Fractional Flow Reserve-Guided PCI or Coronary Bypass Surgery for 3-Vessel Coronary Artery Disease: 3-Year Follow-Up of the FAME 3 Trial.

BACKGROUND: Previous studies comparing percutaneous coronary intervention (PCI) with coronary artery bypass grafting (CABG) in patients with multivessel coronary disease not involving the left main have shown significantly lower rates of death, myocardial infarction (MI), or stroke after CABG. These studies did not routinely use current-generation drug-eluting stents or fractional flow reserve (FFR) to guide PCI. METHODS: FAME 3 (Fractional Flow Reserve versus Angiography for Multivessel Evaluation) is an investigator-initiated, multicenter, international, randomized trial involving patients with 3-vessel coronary artery disease (not involving the left main coronary artery) in 48 centers worldwide. Patients were randomly assigned to receive FFR-guided PCI using zotarolimus drug-eluting stents or CABG. The prespecified key secondary end point of the trial reported here is the 3-year incidence of the composite of death, MI, or stroke. RESULTS: A total of 1500 patients were randomized to FFR-guided PCI or CABG. Follow-up was achieved in >96% of patients in both groups. There was no difference in the incidence of the composite of death, MI, or stroke after FFR-guided PCI compared with CABG (12.0% versus 9.2%; hazard ratio [HR], 1.3 [95% CI, 0.98-1.83]; P=0.07). The rates of death (4.1% versus 3.9%; HR, 1.0 [95% CI, 0.6-1.7]; P=0.88) and stroke (1.6% versus 2.0%; HR, 0.8 [95% CI, 0.4-1.7]; P=0.56) were not different. MI occurred more frequently after PCI (7.0% versus 4.2%; HR, 1.7 [95% CI, 1.1-2.7]; P=0.02). CONCLUSIONS: At 3-year follow-up, there was no difference in the incidence of the composite of death, MI, or stroke after FFR-guided PCI with current-generation drug-eluting stents compared with CABG. There was a higher incidence of MI after PCI compared with CABG, with no difference in death or stroke. These results provide contemporary data to allow improved shared decision-making between physicians and patients with 3-vessel coronary artery disease. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifier: NCT02100722.

Predictors and Outcomes of Stroke After Isolated Coronary Artery Bypass Grafting. A Single-Center Experience in 20,582 Patients.

OBJECTIVE: Stroke remains a devastating complication after cardiac surgical procedures despite perioperative monitoring and management advances. This study aimed to determine the predictors of stroke in a large, contemporary coronary artery surgery population. DESIGN: Patient data were analyzed retrospectively. SETTING: This single-center study was performed in the Catharina Hospital (Eindhoven). PARTICIPANTS: All patients who underwent isolated coronary artery bypass grafting (CABG) between January 1998 and February 2019 were included. INTERVENTIONS: Isolated CABG. MEASUREMENTS AND MAIN RESULTS: The primary endpoint was a postoperative stroke, defined according to the international updated definition for stroke. Logistic regression was performed to retrieve variables associated with postoperative stroke. A total of 20,582 patients underwent CABG during the period of the study. Stroke was observed in 142 patients (0.7%), of which 75 (52.8%) occurred during the first 72 hours. The incidence of postoperative stroke declined over the years. A significantly higher 30-day mortality rate was seen in patients with stroke (20.4%) compared with 1.8% in the rest of the population; p < 0.001. Multivariate logistic regression analysis showed age, peripheral arterial disease, reexploration for bleeding, perioperative myocardial infarction, and year of surgery as independent predictors for stroke. Patients with postoperative stroke had worse long-term survival (log-rank p < 0.001). Cox regression analysis revealed postoperative stroke (odds ratio 2.13 [1.73-2.64)) as an independent predictor of late mortality. CONCLUSIONS: Stroke after CABG is associated with high early and late mortality. Age, peripheral vascular disease, and the year of surgery were associated with postoperative stroke.

