Technical considerations and sizing of external annuloplasty in the Ross procedure.

Pure aortic regurgitation and dilation of aortic annulus are the most significant risk factors for the failure of pulmonary autograft after the Ross procedure. Aortic annuloplasty has a positive effect on the durability of the autograft. Previously, we described a technique for external annuloplasty with dedicated CORONEO ring. In the present manuscript, we suggest the sizing of annuloplasty based on the diameter of pulmonary autograft annulus.

Does bone wax make sense in off-pump coronary surgery? A prospective randomized study.

Introduction: The effect of bone wax on sternal infection and intraoperative bleeding in off-pump coronary surgery has not been reported in current literature. Aim: To prospectively evalute this in a cohort of high risk patients undergoing off-pump coronary artery surgery at our institution. The potential impact on cell saver utilization was also studied. Material and methods: A prospective randomized study was performed in 58 diabetic patients operated on for two-vessel coronary artery disease by the off-pump technique. They were randomly assigned to the wax or no-wax group. Results: There was no significant difference in intraoperative blood loss between the wax (550 ml) and no-wax group (750 ml; p = 0.0711). In multivariate analysis the absence (non-use) of bone wax (odds ratio = 3.9 (1.12-13.51), p = 0.027) and preoperative creatinin level (odds ratio = 1.1 (0.99-1.03), p = 0.03) were identified as independent predictors of blood loss ≥ 750 ml. The number of red blood cell units during hospital stay was similar in both groups (p = 0.42). Wound healing complications were not observed in either group. Conclusions: The use of bone wax does not lead to a higher risk of sternal wound infection. It may reduce the risk of high intraoperative blood loss, thus avoiding the need of a cell saver during off-pump coronary surgery. However, this influence remains questionable.

Aorto-mitral curtain reconstruction in invasive double-valve endocarditis: mid-term outcomes.

Background: Invasive double-valve endocarditis with structural damage (abscess or perforation) of the aorto-mitral curtain is a relatively rare but fatal diagnosis requiring complex surgical reconstruction. This study presents the short-term and mid-term outcomes from a single center. Methods: From 2014 to 2021, 20 patients with double-valve endocarditis with structural damage of the aorto-mitral curtain underwent surgical reconstruction (Hemi-Commando procedure n = 16 and Commando procedure n = 4). Data were obtained retrospectively. Results: In 13 cases, the procedure was a reoperation. The mean cardiopulmonary bypass time was 239 ± 47 min and the mean cross-clamp time was 186 ± 32 min. Concomitant procedures were tricuspid valve repair in two, coronary revascularization in one, closure of a ventricular septal defect in one and hemiarch (using circulatory arrest) in one patient. Eleven patients (55%) required surgical revision for bleeding. Thirty-day mortality was 30% (6 patients)-3 patients from the Hemi-Commando group (19%) and 3 patients from the Commando group (75%). Overall survival at 1, 3 and 5 years was 60%, 50% and 45% respectively. Reoperation was required by 4 patients. Freedom from reoperation at 1, 3 and 5 years was 86%, 71% and 71% respectively. Conclusion: Despite the high postoperative morbidity and mortality, complex surgical reconstruction of the aorto-mitral continuity of patients with double-valve endocarditis represents the only real chance for survival. Mid-term outcomes are acceptable, but strict follow-up is required due to the risk of valve failure.

Impact of smoking on the outcomes of minimally invasive direct coronary artery bypass.

