Hybrid total arterial minimally invasive off-pump coronary revascularization and percutaneous coronary intervention strategy for multivessel coronary artery disease: a cohort study with a median 11-year follow-up.

Background: Hybrid coronary revascularization (HCR) is a treatment approach that combines the benefits of coronary artery bypass grafting (CABG) techniques such as minimally invasive direct coronary artery bypass (MIDCAB) or minimally invasive multivessel CABG (MICS-CABG) with percutaneous coronary intervention (PCI) for carefully selected patients with multivessel coronary artery disease (MV CAD). The extant body of research primarily concentrates on the comparison of outcomes between HCR and CABG or PCI. Furthermore, HCR is defined primarily as MIDCAB and PCI. Given the various criteria for HCR identified in the current body of literature, as well as several hybrid revascularization techniques, our primary goal was to analyse the characteristics and track the development of HCR patients operated on in our centre (Robert Bosch Hospital) over both short and long periods of time. Additionally, we sought to validate the practical challenges that arise during the implementation of an HCR methodology. Methods: This cohort study included 138 patients with MV CAD who had an HCR approach in conjunction with isolated total arterial off-pump MICS-CABG or MIDCAB between 2007 and 2018 at Robert Bosch Hospital in Stuttgart. Data on major adverse cardiac and cerebral events (MACCE), defined as all-cause mortality, myocardial infarction, repeat revascularization and stroke were gathered through a questionnaire. Long-term follow-up, with a mean duration of 8.7±0.3 years and a median duration of 11 years, was available for a significant majority of the patients (92.8%, n=128). Results: The average age was 69.6±11.2 years, with 79% being male. The mean European System for Cardiac Operative Risk Evaluation score I additive (EuroSCORE I) additive was 7.6±10.2 and the mean SYNergy between PCI with TAXUS and Cardiac Surgery (SYNTAX) Score I was 22.9±9.4. A total of 97 MIDCAB surgeries and 41 MICS-CABG procedures were performed without any instances of conversion to sternotomy or cardiopulmonary bypass (CPB). A total of 70 patients, or 50.7% of the sample, received the planned PCI treatment. This percentage was substantially lower in the subgroup with chronic CAD, with just 27, equivalent to 39.1%. The observed 30-day death rate was 2.1% (3/138). During follow-up, 3 myocardial infarctions, 18 PCI repeats, no CABG, and 4 strokes occurred. From 128 followed-up patients, 28 died (21.9%), 7 of which were heart deaths (5.5%). Total MACCE was 36.7%. The survival rates at 3 and 5 years were 92% and 85% respectively. Patients who didn't get the planned PCI had a mean survival rate of 6.8-9.1 years, while those with completed hybrid treatment had a higher mean survival rate of 8.4-10.2 years. Conclusions: In selected individuals with MVCAD, current evidence suggests that HCR is a safe and effective coronary artery revascularization approach. After coronary bypass surgery, the attention going forward needs to be devoted toward the organization of the PCI step in the treatment process.

Minimally invasive strategies of surgical coronary artery revascularization for the aging population.

BACKGROUND: The increasing prevalence of elderly or frail patients with severe coronary disease, who are not suitable for interventional coronary revascularization, necessitates the exploration of alternative treatment options. A less invasive approach, such as minimally-invasive off-pump coronary-artery-bypass (MICS-CABG) grafting through mini-thoracotomy, which avoids both extracorporeal circulation and sternotomy, may be more appropriate for this patient population. This study, a retrospective, monocentric analysis, aimed to evaluate the long-term outcomes of these patients. METHODS: The study included 172 patients aged 80 years or older, who underwent MICS-CABG between 2007 and 2018. The patients underwent single, double, or triple-vessel revascularization using the left internal thoracic artery, and in some cases, the radial artery or saphenous vein. Follow-up, mean duration of 50.4±30.8 months, was available for 163 patients (94.7%). RESULTS: The mean age of the patients was 83.2±3.0 years, 77.3% of them were male. The EuroSCORE I additive was 11.0±12.1. There were no conversions to sternotomy or cardiopulmonary-bypass. The postoperative 30-day mortality rate was 2.9%, with 5 deaths. The in-hospital rate of major adverse cardiac and cerebrovascular events was 4.7% (perioperative myocardial infarction 1.2%, perioperative stroke 2.3%, repeat revascularization 1.2%). Acute renal kidney injury, (stage 3 KDOQI or more), occurred in 5 patients (2.9%) and new-onset atrial fibrillation in 6 patients (3.5%). The 1-, 3-, 5- and 8-year actuarial survival rate of the 30-day survivors was 97%, 82%, 73%, and 42%, respectively. CONCLUSIONS: MICS-CABG grafting is associated with excellent early and long-term outcomes in eligible octogenarians.