Fractional Flow Reserve-Guided PCI as Compared with Coronary Bypass Surgery.

BACKGROUND: Patients with three-vessel coronary artery disease have been found to have better outcomes with coronary-artery bypass grafting (CABG) than with percutaneous coronary intervention (PCI), but studies in which PCI is guided by measurement of fractional flow reserve (FFR) have been lacking. METHODS: In this multicenter, international, noninferiority trial, patients with three-vessel coronary artery disease were randomly assigned to undergo CABG or FFR-guided PCI with current-generation zotarolimus-eluting stents. The primary end point was the occurrence within 1 year of a major adverse cardiac or cerebrovascular event, defined as death from any cause, myocardial infarction, stroke, or repeat revascularization. Noninferiority of FFR-guided PCI to CABG was prespecified as an upper boundary of less than 1.65 for the 95% confidence interval of the hazard ratio. Secondary end points included a composite of death, myocardial infarction, or stroke; safety was also assessed. RESULTS: A total of 1500 patients underwent randomization at 48 centers. Patients assigned to undergo PCI received a mean (±SD) of 3.7±1.9 stents, and those assigned to undergo CABG received 3.4±1.0 distal anastomoses. The 1-year incidence of the composite primary end point was 10.6% among patients randomly assigned to undergo FFR-guided PCI and 6.9% among those assigned to undergo CABG (hazard ratio, 1.5; 95% confidence interval [CI], 1.1 to 2.2), findings that were not consistent with noninferiority of FFR-guided PCI (P = 0.35 for noninferiority). The incidence of death, myocardial infarction, or stroke was 7.3% in the FFR-guided PCI group and 5.2% in the CABG group (hazard ratio, 1.4; 95% CI, 0.9 to 2.1). The incidences of major bleeding, arrhythmia, and acute kidney injury were higher in the CABG group than in the FFR-guided PCI group. CONCLUSIONS: In patients with three-vessel coronary artery disease, FFR-guided PCI was not found to be noninferior to CABG with respect to the incidence of a composite of death, myocardial infarction, stroke, or repeat revascularization at 1 year. (Funded by Medtronic and Abbott Vascular; FAME 3 ClinicalTrials.gov number, NCT02100722.).

Impact of preoperative antithrombotic therapy in patients undergoing elective isolated coronary artery bypass grafting.

OBJECTIVES: The objective of this retrospective study was to assess differences in clinical outcomes between patients on acetylsalicylic acid (ASA) monotherapy and patients on other antithrombotic (AT) regimens undergoing elective coronary artery bypass grafting (CABG). METHODS: Patients who underwent elective isolated CABG between 2017 and 2019 at the Catharina Hospital Eindhoven were eligible for this study. The primary end points were re-exploration for bleeding and postoperative blood product transfusion. Secondary end points included 30-day mortality, in-hospital stroke, in-hospital myocardial infarction and duration of hospitalization. Propensity matching was used to compare outcomes of the main study groups (ASA vs other AT therapy) and subgroups of AT therapy (guideline adherence vs non-adherence). RESULTS: A total of 1068 patients were included: 710 patients on ASA monotherapy and 358 patients on other AT regimens. In the 256 matched patients in the main study groups, using AT regimens other than ASA monotherapy was associated with increased risk of re-exploration for bleeding [6.6% vs 2.0%, P = 0.017; odds ratio (OR) 3.57 (1.29-9.83)] and increased use of blood products [37.5% vs 20.3%, P < 0.001; OR 2.35 (1.58-3.49)]. In 122 matched subgroup patients, non-adherence was associated with an increased risk of re-exploration [10.7% vs 3.3%, P = 0.044; OR 3.52 (1.11-11.12)] and increased blood product use [51.6% vs 25.4%, P < 0.001; OR 3.13 (1.83-5.38)]. Secondary end points were not significantly different among the main study groups and subgroups. CONCLUSIONS: Preoperative use of AT therapy other than ASA monotherapy in patients who elected CABG was associated with the increased postoperative use of blood products and risk of re-exploration for bleeding; this finding was even more pronounced in non-guideline-adherent patients.