BACKGROUND: Tobacco smoking has been associated with an increased risk of complications after conventional coronary surgery. However, the impact of smoking on the risk of postoperative complications in minimally invasive coronary surgery is yet to be studied. We aimed to analyze the impact of the preoperative smoking status on the short- and long-term outcomes of minimally invasive direct coronary artery bypass grafting (MIDCAB) in the context of isolated surgical revascularization or in association with percutaneous coronary intervention. METHODS: This was a retrospective observational study of all patients undergoing MIDCAB at our institution between 2006 and 2020. Patients were divided into three groups: active smokers, ex-smokers who have quit smoking for at least 1 month before surgery, and non-smokers. The groups were compared using conventional statistical methods. Multivariate analysis was then performed where significant differences were found to eliminate bias. RESULTS: Throughout the study period, 541 patients underwent MIDCAB, of which 135 (25%) were active smokers, 183 (34%) were ex-smokers, and 223 (41%) were non-smokers. Smokers presented for surgery at a younger age (p < 0.0001), more frequently with a history of myocardial infarction (p < 0.001), peripheral artery disease (p < 0.001) and chronic obstructive pulmonary disease (p < 0.0001). Using multivariate analysis, active smoking was determined to be a significant risk factor for the need of urgent revascularization (odds ratio 2.36 [1.00-5.56], p = 0.049) and the composite of pulmonary complications (including pneumothorax, respiratory infection, respiratory dysfunction, subcutaneous emphysema and exacerbation of chronic obstructive pulmonary disease; odds ratio 2.84 [1.64-4.94], p < 0.001). Preoperative smoking status did not influence the long-term survival (p = 0.83). CONCLUSIONS: In our study, active smokers presented for MIDCAB at a younger age and more often with signs of atherosclerotic disease (history of myocardial infarction and peripheral artery disease). Active smoking was found to be the most significant risk factor for postoperative pulmonary complications, and is also associated with a more frequent need for urgent surgery at diagnosis. Long-term postoperative survival is not affected by the preoperative smoking status.

Unicuspid Aortic Valve in Patients Undergoing the Ross Procedure.

BACKGROUND: The prevalence and outcomes of the unicuspid aortic valve (UAV) in patients undergoing the Ross procedure have been strongly underreported in the current literature. We sought to evaluate this in comparison with bicuspid (BAV) and tricuspid valve (TAV) in our Ross cohort. METHODS: This was a retrospective observational study of patients undergoing the Ross procedure at 2 dedicated centers between 2009 and 2020. Primary end points were the risks of midterm autograft reoperation and the onset of at least moderate aortic regurgitation during follow-up. The secondary end point was to compare the perioperative outcomes between the groups. RESULTS: Included in the analysis were 286 patients, of those 39% with UAV, 52% with BAV, and 9% with TAV. UAV patients were operated on at the youngest age (P < .001) and more often for a combined hemodynamic aortic valve pathology (P = .02). They had the largest aortic root dimensions: annulus (P = .01), Valsalva sinuses (P = .11), sinotubular junction (P = .001), and ascending aorta (P < .0001). The risks of reoperation (P = .86) and the onset of aortic regurgitation (P = .75) were comparable among the groups over the follow-up of 4.1 years. There was no difference in perioperative outcomes. CONCLUSIONS: UAV is a separate unit characterized by a distinct hemodynamic pathology and generated aortopathy. It is not associated with a higher risk of reoperation or new onset of aortic regurgitation after the Ross procedure in the midterm postoperatively. At the current state, UAV remains acceptable for the Ross procedure.

Cardiac myxoma with atypical cell population mimicking malignancy - a diagnostic pitfall.

Herein, a case of a 45-year-old woman is reported with left atrial myxoma showing unique histological findings mimicking malignancy. For 3 months before surgery, the patient suffered from a long-standing fever of unknown etiology, malaise and weight loss; she had no history of malignancy. The CT scan revealed a tumorous mass in the left atrium. Grossly, the tumor had a smooth rounded surface with areas of haemorrhage on the cut surface. Microscopic examination revealed two distinct regions. One showed classical myxoma histology, the other atypical and highly cellular population with sarcoma-like or melanoma-like features mixed with inflammatory cells and posthemorrhagic changes. Immunohistochemically, the atypical cells expressed calretinin and CD31, analogous to the neighbouring bland myxoma cells. Negative markers included SOX10, S100, Melan A, HMB45, CD34, desmin, ERG, CK, LCA, CD68 and MDM2; SMARCB1/INI1 was retained. The proliferation index Ki67 was low, in about 1 % of atypical cells. The results suggest exaggerated reactive and degenerative changes of the myxoma cells rather than true malignant transformation. Similar case reports of cardiac myxomas and diagnostic challenges are discussed.