A prospective, international, bicentric study to evaluate PremiCron suture material for cardiac valve surgery - PREMIVALVE a cohort study.

The most common age-related heart valve diseases include aortic valve stenosis and mitral valve insufficiency. The suture material is not the focus of most studies. The aim of the study was to assess the performance of PremiCron suture material for cardiac valve reconstruction and/or replacement under clinical routine. Performance was evaluated using the incidence of major adverse cardiac and cerebrovascular events (MACCE) combined with endocarditis. Materials and methods: The study was designed as an international, prospective, bicentric, observational, single-arm study to evaluate the PremiCron suture material in cardiac valve surgery and compare the outcome with literature data regarding postoperative complications. The primary endpoint was a composite of MACCE acquired in the hospital, combined with endocarditis occurring up to 6 months postoperatively. The secondary parameters were intraoperative handling of the suture, incidence of MACCE and other relevant complications and quality of life up to 6 months after surgery. Patients were examined at discharge, 30 days, and 6 months postoperatively. Results: A total of 198 patients were enrolled in two centers in Europe. The cumulative primary endpoint event rate was 5.0%, lower than the reference value of 8.2% from the literature. Comparison of the incidence of individual MACCE until discharge and endocarditis rate 6 months postoperatively also showed that our data were within the range of the published rates. Quality of life significantly increased from preoperatively to 6 months after surgery. Ease of handling of the suture material was rated as very good. Conclusion: The PremiCron suture material is safe and very eligible for cardiac valve replacement and/or cardiac valve reconstruction in a broad patient population with a cardiac valve disorder treated under daily clinical practice.

Robotically assisted mitral valve surgery-experience during the restart of a robotic program in Germany.

Background: Following the first robotic-assisted mitral valve operations in Paris and Leipzig, the era of this innovative technique expired after a few years in Germany. At that time, the main arguments against robotic surgery within the German cardiac surgical community were low cost effectiveness and operative time utilization. Encouraged by favorable results, we re-started our robotic-assisted cardiac program as the first and only center in Germany in 2019. Methods: Between July 2019 and December 2021, 329 patients underwent robotic-assisted operations using the daVinci Xi system, including mitral and coronary operations, myxoma resection, atrial septal closure and stand-alone atrial ablation. Of these, 182 patients underwent mitral valve repair (MVR). Isolated MVR was performed in 96 patients (isolated mitral group, IMG) and 86 underwent concomitant operations, such as tricuspid valve repair, Cox-Maze IV, pulmonary vein isolation (PVI) and left atrial appendage (LAA) closure (complex mitral group, CMG). For cost analysis, the InEK calculation for 2020 was used. Results: MVR was successful (MR ≤I°) in all patients. Patients in the IMG had a hospital mortality of 1.0% (O/E ratio 0.69) and stroke rate of 2.0%. Four patients (4.0%) required conversion to sternotomy and 6 patients (6.0%) needed re-exploration for bleeding. Mortality was 3.5% (O/E ratio 0.74) in the CMG and stroke rate 2.3%. The conversion and bleeding rates were 4.6% each, respectively. The steep learning curve resulted in significant reduction of operating times greater than 25% in the IMG. Comparing the results of robotic-assisted procedures to minimally-invasive mitral surgeries (MIMS) in 2020, a reduction in length of hospital stay of almost 25% resulted in significantly lower costs for the medical service and medical infrastructure. However, within the German health service, overall cost for robotic-assisted procedures were more expensive compared to MIMS by 5% due to higher material costs. Conclusions: The re-establishment of robotic mitral valve surgery in Germany was successful with comparable results to MIMS in terms of mortality and morbidity. Robotic-assisted cardiac operations resulted in accelerated postoperative recovery with significant shortening of the hospital length of stay. The avoidance of liver injury is one focus for the future.