Right Anterolateral Thoracotomy Versus Sternotomy for Resection of Benign Atrial Masses: A Systematic Review and Meta-Analysis.

OBJECTIVE: Primary benign cardiac tumors are rare disease entity that predominantly originate from the atria. Benign masses can induce heart failure, arrhythmia, or thromboembolic events. Therefore, surgical excision is often indicated. Current guidelines on the preferred approaches for resection (i.e., median sternotomy [MST] or right anterolateral thoracotomy [RAT]) are lacking. The aim of the current meta-analysis was to evaluate all studies comparing RAT to MST for excision of benign atrial masses in terms of safety, efficacy, and complications. METHODS: The PubMed and EMBASE databases were searched through 9 June 2020. Data regarding mortality, complications, recurrence, ICU stay, and length of hospital stay were extracted and submitted to meta-analysis using random effects modelling. Heterogeneity was assessed by the I 2 test. RESULTS: Four retrospective observational studies were included, including 196 patients (RAT n = 97, MST n = 99). Mortality was 0% in both groups. Recurrence was <1% in the RAT group and 0% in the MST group. Complication rate tended to be lower in favor of the RAT group. Furthermore, RAT was associated with lower length of ICU stay (-17.7 hr, P = 0.01) and hospital stay (-4.0 days, P < 0.001). No significant differences in cardiopulmonary bypass (P = 0.09) and cross-clamp times (P = 0.15) were observed. CONCLUSIONS: The RAT approach is as safe and effective as MST for the excision of benign atrial masses. Moreover, RAT is associated with a reduced complication rate and a reduced duration of hospitalization and could be considered as the preferred approach in anatomically suitable patients.

Recovery of conduction disorders after sutureless aortic valve replacement.

OBJECTIVES: Conduction disorders and the need for permanent pacemaker (PPM) implantation after surgical aortic valve replacement are well-recognized complications. However, in the case of sutureless valve prostheses, it remains unknown whether pacemaker (PM) dependency and conduction disturbances resolve over time. Our aim was to evaluate whether conduction disorders after Perceval sutureless valve implantation recover during follow-up. METHODS: Patients undergoing isolated surgical aortic valve replacement or concomitant aortic valve replacement with coronary artery bypass surgery using the Perceval sutureless valve, between January 2010 and July 2018, were included. Postoperative electrocardiogram findings were analysed to determine the incidence of new-onset left bundle branch blocks (LBBBs) and the requirement for PPM implantation. During a postoperative period of 6-18 months, electrocardiogram findings during PM checks were analysed to determine PM dependency and LBBB persistence. RESULTS: Out of 184 patients who received a Perceval prosthesis during the study period, 39 (21.2%) patients developed new-onset LBBB and 10 patients (5.4%) received a PPM postoperatively. The occurrence of conduction disorders was not associated with valve size. Follow-up was completed in 176 (95.7%) patients. In patients with a new-onset LBBB, 35.9% recovered during follow-up (P = 0.001). Seven out of 10 (70%) patients remained PM dependent. CONCLUSIONS: After Perceval aortic valve implantation, new-onset LBBB recovers in more than one-third of patients during follow-up. In patients who needed a postoperative PPM, the majority remained PM dependent.

Effect of Adding Ticagrelor to Standard Aspirin on Saphenous Vein Graft Patency in Patients Undergoing Coronary Artery Bypass Grafting (POPular CABG): A Randomized, Double-Blind, Placebo-Controlled Trial.

