal third of the renal arteries are more innervated than the more proximal segments. These findings warrant further evaluation of the spatial innervation patterns of the renal artery in order to understand how it may enhance catheter-based renal arterial denervation procedural strategy and outcomes. CONDENSED ABSTRACT: The SYMPLICITY HTN-3 study dealt a blow to the idea of the catheter-based renal arterial sympathetic denervation. We investigated the location and patterns of periarterial renal nerves in cadaveric human renal arteries. To quantify the density of the renal nerves we created a novel innervation score. On average the right renal arteries were significantly more densely innervated than the left renal arteries, the anterior and superior segments were significantly more innervated compared to the posterior and inferior segments, absolute innervation scores in the proximal third of the left or right renal arteries were always lower when compared to distal segments. These findings may enhance catheter-based renal arterial denervation procedural strategy and outcomes.

Benefits of "Best for Groin" Strategy Leading to a Transapical TAVI Dominance.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is a recognized therapeutic option for high-risk and inoperable patients with aortic valve stenosis. The choice of access route is a matter of debate. We are presenting our 5-year experience of transapical TAVI dominance. PATIENTS: This single-center study includes 575 patients. Two groups were compared: transapical (TA) and transfemoral (TF) with 454 and 121 patients, respectively. Individual access route decision was made by our heart team following a clinical and computed tomography (CT) data based nonbiased strategy. The same team performed all procedures. The mean logistic EuroSCORE was significantly higher in the TA group, however, without difference in STS score. The number of patients with coronary artery disease, previous cardiac surgery, and low left ventricular ejection fraction was higher in the TA group. There were no significant differences in age and presence of other comorbidities. RESULTS: Procedural success in both TA and TF groups was high (97.9% and 97.6%). No patient died during the procedure. Patient survival (30 days: TF, 97.5% vs. TA, 95.7%; 1 year: TF, 94.6% vs. TA, 81.8%; 2 years: TF, 84.7% vs. TA, 76.7%; 3 years: TF, 59.9% vs. TA, 67.8%) and a low TF vascular complication rate (1.6%) are encouraging compared with other registry data. CONCLUSION: A "no competition" team approach strategy along with an experienced hybrid team leads to fewer vascular complications and better outcomes for both TA and TF TAVI patients.

Cinaciguat (BAY 58-2667) improves cardiopulmonary hemodynamics in patients with acute decompensated heart failure.

BACKGROUND: Cinaciguat (BAY 58-2667) is the first of a new class of soluble guanylate cyclase activators in clinical development for acute decompensated heart failure. We aimed to assess the hemodynamic effects, safety, and tolerability of intravenous cinaciguat in patients with acute decompensated heart failure (pulmonary capillary wedge pressure > or =18 mm Hg). METHODS AND RESULTS: After initial dose finding (part A; n=27), cinaciguat was evaluated in the nonrandomized, uncontrolled proof-of-concept part of the study (part B; n=33) using a starting dose of 100 microg/h, which could be titrated depending on hemodynamic response. Patients were categorized as responders if their pulmonary capillary wedge pressure decreased by > or =4 mm Hg compared with baseline. Final doses of cinaciguat after 6 hours of infusion in part B were 50 microg/h (n=2), 200 microg/h (n=12), and 400 microg/h (n=16). Compared with baseline, a 6-hour infusion of cinaciguat led to significant reductions in pulmonary capillary wedge pressure (-7.9 mm Hg), mean right atrial pressure (-2.9 mm Hg), mean pulmonary artery pressure (-6.5 mm Hg), pulmonary vascular resistance (-43.4 dynes . s . cm(-5)), and systemic vascular resistance (-597 dynes . s . cm(-5)), while increasing heart rate by 4.4 bpm and cardiac output by 1.68 L/min. The responder rate was 53% after 2 hours, 83% after 4 hours, and 90% after 6 hours. Cinaciguat was well tolerated, with 13 of 60 patients reporting 14 drug-related treatment-emergent adverse events of mild to moderate intensity, most commonly hypotension. CONCLUSIONS: Cinaciguat has potent preload- and afterload-reducing effects, increasing cardiac output. Further investigation of cinaciguat for acute decompensated heart failure is warranted.

