Conventional versus minimally invasive extra-corporeal circulation in patients undergoing cardiac surgery: A randomized controlled trial (COMICS).

INTRODUCTION: The trial hypothesized that minimally invasive extra-corporeal circulation (MiECC) reduces the risk of serious adverse events (SAEs) after cardiac surgery operations requiring extra-corporeal circulation without circulatory arrest. METHODS: This is a multicentre, international randomized controlled trial across fourteen cardiac surgery centres including patients aged ≥18 and <85 years undergoing elective or urgent isolated coronary artery bypass grafting (CABG), isolated aortic valve replacement (AVR) surgery, or CABG + AVR surgery. Participants were randomized to MiECC or conventional extra-corporeal circulation (CECC), stratified by centre and operation. The primary outcome was a composite of 12 post-operative SAEs up to 30 days after surgery, the risk of which MiECC was hypothesized to reduce. Secondary outcomes comprised: other SAEs; all-cause mortality; transfusion of blood products; time to discharge from intensive care and hospital; health-related quality-of-life. Analyses were performed on a modified intention-to-treat basis. RESULTS: The trial terminated early due to the COVID-19 pandemic; 1071 participants (896 isolated CABG, 97 isolated AVR, 69 CABG + AVR) with median age 66 years and median EuroSCORE II 1.24 were randomized (535 to MiECC, 536 to CECC). Twenty-six participants withdrew after randomization, 22 before and four after intervention. Fifty of 517 (9.7%) randomized to MiECC and 69/522 (13.2%) randomized to CECC group experienced the primary outcome (risk ratio = 0.732, 95% confidence interval (95% CI) = 0.556 to 0.962, p = 0.025). The risk of any SAE not contributing to the primary outcome was similarly reduced (risk ratio = 0.791, 95% CI 0.530 to 1.179, p = 0.250). CONCLUSIONS: MiECC reduces the relative risk of primary outcome events by about 25%. The risk of other SAEs was similarly reduced. Because the trial terminated early without achieving the target sample size, these potential benefits of MiECC are uncertain.

Radiofrequency ablation of atrial fibrillation during mitral valve surgery.

OBJECTIVES: Atrial fibrillation is the most common form of arrhythmia in mitral valve disease. Radiofrequency ablation is most commonly used for atrial fibrillation ablation during mitral valve surgery. METHODS: This prospective study evaluated the midterm outcomes of intraoperative radiofrequency atrial fibrillation ablation during mitral valve surgery. RESULTS: 52 patients were eligible for the study. Fifteen (28.8%) had a transseptal approach and 37 had a left atriotomy. Mitral valve replacement was performed in 16 patients, mitral valve repair in 31, and tricuspid repair in 8. Mean crossclamp time was 58.14.± 20.08 min, and mean cardiopulmonary bypass time was 71.28 ± 20.31 min. The mean ablation time was 6.41 ± 0.21 min. There was no postoperative mortality. Sinus rhythm was documented in 44 (84.6%) patients on discharge, and 8 (15.4%) were discharged with atrial fibrillation; 2 of them returned to sinus rhythm after 3 months. After 12 months of follow-up, 46 (88.5%) patients were in sinus rhythm. CONCLUSION: Left atrial monopolar radiofrequency ablation during mitral valve surgery is a safe procedure with a high success rate.

Left ventricular hemangioma.

A young Saudi woman presented with symptoms of palpitation, near syncope, anxiety, and fatigue. Transthoracic echocardiography showed a left ventricular mass. Under cardiopulmonary bypass, brief cardioplegic arrest, and the aid of a thoracoscope, the mass was resected. Histologic examination showed a rare benign cardiac tumor: mixed cavernous-capillary hemangioma.

Vacuum-assisted closure system in treatment of postoperative mediastinitis.

OBJECTIVES: Post-cardiac surgery mediastinitis is a serious complication with high morbidity and high financial costs. Using a vacuum-assisted closure system is the established line of treatment for mediastinitis, which improves outcome, especially in the high-risk group of patients. METHODS: From January 2007 to April 2011, a retrospective study was carried out to evaluate the outcome of vacuum-assisted closure in the treatment of postoperative mediastinitis. RESULTS: There were 34 patients; 27 were male and 7 female. Mean time from infection to vacuum-assisted closure was 3.34 ± 1.10 days. The duration of vacuum-assisted closure was 6.51 ± 1.85 days (3-9 days). The mean amount of discharge was 759.60 ± 175.28 mL (range, 354-990 mL). Of the 34 patients, 21 (61.76%) had direct surgical wound closure and 13 (41.16%) had re-wiring. Two patients had bilateral pectoral flaps. One patient had chronic fistula formation, and one had a tear in the right ventricle. Mean hospital stay was 11.28 ± 2.09 days (range, 6-16 days). CONCLUSION: Vacuum-assisted closure therapy is a safe, reliable, and cost-effective modality of treatment for postoperative mediastinitis. It improves the outcome and can be combined with other modalities of conventional treatment, especially in high-risk groups such as the elderly or patients with diabetes.

Impressive echocardiographic images of a rare pathology: Aneurysm of the mitral valve - Report of two cases and review of the literature.

Aneurysm of the mitral valve (AMV) is rarely reported. The etiology of this unusual pathology is commonly attributed to aortic valve endocarditis (AVE) with aortic regurgitation (AR) or connective tissue disease. We present two recent cases of AMV with good correlation between pre-operative trans-esophageal echocardiography (TEE), intra-operative real-time 3-dimensional echocardiography (RT-3D-Echo) and surgical findings. The importance of diligent surveillance by TEE in patients with AVE for occurrence of AMV is emphasized. The literature on this topic is briefly reviewed.