BACKGROUND: Approximately 15% of saphenous vein grafts (SVGs) occlude during the first year after coronary artery bypass graft surgery (CABG) despite aspirin use. The POPular CABG trial (The Effect of Ticagrelor on Saphenous Vein Graft Patency in Patients Undergoing Coronary Artery Bypass Grafting Surgery) investigated whether ticagrelor added to standard aspirin improves SVG patency at 1 year after CABG. METHODS: In this investigator-initiated, randomized, double-blind, placebo-controlled, multicenter trial, patients with ≥1 SVGs were randomly assigned (1:1) after CABG to ticagrelor or placebo added to standard aspirin (80 mg or 100 mg). The primary outcome was SVG occlusion at 1 year, assessed with coronary computed tomography angiography, in all patients that had primary outcome imaging available. A generalized estimating equation model was used to perform the primary analysis per SVG. The secondary outcome was 1-year SVG failure, which was a composite of SVG occlusion, SVG revascularization, myocardial infarction in myocardial territory supplied by a SVG, or sudden death. RESULTS: Among 499 randomly assigned patients, the mean age was 67.9±8.3 years, 87.1% were male, the indication for CABG was acute coronary syndrome in 31.3%, and 95.2% of procedures used cardiopulmonary bypass. Primary outcome imaging was available in 220 patients in the ticagrelor group and 223 patients in the placebo group. The SVG occlusion rate in the ticagrelor group was 10.5% (51 of 484 SVGs) versus 9.1% in the placebo group (43 of 470 SVGs), odds ratio, 1.29 [95% CI, 0.73-2.30]; P=0.38. SVG failure occurred in 35 (14.2%) patients in the ticagrelor group versus 29 (11.6%) patients in the placebo group (odds ratio, 1.22 [95% CI, 0.72-2.05]). CONCLUSIONS: In this randomized, placebo-controlled trial, the addition of ticagrelor to standard aspirin did not reduce SVG occlusion at 1 year after CABG. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02352402.

Unraveling postoperative alterations after mitral valve replacement with three-dimensional printing.

Mitral valve (MV) surgery is the second most performed valve operation in Europe. MV pathology is associated with atrial fibrillation, and, therefore, frequently combined with rhythm surgery and left atrial appendage exclusion (LAAE). Currently, no guidelines exist regarding the follow up after LAAE postoperative. Postoperative imaging with computed tomography (CT), in the absence of complaints, will inherently reveal unsuspected cardiac and noncardiac findings with potential clinical significance. However, poststernotomy alterations are nonspecific and often overlap with normal postoperative changes and could, therefore, not directly be recognized. Virtual three-dimensional (3D) CT reconstructions can help us to visualize 2D structures, especially in areas where structures overlap like coronary arteries or when devices (atrial clip, MV prosthesis) cause scattering artifacts. Advanced imaging reconstructions and 3D printing can enhance understanding of the cardiac anatomy in the postoperative phase and help us to determine follow-up strategies.

A randomized, double-blind, placebo-controlled trial investigating the effect of ticagrelor on saphenous vein graft patency in patients undergoing coronary artery bypass grafting surgery-Rationale and design of the POPular CABG trial.

RATIONALE: An estimated 15% of saphenous vein grafts (SVGs) occlude in the first year after coronary artery bypass grafting (CABG) despite aspirin therapy. Graft occlusion can result in symptoms, myocardial infarction, and death. SVG occlusion is primarily caused by atherothrombosis, in which platelet activation plays a pivotal role. Evidence regarding the effect of stronger platelet inhibition on SVG patency after CABG is limited. The main objective of the POPular CABG trial is to determine whether dual antiplatelet therapy with aspirin plus ticagrelor improves SVG patency when compared to aspirin alone. STUDY: The POPular CABG is a randomized, double-blind, placebo-controlled, multicenter trial investigating the effect of adding ticagrelor to standard aspirin therapy on the rate of SVG occlusion. A total of 500 patients undergoing CABG with ≥ 1 SVG are randomized to ticagrelor or placebo. The primary end point is SVG occlusion rate, assessed with coronary computed tomography angiography at 1 year. Secondary end points are stenoses and occlusions in both SVGs and arterial grafts and SVG failure at 1 year, defined as a composite of SVG occlusion on coronary computed tomography angiography or coronary angiography, SVG revascularization, myocardial infarction in the territory supplied by an SVG, or sudden death. Safety end points are bleeding events at 30 days and 1 year. CONCLUSION: The POPular CABG trial investigates whether adding ticagrelor to standard aspirin after CABG reduces the rate of SVG occlusion at 1 year.