Cryopreserved aortic homograft, lifeline treatment for infected vascular prosthesis with mediastinal abscess in a re-redo case.

We report about a 61-year-old man who, 6 years after initial uncomplicated mitral valve repair and 3 months after treatment of a pseudo-aneurysm of the ascending aorta with a Dacron patch, was admitted in our institution with an infection of the vascular graft, which was associated with sternal osteomyelitis and purulent cutaneous fistula. In a re-redo procedure, the proximal aortic arch and the ascending aorta were replaced with a cryopreserved aortic homograft. The infected part of the sternum was resected and the defect was covered by mobilizing the mediastinal tissue and with a bilateral muscle flap. The patient was discharged 20 days after surgery. This treatment concept outlines the benefit of cryopreserved aortic homograft when faced with a complex thoracic aortic infection.

Off-pump versus on-pump redo coronary artery bypass grafting: A propensity score analysis of long-term follow-up.

OBJECTIVE: Redo coronary artery bypass grafting (CABG) is associated with an increased early mortality reported up to 16%. The aim of this study was to analyze the early and long-term results after redo CABG with special focus on the feasibility and safety of the off-pump technique in the setting of a high-volume off-pump CABG center. METHODS: From January 2006 to June 2015, isolated redo CABG was performed in 304 patients (179 = on-pump redo CABG, 125 = off-pump redo CABG). We used propensity score matching with 14 preoperative variables to adjust for differences in baseline characteristics between the on-pump redo CABG and the off-pump redo CABG groups. After 1:1 matching we selected 108 pairs for each group. Mean follow-up rate was 4.01 years. RESULTS: The final sample was 83.9% men (n = 225) with a mean age of 69.77 ± 8 years. After propensity score matching there was a significant difference in the total number of grafts performed in favor of on-pump redo CABG (P = .011), whereas 66.7% (72 out of 108) of off-pump redo CABG patients received total arterial grafts. Off-pump redo CABG patients had a lower rate of postoperative renal failure necessitating dialysis (4.6% vs 0%; P = .06), required less recovery time in the intensive care unit (1.33 ± 1.03 days vs 4.4 ± 7.98 days; P < .001) and were discharged more quickly (10.08 ± 5.35 days vs 14.1 ± 10.6 days; P = .001). Off-pump redo CABG led to better long-term survival (log-rank test, P = .086). CONCLUSIONS: In our study, patients undergoing off-pump redo CABG had fewer postoperative complications, achieved faster recovery, and had better long-term survival. Hence, off-pump redo CABG is safe and feasible.

Total arterial myocardial revascularization using bilateral internal mammary arteries and the role of postoperative sternal stabilization to reduce wound infections in a large cohort study.

OBJECTIVES: Total arterial myocardial revascularization using bilateral internal mammary arteries shows improved results for mortality, long-term survival and superior graft patency. It has become the standard technique according to recent guidelines. However, these patients may have an increased risk of developing sternal wound infections, especially obese patients or those with diabetes. One reason for the wound complications may be early sternum instability. This situation could be avoided by using a thorax support vest (e.g. Posthorax® vest). This retrospective study compared the wound complications after bilateral internal mammary artery grafting including the use of a Posthorax vest. METHODS: Between April 2015 and May 2017, 1613 patients received total arterial myocardial revascularization using bilateral internal mammary artery via a median sternotomy. The Posthorax support vest was used from the second postoperative day. We compared those patients with 1667 patients operated on via the same access in the preceding 26 months. The end points were the incidence of wound infections, when the wound infection occurred and how many wound revisions were needed until wound closure. RESULTS: The demographic data of both groups were similar. A significant advantage for the use of a thorax support vest could be seen regarding the incidence of wound infections (P = 0.036) and the length of hospital stay when a wound complication did occur (P = 0.018). CONCLUSIONS: As seen in this retrospective study, the early perioperative use of a thorax stabilization vest, such as the Posthorax vest, can reduce the incidence of sternal wound complications significantly. Furthermore, when a wound infection occurred, and the patient returned to the hospital for wound revision, patients who were given the Posthorax vest postoperatively had a significantly shorter length of stay until wound closure.