Robot-assisted vs. conventional MIDCAB: A propensity-matched analysis.

Background: Robotic assistance (RA) in the harvesting of internal thoracic artery during minimally invasive direct coronary artery bypass grafting (MIDCAB) provides several potential benefits for surgeon and patient in comparison with conventional MIDCAB. The two technical options have not been thoroughly compared in the literature yet. We aimed to perform this in our cohort with the use of propensity-score matching (PSM). Methods: This was a retrospective comparison of all consecutive patients undergoing conventional MIDCAB (2005-2021) and RA-MIDCAB (2018-2021) at our institution with the use of PSM with 27 preoperative covariates. Results: Throughout the study period 603 patients underwent conventional and 132 patients underwent RA-MIDCAB. One hundred and thirty matched pairs were selected for further comparison. PSM successfully eliminated all preoperative differences. Patients after RA-MIDCAB had lower 24 h blood loss post-operatively (300 vs. 450 ml, p = 0.002). They had shorter artificial ventilation time (6 vs. 7 h, p = 0.018) and hospital stay (6 vs. 8 days, p < 0.001). There was no difference in the risk of perioperative complications, short-term and mid-term mortality between the groups. Conclusions: RA-MIDCAB is an attractive alternative to conventional MIDCAB. It is associated with lower post-operative blood loss and potentially faster rehabilitation after surgery. The mortality and the risk of perioperative complications are comparable among the groups.

Solitary metastasis of clear cell renal cell carcinoma in sternum diagnosed unexpectedly during cardiac surgery - A rare but potentially fatal trap.

We present a very rare case of fatal complication during the cardiac surgery caused by unrecognized solitary metastasis of clear cell renal cell carcinoma in the sternum.

The outcome of a preoperative one-minute sit-to-stand test is associated with ventilation time after cardiac surgery.

Objectives. The One-minute Sit-To-Stand Test (STST) is a relatively novel physical performance test in the field of pulmonology. It measures the exercise tolerance of the patient. In this pilot study, we evaluated its predictive value for the postoperative course in cardiac surgery patients. Design. This was a prospective observational cohort study of patients undergoing elective aortic valve replacement. STST was applied in the patients, along with pulmonary function testing, a day prior to surgery, on postoperative day 7, and 3 months after surgery. A Short Form-36 health related quality of life survey (SF-36) was also included. The patients were divided into two groups according to the preoperative STST outcome: group A (≤20 repetitions, n = 12), and group B (>20 repetitions, n = 18). Results. We enrolled 30 patients in the study between May 2017 and May 2019. No complication were observed during the STST. The standard perioperative measures were identical for both groups. However, group A exhibited a significantly longer artificial ventilation time, as well as worse pulmonary function (VC, FVC, TLCO), on postoperative day 7. Concerning the SF-36, group A displayed a worse pre- and postoperative evaluation in both physical functioning and vitality. Conclusions. STST is a short and practical physical performance test that could enable a better prediction of the postoperative course after cardiac surgery. Patients with lower preoperative STST performance may require longer postoperative artificial ventilation, as they may present worse in some parameters of pulmonary functions and quality of life. However, these findings must be corroborated in larger studies.

Lung Collapse during Mini-Thoracotomy Reduces Penetration of Cefuroxime to the Tissue: Interstitial Microdialysis Study in Animal Models.