Benefits of Endoscopic Vein Harvesting in Coronary Artery Bypass Grafting.

BACKGROUND: Earlier reports concerning endoscopic vein harvesting have been controversial regarding the patency of the vein graft after coronary artery bypass grafting (CABG). In addition, data on the quality of life are lacking. In this study, we investigated our experience with endoscopic vein harvesting with regard to these end points. METHODS: The analysis included patients undergoing isolated CABG between 2012 and 2016. Patients were divided in 2 groups stratified by the technique of saphenous vein harvesting: open vs endoscopic. Primary end points were the rate of repeat revascularization and leg wound complications. Secondary end points were the physical and mental quality of life scores of the 36-Item Short Form Health Survey questionnaire. Cox proportional hazard analysis was performed to adjust the end point of repeat revascularization for relevant covariates. RESULTS: The open group included 2123 patients, and the endoscopic group included 883 patients. Overall mortality was not significantly different between the groups (P = .060). Revascularization-free survival was similar between the groups (adjusted hazard ratio, 0.65; 95% confidence interval, 0.42 to 1.02; P = .059). Endoscopic vein harvesting was significantly associated with a decreased hazard for the combined end point of death or repeat revascularization (adjusted hazard ratio, 0.64; 95% confidence interval, 0.46 to 0.90; P = .009). Significantly more leg wound complications were seen in the open group (24 vs 0; P = .002). Postoperative quality of life showed no significant differences between the 2 groups. CONCLUSIONS: Apart from the benefits on leg wound complications, endoscopic vein harvesting was comparable to open vein harvesting in the rate of repeat revascularization and quality of life.

Sex Difference in Coronary Artery Bypass Grafting: Preoperative Profile and Early Outcome.

OBJECTIVE: According to the available risk-stratification systems, women have a higher risk of mortality than men after coronary artery bypass grafting (CABG). In this study, the authors investigated the authors' CABG database to trace factors contributing to this difference in outcome between sexes. DESIGN: A retrospective patient record study. SETTING: This single-center study was performed at the Catharina Hospital in Eindhoven, the Netherlands. PARTICIPANTS: The study comprised 17,919 patients, of whom 4,016 (22.4%) were women and 13,903 (77.6%) were men. INTERVENTIONS: Coronary artery bypass grafting was performed between January 1998 and July 2016. MEASUREMENTS AND MAIN RESULTS: Early mortality was significantly higher in women than in men (2.7% v 1.9%; p = 0.001). Regarding the baseline characteristics, women were older and had a lower hemoglobin level and a lower creatinine level than men. Women more often had hypertension, diabetes, underweight (body mass index [BMI] <20 kg/m2), and obesity (BMI >30 kg/m2). The mean number of grafts per patient was less in women than in men (3.2 ± 1.1 v 3.5 ± 1.1; p < 0.001). However, the mean cross-clamp time per graft was longer in female patients than in male patients (11.6 ± 8.7 min. v 11.2 ± 7.0 min.; p = 0.013). Logistic regression analyses showed that chronic obstructive pulmonary disease, peripheral vascular disease, cross-clamp time, and underweight were independent risk factors for early mortality only in men. CONCLUSION: The preoperative patient profile is significantly different between men and women undergoing CABG. The predictive value of well-known risk factors for early mortality is different between the 2 sexes.

Impact of Sex on the Outcome of Isolated Aortic Valve Replacement and the Role of Different Preoperative Profiles.