Clinical value of the 20% logistic EuroSCORE cut-off for selecting TAVI candidates: a single-centre cohort study analysis.

Background: A logistic European System for Cardiac Operative Risk Evaluation (logEuroSCORE) ≥20% is frequently recognised as a finite criteria for transcatheter aortic valve implantation (TAVI) reimbursement, despite guideline modifications to reflect the appropriacy of TAVI in selected lower-risk patients. The aim was to evaluate the clinical value of this threshold cut-off in TAVI patients and to identify factors associated with mortality in those below this threshold. Methods: We analysed data from a single-centre, German, observational, TAVI-patient registry, gathered between 2008 and 2016. Patients were stratified by logEuroSCORE (≥ or <20%) for comparisons. Logistic regression was performed to identify predictors of mortality at 1 year, with this analysis used to generate a calculated ('real') risk value for each patient. Results: 1679 patients (logEuroSCORE <20%: n=789; logEuroSCORE ≥20%: n=890) were included. LogEuroSCORE <20% patients were significantly younger (80.1 vs 81.6 years; p<0.001) and less comorbid than logEuroSCORE ≥20% patients, with a higher rate of transfemoral TAVI (35.6% vs 26.1%; p<0.001) and predilation (70.0% vs 63.3%; p=0.004). Patients with a logEuroSCORE <20% experienced more vascular complications (3.4% vs 1.5%; p=0.010). One-year survival was 88.3% in the logEuroSCORE <20% and 81.8% in the logEuroSCORE ≥20% group (p=0.005), with the calculated mortality risk falling within 2% of the logEuroSCORE in just 12.9% of patients. In the logEuroSCORE <20% group, only coronary artery disease was significantly predictive of 1-year mortality (OR 2.408; 95% CI 1.361 to 4.262; p=0.003). Conclusions: At our institution, patients with a logEuroSCORE <20% selected for TAVI have excellent outcomes. The decision not to reimburse TAVI in such patients may be viewed as inappropriate.

Successful catheter-based valve-in-valve implantation for a regurgitant stentless bioprosthesis.

Catheter-based transapical aortic valve implantation (TA-AVI) in patients with severe stenosis of the aortic valve and with a high operative risk is a new procedure which is becoming established in clinical practice. Aortic regurgitation is not yet a recognized indication for TA-AVI, and to date valve-in-valve (V-in-V) implantation in patients with incompetent stentless bioprostheses has not been attempted. The case is reported of a successful TA-AVI in a regurgitant, uncalcified stentless Medtronic Freestyle bioprosthesis. The position and hemodynamic function of the apically implanted valve were excellent, and the patient's current state of health is good.

Transapical transcatheter aortic valve implantation in patients with a low ejection fraction.

OBJECTIVES: It may be expected that patients with left ventricular dysfunction may be at greater risk of complications after transcatheter aortic valve implantation (TAVI) via transapical (TA) access compared with via transfemoral (TF) access. There is a lack of data comparing the outcomes of TAVI using TA and TF access in patients with a reduced left ventricular ejection fraction (EF). METHODS: This is a retrospective analysis of data from a high-volume heart centre in Germany. TAVI access route assignment was based on a 'best for TF' approach, where only patients who met a strict set of criteria underwent TF-TAVI, with the remainder receiving TA-TAVI. For this analysis, patients were included if they had a pre-TAVI EF of ≤ 40%. Early mortality and late (1-year) mortality were compared through multivariate logistic regression. RESULTS: A total of 342 patients in the registry had an EF of ≤ 40%, of which 74.9% underwent TA-TAVI and 25.1% underwent TF-TAVI. Higher proportions of the TA group presented with certain comorbidities, and their logistic EuroSCORE and Society of Thoracic Surgeons (STS) risk scores were higher than in the TF group. At 1 year, TA access was associated with greater mortality in the univariate analysis (odd ratio 2.43; 95% confidence interval 1.04-5.69). However, after multivariate adjustment, no significant differences were found in either 30-day or 1-year mortality rates. CONCLUSIONS: The data suggest that, for patients with a reduced EF, TA-TAVI is not associated with a poorer outcome compared with TF-TAVI. Therefore, TA access should not be discounted based on the presence of left ventricular dysfunction alone.