Background: Single-lung ventilation facilitates surgical exposure during minimally invasive cardiac surgery. However, a deeper knowledge of antibiotic distribution within a collapsed lung is necessary for effective antibiotic prophylaxis of pneumonia. Patients and Methods: The pharmacokinetics/pharmacodynamics (PK/PD) of cefuroxime were compared between the plasma and interstitial fluid (ISF) of collapsed and ventilated lungs in 10 anesthetized pigs, which were ventilated through a double-lumen endotracheal cannula. Cefuroxime (20 mg/kg) was administered in single 30-minute intravenous infusion. Samples of blood and lung microdialysate were collected until six hours post-dose. Ultrafiltration, in vivo retrodialysis, and high-performance liquid chromatography-tandem mass spectrometry were used to determine plasma and ISF concentrations of free drug. The concentrations were examined with non-compartmental analysis and compartmental modeling. Results: The concentration of free cefuroxime in ISF was lower in the non-ventilated lung than the ventilated one, evidenced by a lung penetration factor of 47% versus 63% (p < 0.05), the ratio between maximum concentrations (65%, p < 0.05), and the ratio between the areas under the concentration-time curve (78%, p = 0.12). The time needed to reach a minimum inhibitory concentration (MIC) was 30%-40% longer for a collapsed lung than for a ventilated one. In addition, a delay of 10-40 minutes was observed for lung ISF compared with plasma. The mean residence time values (ISF collapsed lung > ISF ventilated lung > plasma) could explain the absence of practically important differences in the time interval with the concentration of cefuroxime exceeding the MICs of sensitive strains (≤4 mg/L). Conclusion: The concentration of cefuroxime in the ISF of a collapsed porcine lung is lower than in a ventilated one; furthermore, its equilibration with plasma is delayed. Administration of the first cefuroxime dose earlier or at a higher rate may be warranted, as well as dose intensification of the perioperative prophylaxis of pneumonia caused by pathogens with higher MICs.

Female sex as a risk factor in minimally invasive direct coronary artery bypass grafting.

Objectives. Female sex has been generally accepted as a risk factor for short-term mortality and adverse events in surgical myocardial revascularization. However, there have been no data published yet about sex differences in minimally invasive settings. The aim of our study was to analyse short- and long- term outcomes of minimally invasive direct coronary artery bypass grafting (MIDCAB) in terms of sex comparison. Design. We retrospectively analysed the in-hospital data of all patients (n = 384) undergoing MIDCAB at our department in years 2006-2016. Subsequently, the data were enriched by long-term outcomes from national registries. Results. There were 96 women in our group (25%). Females were significantly older (67.1 vs 63.8 years; p < .01) and were more often diabetic (43.8% vs. 31.8%; p < .01). Surgery time was longer in females (160 vs 155 min; p = .02), and also the need for blood transfusion (19.8% vs 10.4%; p = .02) and wound complications (15.6% vs 2.4%; p < .001) were more frequent in women. After multivariate analysis, the wound complications risk (p < .001) and longer surgery times (p < .01) remained associated with sex. All-cause in-hospital mortality (2.1% vs 0.7%; p = .26), long-term mortality (p = .73), and the risk of coronary intervention post-operatively (p = .16) were the same in both sexes. Higher incidence of cardiac cause of death in women was observed from long-term aspect (69.6% vs 38.7%; p = .01). However, after adjustment it lost its significance. Conclusions. Female sex is not connected with higher risk of mortality or other major events in MIDCAB. Wound healing complications remain the leading attribute associated with female sex.

Surgical cryoablation of drug resistant ventricular tachycardia and aneurysmectomy of postinfarction left ventricular aneurysm.

Heart failure is usually associated with left ventricle remodelling, wall thickening, and worsening of the systolic function. Ventricular tachycardia is a common and a negative prognostic factor in patients with endocardial scarring following myocardial infarction and aneurysm formation. The authors present a case of a 51-year-old man with ischemic heart disease, who suffered myocardial infarction four years ago. The patient was admitted to the hospital with sustained ventricular tachycardia despite maximal pharmacotherapy and also underwent unsuccessful percutaneous radiofrequency ablation in the right ventricle. Transthoracic echocardiography revealed left ventricle dysfunction with ejection fraction of 25%, aneurysm of the apex of the left ventricle with thrombus formation inside the aneurysm. Surgical therapy consisted of the cryoablation applied at the transitional zone of the scar and viable tissue and the resection of the aneurysm. The patient remained free of any ventricular tachycardia four months later.

Thoracoscopic radiofrequency ablation for lone atrial fibrillation: box-lesion technique.