OBJECTIVE: The aim of this study was to compare the patient profiles and outcomes of men and women undergoing isolated aortic valve replacement. DESIGN: Patient data were analyzed retrospectively. SETTING: This single-center study was performed at Catharina Hospital in Eindhoven, the Netherlands. PARTICIPANTS: The study comprised 2,362 patients, of whom 1,040 (44%) were women and 1,322 were men (56%). INTERVENTIONS: Isolated aortic valve replacement was performed between January 1998 and December 2016. MEASUREMENTS AND MAIN RESULTS: The mean follow-up was 8.3 ± 5.1 years. Women were relatively older (69.9 years v 64.6 years; p < 0.001); more of them were underweight, obese, and diabetic; and they had lower hemoglobin values and worse renal function than did men. However, fewer women than men experienced chronic obstructive pulmonary disease, aortic regurgitation, left ventricular dysfunction, and endocarditis. Early mortality did not differ significantly between men and women (p = 0.238). Overall survival was worse in women (p < 0.001). After correction for potential risk factors, female sex was not associated with worse survival. During the study period, the mean age of patients undergoing aortic valve replacement increased. In addition, the mean age at the time of death increased, following the trend of national statistics. CONCLUSIONS: Although women undergoing aortic valve replacement have relatively more risk factors than do men, early mortality in women is not significantly higher than in men. Overall survival is worse in women than in men; however, after adjustment for preoperative risk factors, there is no difference in overall survival between women and men.

Conduction disorders and impact on survival after sutureless aortic valve replacement compared to conventional stented bioprostheses.

OBJECTIVES: Sutureless and rapid-deployment aortic valve prostheses are frequently used for the treatment of aortic stenosis. However, postoperative left bundle branch block (LBBB) and permanent pacemaker (PPM) implantation have emerged as frequent complications. The aim of this study was to compare the incidence of new-onset LBBB and PPM implantation after sutureless aortic valve replacement (sAVR) with stented bioprostheses, and the impact on postoperative survival. METHODS: Patients undergoing isolated surgical aortic valve replacement (AVR) or concomitant AVR with coronary artery bypass surgery between January 2010 and July 2017 were included in the study. Two groups were defined: sAVR and conventional AVR (cAVR). The findings of preoperative electrocardiograms were compared with postoperative electrocardiogram findings for both groups. The incidence of new-onset LBBB and the requirement for PPM implantation were recorded. The effect of these conduction disorders on late survival was analysed. RESULTS: A total of 987 patients were analysed, consisting of 132 sAVR and 855 cAVR patients. The sAVR group had an increased incidence of new-onset LBBB compared to the cAVR group (16.7% vs 2.3%, P < 0.001). A significantly higher rate of postoperative PPM implantation was found for sAVR patients compared to cAVR (6.8% vs 1.6%, P = 0.001). The multivariate Cox analysis revealed that neither postoperative new-onset LBBB nor PPM implantation was associated with increased mortality (hazard ratio 1.73, 95% confidence interval 0.74-4.03, P = 0.204). CONCLUSIONS: sAVR is associated with an increased risk of new-onset LBBB and PPM requirement compared to cAVR. In this population, postoperative conduction disorders did not affect the mid-term survival.

Significantly Elevated C-Reactive Protein Levels After Epicardial Clipping of the Left Atrial Appendage.

OBJECTIVE: Besides mechanical and anatomical changes of the left atrium, epicardial closure of the left atrial appendage has also possible homeostatic effects. The aim of this study was to assess whether epicardial clipping of the left atrial appendage has different biochemical effects compared with complete removal of the left atrial appendage. METHODS: Eighty-two patients were included and underwent a totally thoracoscopic AF ablation procedure. As part of the procedure, the left atrial appendage was excluded with an epicardial clip (n = 57) or the left atrial appendage was fully amputated with an endoscopic vascular stapler (n = 25). From all patients' preprocedural and postprocedural blood pressure, electrolytes and inflammatory parameters were collected. RESULTS: The mean age and left atrial volume index were comparable between the epicardial clip and stapler group (64 ± 8 years vs. 60 ± 9 years, P = non-significant; 44 ± 15 mL/m vs. 40 ± 13 mL/m, P = non-significant). Patients receiving left atrial appendage clipping had significantly elevated C-reactive protein levels compared with patients who had left atrial appendage stapling at the second, third, and fourth postoperative day (225 ± 84 mg/L vs. 149 ± 76 mg/L, P = 0.002, 244 ± 78 vs. 167 ± 76, P = 0.004, 190 ± 74 vs. 105 ± 48, P < 0.001, respectively). Patients had a significant decrease in sodium levels, systolic, and diastolic blood pressure at 24 and 72 hours after left atrial appendage closure. However, this was comparable for both the left atrial appendage clipping and stapling group. CONCLUSIONS: Increased activation of the inflammatory response was observed after left atrial appendage clipping compared with left atrial appendage stapling. Furthermore, a significant decrease in blood pressure was observed after surgical removal of the left atrial appendage. Whether the inflammatory response affects the outcome of arrhythmia surgery needs to be further evaluated.