Real-world experience using the ACURATE neo prosthesis: 30-day outcomes of 1,000 patients enrolled in the SAVI TF registry.

AIMS: The aim of the SAVI TF registry was to assess the safety and performance of the self-expanding ACURATE neo transfemoral transcatheter heart valve in a large patient population with severe aortic stenosis and to investigate whether the outcomes obtained in the CE-mark cohort can be replicated in an unselected all-comers population. METHODS AND RESULTS: From October 2014 until April 2016, 1,000 patients were enrolled in this prospective, European multicentre registry. Patients were 81.1±5.2 years and had a logistic EuroSCORE II and STS score of 6.6±7.5% and 6.0±5.6%, respectively. Predilatation was performed in 96.1% of patients and postdilatation in 44.8%. Procedural and device success were both obtained in 98.7%; failure comprised nine valve-in-valve procedures, three conversions to surgery, and one aborted procedure. The primary endpoint was 30-day mortality, which was observed in 14 patients (1.4% [95% CI: 0.7-2.1]). Disabling stroke was seen in 1.2% (95% CI: 0.5-1.9) and new pacemaker implantation in 8.3% (95% CI: 6.6-10.0). At discharge, mean effective orifice area was 1.77±0.46 cm² and mean gradient 8.4±4.0 mmHg; 4.1% of patients had a more than mild paravalvular leak. CONCLUSIONS: In this initial experience, treatment with the ACURATE neo prosthesis resulted in good clinical outcomes with very low complication rates.

The SAVI-TF Registry: 1-Year Outcomes of the European Post-Market Registry Using the ACURATE neo Transcatheter Heart Valve Under Real-World Conditions in 1,000 Patients.

OBJECTIVES: The SAVI-TF (Symetis ACURATE neo Valve Implantation Using Transfemoral Access) registry was initiated to study the ACURATE neo transcatheter heart valve in a large patient population treated under real-world conditions. BACKGROUND: The self-expanding, supra-annular ACURATE neo prosthesis is a transcatheter heart valve that gained the Conformité Européene mark in 2014, but only limited clinical data are available so far. METHODS: This prospective, multicenter registry enrolled 1,000 patients at 25 European centers who were followed for 1 year post-procedure. RESULTS: Mean patient age was 81.1 ± 5.2 years; mean logistic European System for Cardiac Operative Risk Evaluation I score, European System for Cardiac Operative Risk Evaluation II score, and Society of Thoracic Surgeons score were 18.1 ± 12.5%, 6.6 ± 7.5%, and 6.0 ± 5.6%, respectively. At 1 year, 8.0% (95% confidence interval [CI]: 6.3% to 9.7%) of patients had died, 2.3% (95% CI: 1.3% to 3.2%) had disabling strokes, and 9.9% (95% CI: 8.1% to 11.8%) had permanent pacemaker implantations. Through 1 year, 5 reinterventions (0.5%; 95% CI: 0.1% to 1.0%) were performed: 3 valve-in-valve and 2 surgical aortic valve replacements. Mean effective orifice area was 1.84 ± 0.43 cm2, mean gradient was 7.3 ± 3.7 mm Hg, and greater than mild paravalvular leakage was observed in 3.6% of patients. CONCLUSIONS: Transfemoral implantation of the ACURATE neo prosthesis resulted in favorable 1-year clinical and echocardiographic outcomes with very low mortality and new pacemaker rates.

Transcatheter aortic valve implantation at a high-volume center: the Bad Rothenfelde experience.