Combined David and Frozen Elephant Trunk Procedure in Acute Aortic Dissection.

BACKGROUND: Valve sparing aortic root repair by reimplantation (David procedure) is an established technique in acute aortic dissection Stanford type A involving the aortic root. In DeBakey type I dissection, aortic arch replacement using the frozen elephant trunk (FET) was introduced to promote aortic remodeling of the downstream aorta. The combination of these two complex procedures represents a challenging surgical strategy and was considered too risky so far. METHODS: All patients with acute aortic dissection DeBakey type I undergoing valve sparing aortic root repair by reimplantation technique of David combined with extended aortic repair using the FET at our center between October 2009 and December 2016 were evaluated. Outcomes are compared with patients who underwent prosthetic aortic root replacement and FET for aortic dissection in the same timeframe. RESULTS: A total of 28 patients received combined David and FET procedure, while 20 patients received prosthetic aortic root replacement and FET procedure. Thirty-day mortality was 10.7% (n = 3) for the David group and 20% (n = 4) for the root replacement group (p = 0.43). Postoperative echocardiographic control revealed an excellent aortic valve function with regurgitation grade 0° or maximum grade I° and a mean gradient of 4.3 ± 2.1 mm Hg in all patients in the David group versus 7.2 ± 2.4 mm Hg in the aortic root replacement group, p = 0.003. Computed tomography angiography scan showed positive aortic remodeling in all but three patients (91.9%). Mid-term follow-up survival was 82.1% in the David group and 68.4% in the root replacement group, p = 0.28. There was no need for reintervention at the root or descending aorta. CONCLUSION: Simultaneous application of the David and FET procedure in patients with acute aortic dissection is safe and feasible in experienced hands as compared with standard aortic root replacement plus FET. The mid-term outcomes are encouraging and noninferior to conventional surgery results.

One-stage hybrid aortic repair using the frozen elephant trunk in acute DeBakey type I aortic dissection.

BACKGROUND: The extent of emergent surgery for acute DeBakey type I aortic dissection is discussed controversial. The frozen elephant trunk (FET) technique in addition to ascending and arch repair promotes aortic remodelling in the descending aorta and thus may provide superior long-term results in terms of less secondary re-interventions and reduced mortality linked to the downstream aorta. METHODS: Between October 2009 and December 2016, a total of 72 patients underwent emergent hybrid aortic repair using the FET for acute DeBakey type I aortic dissection at our centre. Data were analysed from our prospectively collected database and clinical and imaging mid-term follow-up was obtained. RESULTS: Implant success was 98.6% with an overall 30-day-mortality of 15.3%. New postoperative stroke was seen in 2.8%, new spinal cord injury in 4.2%. In follow-up (mean 37.8±21.2 months) cumulative survival was 75.0% with freedom from distal reintervention in 96.7% and aortic remodelling rate in the descending aorta in 96.5%. CONCLUSIONS: Hybrid aortic repair using the FET in acute DeBakey type I aortic dissection does not elevate the perioperative risk of mortality and provides excellent aortic remodelling with low distal re-intervention rate in mid-term follow-up.

Optilene, a new non-absorbable monofilament is safe and effective for CABG anastomosis. OPTICABG - A prospective international, multi-centric, cohort study.