BACKGROUND: We report the feasibility and outcomes of box-lesion ablation technique to treat stand-alone atrial fibrillation (AF). METHODS: There were 41 patients with a mean age of 57.6 ± 8.0 years who underwent bilateral totally thoracoscopic ablation of symptomatic paroxysmal AF (n = 24; 58.5%), persistent AF (n = 9; 22.0%), or long-standing persistent AF (n = 8; 19.5%). The box-lesion procedure included bilateral pulmonary vein and left atrial posterior wall ablation using irrigated bipolar radiofrequency with documentation of conduction block. RESULTS: There were no intra- or perioperative ablation-related complications. There was no operative mortality, no myocardial infarction, and no stroke. Skin-to-skin procedure time was 119.5 ± 23.7 minutes and the postoperative average length of stay was 7.4 ± 2.5 days. At discharge, 38 patients (93%) were in sinus rhythm. Median follow-up time was 641 days (ranges, 185-1636 days). At six months postsurgery, 31 patients of 41 (76%) were free from AF without the need of antiarrhythmic drugs. One-year success rate was 73% (off antiarrhythmic drugs). Eight patients (19.5%) underwent catheter reablation. Thirty-six patients (90%) were in sinus rhythm at six months after the last performed ablation (surgical ablation or catheter reablation). At 12 months follow-up, 61% patients discontinued oral anticoagulant therapy. CONCLUSION: The thoracoscopic box-lesion ablation procedure is a safe, effective, and minimally invasive method for the treatment of isolated (lone) AF. This procedure provided excellent short-term freedom from AF.

Left hemothorax: an unusual complication of delayed right ventricular perforation by a permanent pacemaker lead.

Cardiac ventricle perforation by a pacemaker (PM) lead is an uncommon complication of PM implantation. We report a patient with a delayed right ventricular perforation from a permanent PM lead which presented as a left hemothorax.

Early and long-term results of minimally invasive coronary artery bypass grafting in elderly patients.

BACKGROUND: Standard (conventional) coronary artery bypass grafting (CABG) is an invasive procedure which requires full median sternotomy and is performed with extracorporeal circulation (ECC), which can lead to serious complications. AIM: To analyse the results of minimally invasive CABG (MIDCAB) in elderly patients. METHODS: Between 1999 and 2007, a total of 698 MIDCAB procedures were performed at our institution. We present the data on 235 elderly (≥ 70 years) patients (160 males, mean age 74.5 ± 3.2 years, range: 70-83 years) who were consecutively operated on in this period. Early mortality, post-operative complications, long-term survival, impact of multivessel disease (MVD) and hybrid coronary artery revascularisation on total mortality were analysed. Logistic EuroSCORE was 8.7%. The survival of 235 elderly patients was compared to the survival of the remaining 463 MIDCAB patients aged < 70 years (including risk factors for total mortality). RESULTS: The 30-day mortality was 2.5% (six patients). During follow-up, two patients underwent coronary reoperation and percutaneous coronary intervention (PCI) was performed in 16 patients. Kaplan-Meier analysis revealed a 1.5-year survival of 89.8% (95% CI 85.9-93.7%) and five-year survival of 79.7% (95% CI 74.3-85%). Compared to single vessel disease (SVD) patients, the MVD patients had significantly higher total mortality (p = 0.0038). Our study revealed MVD (p = 0.0016) and male sex (p = 0.0091) as important independent factors of total mortality in this group of elderly patients. The difference in total mortality between non-hybrid vs hybrid MIDCABs was not significant (p = 0.63). The younger MIDCAB patients (< 70 years) have a tendency to better survival, but the difference did not achieve statistical significance (p = 0.088). They had the same independent factors of total mortality as in the elderly group: MVD (p = 0.0001) and male sex (p = 0.0059). CONCLUSIONS: The MIDCAB is a reasonable option for elderly patients with SVD, and in selected patients with MVD. The decision to perform MIDCAB rather than PCI in these high risk patients should always be very carefully considered in conjunction with the interventional cardiologist.