INTRODUCTION: The "transfemoral (TF) first" approach to access route selection in transcatheter aortic valve implantation (TAVI) is popular; however, the risk of major vascular complications is substantial. The "best for TF" approach identifies only the patients with ideal anatomy for TF-TAVI, potentially minimizing complications. AIM: To characterize the outcomes of patients undergoing TAVI at a large-volume site that employs this approach. MATERIAL AND METHODS: Patients who underwent TAVI at the Bad Rothenfelde Heart Centre between 2008 and 2016 were consecutively enrolled. Findings were compared to those from large, multicenter registries. RESULTS: Of the 1,644 patients enrolled, 1,140 underwent TA- and 504 TF-TAVI. Comorbidities were more frequent in TA patients, who also had higher risk scores (EuroSCORE: 25.5% vs. 21.2%; STS score: 11.0% vs. 7.5%; p < 0.001 for both). Rates of conversion to open surgery, major vascular complications and intra-procedural mortality did not differ between groups. At 30 days, mortality rates were higher in the TA group (3.9% vs. 1.9%, p = 0.036). Stroke/transient ischemic attack and permanent pacemaker implantation rates did not differ significantly between groups (2.0% and 9.1% overall, respectively). Compared to multicenter registries, trends in mortality and complication rates were similar, though magnitudes were lower in the present study. In contrast with the present study, major vascular complication rates in multicenter registries are significantly higher for TF compared to TA patients. CONCLUSIONS: At this high-volume center, the use of a "best for TF" approach to TAVI resulted in low mortality and complication rates.

A Novel Method of Axillary Venipuncture Using the Cephalic Vein as a Sole Anatomic Landmark.

The use of axillary venipuncture for pacemaker lead implantation has become a common technique. However, because of its relatively high complexity, it is still not the method of choice in most hospitals. As such, we propose an effective, simple, and safe technique for axillary venipuncture using only the cephalic vein as an anatomic landmark, with the possibility of selective cephalic contrast venography as a backup. A total of 108 patients were examined. After preparation of the cephalic vein, the puncture needle was inserted into the superficial pectoral muscle 1.5-2 cm medial to the cephalic vein and advanced in the direction parallel to the course of the cephalic vein. The needle was advanced up to 3-4 cm at an angle of 30° relative to the body surface, applying gentle suction during advancement. If after 3 attempts the axillary vein was not accessed, the same process was repeated 3-4 cm medial to the cephalic vein. If this was not effective, contrast venography of the axillary vein through the cephalic vein was performed. In 92.6% of all cases, the axillary vein was cannulated without fluoroscopic control, and in 7.4% of cases, fluoroscopic control and selective contrast venography were needed. A novel technique for axillary venipuncture using the cephalic vein as a single landmark is a simple, effective, and safe tool for pacemaker lead implantation. In some cases, selective cephalic contrast venography is an elegant and effective addition.

Simultaneous transfemoral transcatheter mitral and tricuspid valve edge-to-edge repair (using MitraClip system) completed by atrial septal defect occlusion in a surgically inoperable patient. First-in-human report.

Transcatheter transfemoral mitral valve repair using the MitraClip system (Abbott Vascular, USA) is used in high-risk or inoperable patients with severe mitral regurgitation. We report the first-in-human simultaneous transfemoral clipping of the mitral and tricuspid valve completed by occlusion of an atrial septal defect (ASD). The procedure was performed in an 84-year-old patient in October 2015. After effective reduction of mitral and tricuspid regurgitations using the MitraClip system a PFO Occluder (St. Jude Medical, USA) was implanted. Transfemoral simultaneous mitral and tricuspid valve repair using the MitraClip system with ASD occlusion seems to be an effective therapy for high-risk or inoperable patients.

The relationship between urotensin II plasma immunoreactivity and left ventricular filling pressures in coronary artery disease.