INTRODUCTION: Coronary artery bypass grafting (CABG) is performed to improve quality of life and to reduce cardiac-related mortality and morbidity in patients with coronary artery disease (CAD). The aim of the present observational study was to assess the performance of a new suture material (Optilene) for anastomosis construction in CABG surgery using a routine clinical procedure. Performance was assessed using the incidence of major adverse cardiac and cerebrovascular events (MACCE). METHODS: The study was designed as an international, multi-centre, prospective cohort study to evaluate the safety and efficacy of a new non-absorbable monofilament for CABG surgery compared to data published in a previous meta-analysis. Optilene suture was used to create the distal and proximal coronary artery anastomoses. The primary endpoint was the cumulative MACCE rate up to discharge. Secondary parameters were intraoperative handling of the suture material and QoL up to 3 months after surgery. Patients were examined 30 days and 3 months postoperatively. RESULTS: In total, 199 patients were enrolled in 3 centres in Europe. The cumulative CABG adverse event rate up to the day of discharge was 3%, in contrast to the 8.46% given by the data generated by Nalysnyk et al. A t-test showed that our CABG rate was significantly lower. QoL significantly increased from preoperatively until 3 months after surgery. Ease of handling the suture material was rated as very good. CONCLUSION: Optilene suture material represents a safe and effective alternative to existing sutures used in CABG surgery for anastomosis construction.

Minimally Invasive Access Aortic Arch Surgery.

OBJECTIVE: Median sternotomy is still the standard approach for aortic arch surgery. Minimally invasive techniques promise faster recovery with shorter hospital stay due to thoracic stability, reduced pain, and superior cosmetic results. However, safety is a concern in complex aortic surgery. The aim of our study was to demonstrate that aortic arch surgery via partial upper sternotomy is viable, safe, and equivalent to standard procedure both in terms of its safety and the risk of major adverse cardiac and cerebrovascular events. METHODS: We interrogated our prospectively collected database and identified a total of 21 nonemergent patients operated on at our center between October 2008 and February 2015. Indication for operation was aneurysmatic disease in 18 and aortic dissection in 3 patients. Data were analyzed for in-hospital mortality, stroke, bleeding complications, and acute kidney injury. RESULTS: Mean ± standard deviation age of patients was 69.3 ± 14.4 years, 57.1% were female, and mean ± standard deviation logistic EuroSCORE was 17.0 ± 7.2%. Surgery on the aortic arch comprised proximal arch in 9, hemiarch in 9, and total arch replacement plus frozen elephant trunk in 3 patients. Concomitant procedures included aortic root repair in 10, aortic root replacement in 2, and aortic valve replacement in 3 patients. We lost one patient because of septic shock, no stroke occurred, but a transient neurologic deficit in three and a postoperative delirium in four patients. Re-exploration for bleeding was necessary in two patients, and one patient had acute kidney injury. CONCLUSIONS: Minimally invasive aortic arch surgery via partial upper sternotomy does not increase the risk of morbidity or mortality. Thus, in experienced hands, it is viable, safe, and therefore favorable and as a result should be offered to more patients.

Concomitant therapy: off-pump coronary revascularization and transcatheter aortic valve implantation.

OBJECTIVES: Significant coronary artery disease (CAD) is common among patients evaluated for transcatheter aortic valve implantation (TAVI). Only little data exist on outcome of patients undergoing concomitant off-pump coronary revascularization and TAVI. The goal of this study was to analyse the impact of concomitant off-pump revascularization on early clinical outcome and 2-year follow-up of patients undergoing TAVI. METHODS: A total of 70 patients with significant CAD and aortic valve stenosis were included between January 2011 and January 2016. Decision to perform concomitant off-pump coronary revascularization and TAVI was made by the interdisciplinary heart team according to the SYNTAX score. Prospectively assigned data were analysed retrospectively and follow-up was performed up to 2 years. RESULTS: Mean age was 82.2 ± 4.0 years and 43 (61.4%) patients were male. Mean logistic European system for cardiac operative risk evaluation and Society of Thoracic Surgeons European system for cardiac operative risk evaluation score were 35.9 ± 21.9% and 12.2 ± 7.9%, respectively. SYNTAX score was 29.0 ± 12.9. Access site for TAVI was transapical in 60.0% and transaortic in 40.0%. Procedural success was 94.3%. Eighty percent of the patients had none or trace paravalvular leakage after TAVI. Severe complications requiring consecutive surgical aortic valve replacement occurred in 2 patients (2.9%). The use of cardiopulmonary bypass due to haemodynamic instability or conversion to surgical aortic valve replacement was necessary in 7 patients (10.0%). Stroke occurred in 1 patient (1.4%). Re-exploration for bleeding was necessary in 6 patients (8.6%). Thirty-day mortality was 14.3%. Two-year survival was 68.4% (95% confidence interval: 55.7-81.1%). CONCLUSIONS: Simultaneously performed complete off-pump coronary revascularization is a feasible and valid option in patients with significant CAD undergoing TAVI.