The role of urotensin II (U-II)--a vasoactive, mitogenic, and inotropic, peptide--in the pathophysiology of heart failure is controversial. The present study explores the relationship between plasma U-II immunoreactivity (U-IIIR) and hemodynamics in patients with coronary artery disease (CAD). Thirty-six patients with CAD-3 undergoing coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB) and 36 medical patients (MED group) with CAD-1 to CAD-3 during right heart catheterization were studied. Significant correlations were observed between pulmonary capillary wedge pressure (PCWP) and U-IIIR--determined by enzyme immunoassay (EIA)--before (rho = 0.83) and after (rho = 0.6) cardiopulmonary bypass in the CABG group. With the exception of the CPB period, CABG patients with increased PCWP before CPB had higher U-II(IR) concentrations throughout the procedure. Significant correlations were observed between U-IIIR, proANP, proBNP, and mean right ventricular pressure (RVPM) in MED patients. No correlation was detectable between U-IIIR and PCWP. However, MED patients with CAD-3 (n = 13) had higher levels of U-IIIR, NTproANPIR (RIA), NTproBNPIR (EIA) and higher cardiac filling pressures than patients with CAD-1 (n = 13). These findings support an association between plasma U-IIIR levels and diastolic myocardial dysfunction in ischemic heart failure. The discrepancies regarding left and right cardiac filling pressures and U-IIIR levels in CABG and MED patients require further evaluation.

Case of Takotsubo cardiomyopathy after tooth extraction - Unusual trigger of a rare syndrome.

We describe a case of Takotsubo cardiomyopathy in a 75-year-old woman after an elective extraction of 10 teeth of the lower jaw using bilateral mandibular anesthesia. The patient complained of shortness of breath and chest pain after 24 h. Coronary angiography showed smooth normal coronary arteries with thrombolysis in myocardial infarction III flow. Left ventriculography demonstrated apical ballooning. Three months later, the patient is symptom-free, with normal left ventricular function. We assume that the complex and robust procedures in dentistry together with a systemic absorption of epinephrine are sufficient triggers for the development of Takotsubo cardiomyopathy. In our case, we advocate an external catecholamine exposure rather than an internal catecholamine excess. We need more vigilance when assessing such patients. .

Transapical angiography in a patient with severe aortic stenosis undergoing transapical transcatheter aortic valve implantation.

Transapical transcatheter aortic valve implantation (TA-TAVI) is the method of choice in patients with severe stenosis of the aortic valve, high operative risk, and an adverse peripheral vasculature. The procedure is generally guided by peripheral arterial access angiography. We report on a 71-year-old patient in whom, because of the absence of an alternative peripheral arterial access route, TA-TAVI was supported by the apical insertion of the angiography catheter. This approach was effective and safe, and proper valve deployment was feasible without unexpected procedural complications.

Factors associated with the need of biventricular mechanical circulatory support in children with advanced heart failure.

OBJECTIVES: Postimplantation right ventricular dysfunction is associated with increased morbidity and mortality in ventricular assist device (VAD) recipients. This study aimed to determine the preoperative risk factors for severe right heart failure needing biventricular mechanical circulatory support in children with end-stage heart failure. METHODS: We reviewed data from 84 children supported with long-term VADs at the German Heart Institute Berlin between January 1999 and October 2010. Right ventricular assist device (RVAD) support was needed for 24 (29%) patients, and the other 60 (71%) were implanted with left ventricular assist devices (LVADs). RESULTS: The median age at implantation was 7 years (12 days-18 years), and the median support time was 41 days (1-432 days). Of the 84 patients, the overall survival to transplantation or recovery of ventricular function was 69%. Compared with children implanted with LVAD, patients receiving biventricular support had significantly higher postoperative mortality (P = 0.04). The multivariate logistic regression indicated that decreased milrinone use was the only preoperative factor independently associated with increased requirement for biventricular support (odds ratio: 0.1, 95% confidence interval: 0.04-0.64, P = 0.01). Children treated with milrinone preoperatively showed improved survival after implantation (P = 0.04). CONCLUSIONS: Paediatric patients needing biventricular support had significantly higher postoperative mortality. Preoperative milrinone use might decrease the risk of severe right ventricular failure requiring additional RVAD insertion and improve postimplantation survival in children with advanced heart failure.