Feasibility and clinical outcome after minimally invasive valve-sparing aortic root replacement.

Objectives: This study aims to examine the feasibility and clinical course after minimally invasive David procedure compared with those via a conventional median sternotomy. Methods: One hundred and ninety-two consecutive patients who underwent elective valve-sparing aortic root replacement (David procedure) with or without additional cusp repair for aortic regurgitation ( n = 17, 8.9%), dilatation of the aortic root ( n = 95, 49.5%) or a combination of both pathologies ( n = 80, 41.7%) were included. Patients with systemic disorders, such as Marfan's syndrome, and emergency cases were excluded. Assessment of quality of life was performed by modified Short Form Health Survey (SF-36) questionnaire. To minimize baseline differences, a matched pair analysis was conducted. Results: One hundred and seventeen patients (60.9%) received a minimally invasive hemisternotomy (Group 1), 75 patients a conventional median sternotomy (39.1%, Group 2). Patients of Group 1 were significantly younger (56.5 ± 13.6 vs 64.8 ± 11.6, P < 0.001). Understandably, concomitant cardiac procedures were more frequent in Group 2 ( n = 7 [6.0%] vs n = 48 [64.0%], P < 0.001). In hospital, mortality was 0.9% in Group 1 (1/117) and 2.7% in Group 2 (2/75; P = 0.562). Blood loss was significantly less in Group 1 (542.6 ± 441.8 vs 996.7 ± 822.6 ml, P < 0.001). Duration of mechanical ventilation (10.2 ± 21.8 vs 26.9 ± 109.0 h, P < 0.001) and ICU-stay (1.9 ± 3.6 vs 3.2 ± 5.6 days, P < 0.001) were significantly shorter in the minimally invasive group, but this differences did not remain after matching. According to SF-36 questionnaire, patients in the minimally invasive group tend to have a higher quality of life. Conclusions: Minimally invasive valve-sparing aortic root replacement can be done safely via an upper partial sternotomy in experienced hands even if additional cusp repair is required.

Quadruple Valve Reoperation after the Ross Procedure.

Reoperations after the Ross procedure are rare, with autograft as well as homograft failure being the dominant causes for redo cardiac procedures. Due to increasing experience with valve-sparing aortic valve procedures, more valves can be preserved during redo surgery. Herein are reported the details of a patient who underwent quadruple valve reoperation comprising redo with a reconstructive approach after the short-term failure of pulmonary autograft and homograft with concomitant mitral and tricuspid regurgitation.

Complex Cusp Repair in Patients Undergoing the David Procedure: Is It Worth It?

BACKGROUND: Valve-sparing aortic root replacement has already proven its excellent long-term results, with low valve-related complications comparable with conventional aortic valve replacement. The aim of this study was to investigate whether additional expanded cusp repair is an alternative with comparable results. METHODS: Data of 192 elective patients undergoing valve-sparing aortic root replacement were prospectively recorded: 58 patients (30.2%) received an isolated aortic root replacement (group I, isolated David), and 134 patients (69.8%) received additional cusp repair (group II, complex David), such as plication of the free margin (n = 77), decalcification (n = 45), or pericardial patch (n = 39). Cumulative follow-up was 480 patient-years, with a mean of 2.5 ± 1.5 years. RESULTS: Mean age was 60 years, and 76.6% were men. In hospital mortality was 3.4% in group I and 0.0% in group II. Freedom from cardiac death at 5 years (by Kaplan-Meier estimation) was 83% vs 98% (p = 0.058). Freedom from moderate or severe aortic insufficiency at 5 years was 100% in group I vs 93% (95% confidence interval, 86% to 97%) in group II (p = 0.110). Seven patients required reoperation for aortic insufficiency or stenosis: repeat repair (n = 3), Ross procedure (n = 2), and biologicical aortic valve replacement (n = 2). Freedom from reoperation at 5 years was 96% (95% confidence interval, 76% to 99%) in group I vs 89% (95% confidence interval, 71% to 96%) in group II (p = 0.305). CONCLUSIONS: Overall survival and freedom from reoperation after valve-sparing aortic root replacement, even with additional complex cusp repair, provides excellent midterm results. Low risk of valve-related complications and absence of anticoagulation therapy are distinctive advantages of this complex procedure.

Results and Quality of Life after Minimally Invasive Ross Procedure.

BACKGROUND AND AIM OF THE STUDY: Based on superior long-term results, an increasing interest in the Ross procedure for young adult patients can be observed. After the first publication of this challenging procedure through a minimally invasive access, this operation has become an alternative to conventional sternotomy at the authors' department. This analysis compares the results and quality of life of the conventional and the minimally invasive Ross procedures. METHODS: By April 2013, a total of 136 patients had undergone the Ross procedure at the authors' institution. Preoperative parameters did not differ between the conventional group (C-group; n = 58; mean age 49 years) and the minimally invasive group (M-group; n = 78; mean age 50 years). Only the aortic cross-clamp time was longer for the M-group (151 versus 140 min). RESULTS: One C-group patient died on the day of operation. Consecutively, survival was 99% for the follow up period of 1,093 ± 601 days. Valve-related reoperations were necessary for four patients. One C-group patient developed a distal pulmonary stenosis due to fibrotic scar tissue. Two M-group patients showed fistulas after early endocarditis, but the native valves could be preserved in these cases. One C-group patient with recurrent severe aortic regurgitation showed holes in two of three cusps. The SF-36 questionnaire detected better physical parameters (physical function, physical role function) for patients after minimally invasive access. CONCLUSION: The minimally invasive Ross procedure allows the same excellent clinical outcome as the conventional technique. However, the physical quality of life is better with the minimally invasive procedure, in addition to an improved cosmetic result.

Interdisciplinary Approach in a Complex Case of STEMI.

We reported the case of a young man with ST-Segment Elevation Myocardial Infarction (STEMI), with ventricular fibrillation on debut and cardiogenic shock, who needed a complex interdisciplinary approach for a favourable long term outcome. A 43-year-old man was admitted with inferior STEMI and cardiogenic shock. First coronary angiography revealed total chronic occlusion of left anterior descending artery (LAD) and tight stenosis with thrombus on right coronary artery (RCA). Thrombus aspiration and stent implantation on RCA was performed with good results. LAD couldn't be opened. Intraaortic balloon pump was implanted. Forty-eight hours later, we try again to open LAD, without success. After a lot of complications, all solved with difficulty, patient was discharged cachectic and with progressive exertion on mild exercise. Two months later an implantable cardioverter-defibrillator (ICD) was decided for persistent ventricular tachycardia and after one year he was referred to a cardiac surgery centre abroad for aneurismectomy with left ventricle (LV) reconstruction and mitral valve repair. The patient is currently asymptomatic with a normal social and professional life. In conclusion, high performance cardiac surgery, after a complete interventional treatment, can improve quality of life and long-term outcome to a patient with severe cardiovascular disease. Team work between clinical cardiologists, interventional cardiologists, electrophisyologists, intensi-vists and cardiac surgeons is the key to success.

Clinical outcome and quality of life after reoperative CABG: off-pump versus on-pump - observational pilot study.