Outcomes of ventricular assist device support in young patients with small body surface area.

OBJECTIVE: Although the ventricular assist device (VAD) has been a well-established therapy for larger adolescents and adult patients with advanced heart failure, current experience with the use of VAD for mechanical circulatory support in infants and young children with small body surface area is still limited. METHODS: Between January 1999 and December 2009, 56 small children with body surface area<1.2 m² were implanted with Berlin Heart EXCOR pediatric VAD in Germany Heart Institute Berlin. The etiology of end-stage myocardial failure included non-congenital (75%) and congenital heart disease (25%); the median age at implant was 1 year (12 days to 14 years), and the median support time was 55 days (1-432 days). RESULTS: Of the 56 pediatric patients, 24 were bridged to heart transplantation, 12 were explanted following myocardial recovery, two continued to receive support, and the other 18 died on support. The accurate rate of survival on VAD support was 81.1% ± 5.8% and 51.4% ± 9.3% at 30 days and 1 year after EXCOR implantation. Patients receiving biventricular support had a trend towards higher post-implantation mortality as compared with children implanted with left ventricular assist device (LVAD) (P = 0.09). Lower post-implantation survival was also observed in patients with congenital cardiac disease compared with children with a non-congenital etiology (P < 0.001). CONCLUSIONS: Berlin Heart EXCOR pediatric VAD could provide satisfactory and safe circulatory support for small children with end-stage heart disease.

Predictors of in-hospital mortality in children after long-term ventricular assist device insertion.

OBJECTIVES: This study aimed to determine the pre-implantation predictors for in-hospital mortality in children with ventricular assist device (VAD) support. BACKGROUND: Candidate selection is of critical importance for improved outcomes in patients supported with VAD. However, risk factors for post-VAD survival in children are still not clearly understood. METHODS: From June 1996 to December 2009, 92 children underwent implantation of a long-term VAD at Germany Heart Institute Berlin. Data on all these patients were retrospectively analyzed, and pre-operative risk factors for in-hospital survival after VAD implantation were identified by multivariate logistic regression. RESULTS: Of the 92 subjects, the median age at implantation was 7 years (range 12 days to 18 years), and the median support time was 35 days (range 1 to 591 days). The overall survival rate to transplantation or recovery of ventricular function was 63%. Independent predictors of in-hospital mortality in children included congenital etiology (odds ratio [OR]: 11.2; 95% confidence interval [CI]: 2.6 to 47.5), norepinephrine requirement (OR: 6.9; 95% CI: 1.4 to 31), C-reactive protein level >6.3 mg/dl (OR: 4.9; 95% CI: 1.1 to 22.1), and central venous pressure >17 mm Hg (OR: 4.6; 95% CI: 1.1 to 20). CONCLUSIONS: Congenital etiology, pre-operative norepinephrine requirement, higher serum C-reactive protein, and central venous pressure were associated with increased in-hospital mortality in children with VAD support. Optimal candidate selection and timing of VAD insertion may be of great importance for improved outcomes in children with advanced heart failure.

Preoperative balloon sealing of a false ascending aortic aneurysm for safe redo sternotomy.

Sternal contact of aortic aneurysms in redo operations may require specific techniques to safely control bleeding during sternotomy and surgical dissection. This is the first report on the preoperative use of an inflatable balloon to prevent massive hemorrhage by inserting the balloon--a procedure performed in the cardiac catheterization laboratory--before rethoracotomy. A false ascending aortic aneurysm was successfully sealed by transaortic wire-guided balloon placement from the iliac artery. Gentle traction on the inflated balloon catheter, which was placed inside the false aneurysm, effectively sealed the entrance to the aneurysm. A straightforward median redo sternotomy procedure was subsequently performed without blood loss from the unavoidably opened aneurysm. My colleagues and I propose this technique for aneurysms of mycotic or anastomotic origin, which have an anatomically distinct entry channel.