BACKGROUND: Coronary artery bypass grafting (CABG) on cardiopulmonary bypass (CBP) is associated with significant morbidity and mortality. In high-risk patients, doomed for reoperation the adverse effects of CBP may be more striking. We evaluated the results of reoperative CABG (redo-CABG) by either off-pump (OPCAB) or on-pump (ONCAB). Clinical endpoints were perioperative myocardial infarction, mortality, survival and as the most striking difference between prior studies the quality of life (QoL). METHODS: We performed a prospective, non-randomized assessment for patients who underwent redo-CABG by redo-OPCAB (n=40) or redo-ONCAB (n=40) at our institution between January 2007 and December 2010. For evaluation of QoL the SF-36 health survey was used with self-administered assessment. RESULTS: During follow-up 37 of 40 patients were alive in the redo-OPCAB group versus 32 of 40 patients in the redo-ONCAB group (p<0.05). The shorter operation time, less blood loss, fewer perioperative myocardial infarctions, the higher rate of totally arterial revascularisation and shorter intensive care stay were the significantly beneficial differences for patients in the redo-OPCAB group (p<0.05). The 3-year survival rate was higher in the redo-OPCAB group with 81 ± 12% versus 63 ± 9%in the redo-ONCAB group. The quality of life survey did not reveal any significant differences between both groups. CONCLUSION: In conclusion, with our present retrospective study, we could demonstrate the safety and efficacy of the redo-OPCAB technique with even higher 3-year survival rate. Both techniques seem to have similar impact on the outcome of patients.

Off-pump versus on-pump coronary-artery bypass grafting in elderly patients.

BACKGROUND: The benefits of coronary-artery bypass grafting (CABG) without cardiopulmonary bypass in the elderly are still undetermined. METHODS: We randomly assigned patients 75 years of age or older who were scheduled for elective first-time CABG to undergo the procedure either without cardiopulmonary bypass (off-pump CABG) or with it (on-pump CABG). The primary end point was a composite of death, stroke, myocardial infarction, repeat revascularization, or new renal-replacement therapy at 30 days and at 12 months after surgery. RESULTS: A total of 2539 patients underwent randomization. At 30 days after surgery, there was no significant difference between patients who underwent off-pump surgery and those who underwent on-pump surgery in terms of the composite outcome (7.8% vs. 8.2%; odds ratio, 0.95; 95% confidence interval [CI], 0.71 to 1.28; P=0.74) or four of the components (death, stroke, myocardial infarction, or new renal-replacement therapy). Repeat revascularization occurred more frequently after off-pump CABG than after on-pump CABG (1.3% vs. 0.4%; odds ratio, 2.42; 95% CI, 1.03 to 5.72; P=0.04). At 12 months, there was no significant between-group difference in the composite end point (13.1% vs. 14.0%; hazard ratio, 0.93; 95% CI, 0.76 to 1.16; P=0.48) or in any of the individual components. Similar results were obtained in a per-protocol analysis that excluded the 177 patients who crossed over from the assigned treatment to the other treatment. CONCLUSIONS: In patients 75 years of age or older, there was no significant difference between on-pump and off-pump CABG with regard to the composite outcome of death, stroke, myocardial infarction, repeat revascularization, or new renal-replacement therapy within 30 days and within 12 months after surgery. (Funded by Maquet; GOPCABE ClinicalTrials.gov number, NCT00719667.).

Concomitant transapical transcatheter aortic valve implantation and minimally invasive direct coronary artery bypass.

We represent a successful minimally invasive combined off-pump procedure consisting of a transapical aortic valve implantation and a direct coronary artery bypass grafting in a woman with a severe aortic stenosis and a critical coronary artery disease. Due to her comorbidities, she was classified as a high-risk patient qualifying for a transcatheter procedure. We performed this combined procedure in a hybrid operation room, starting with the coronary bypass to maintain a coronary blood flow during the transapical valve implantation. The operation processed without any complications and she was discharged at the seventh postoperative day into the allocating hospital.