Use of an intraoperative checklist to decrease the incidence of re-exploration for postoperative bleeding after cardiac surgery.

OBJECTIVES: We have implemented an intraoperative checklist aiming to reduce the incidence of re-exploration for bleeding after cardiac surgery. The present report addresses the results of adopting such a checklist regarding the incidence of postoperative bleeding. METHODS: The checklist was implemented by presenting it in several staff meetings of the Catharina Heart Center. Copies of the checklist were presented in every operating room. Data were collected by the Catharina Heart Center, aligned with the 'Meetbaar Beter' data manual and validated by 'Meetbaar Beter' through their data quality system. The incidence of re-exploration for bleeding was analysed in a variable life-adjusted display curve. The patient population operated after the implementation of the checklist was compared with a recent historical population before its implementation. RESULTS: From January 2013 through April 2016, 4817 cardiac surgical procedures were performed in our institution. Before May 2015, 3210 procedures were performed (Group 1), complicated by 112 re-exploration for bleeding (3.5%). The 'reoperation for bleeding checklist' was implemented on 1 May 2015. After this date, the number of re-explorations for bleeding decreased to 29 (1.8%) of the 1607 cardiac surgical procedures (Group 2) (P < 0.05). CONCLUSIONS: An intraoperative checklist is feasible to implement, low cost, quick and simple to measure with a significant reduction in the incidence of re-exploration for bleeding. This report shows an example of the positive effects of transparency in publishing outcomes' data in cardiac surgery.

Use of Postoperative Peak Arterial Lactate Level to Predict Outcome After Cardiac Surgery.

OBJECTIVES: In the present study, the authors investigated the predictive value of postoperative peak arterial lactate levels for early and late mortality after cardiac surgery. DESIGN: Retrospective analysis of prospectively collected data. SETTING: Single-center study in an academic hospital. PARTICIPANTS: Adult patients who underwent cardiac surgery between 2004 and 2014 (n = 16,376). INTERVENTIONS: Different cardiac surgical procedures. MEASUREMENTS AND RESULTS: Patients were classified according to the peak arterial lactate level (PALL) within 3 days postoperatively. Logistic regression analysis and Cox regression analysis were performed to identify postoperative peak arterial lactate level as a predictor for early and late mortality respectively. In 8460 patients (51.7%), lactate was not measured postoperatively because these patients were managed according to the fast-track protocol. These patients constituted group 1 in our population but were excluded from the regression analysis. The remaining patients (n = 7,916; 48.3%) were divided according to the postoperative peak arterial lactate level (PALL): PALL<5 mmol/L (group 2), PALL 5 to 10 mmol/L (group 3), and PALL of>10 mmol/L (group 4). Early mortality was 3.7%, 20.4%, and 62.9% in groups 2, 3, and 4 respectively (p<0.0001). This mortality rate was significantly higher than that of group 1 (1.6%); p<0.0001. Multivariate regression analyses revealed postoperative peak arterial lactate as a significant predictor of 30-day mortality (odds ratio = 1.44 [1.39-1.48], p<0.001) as well as for late mortality (hazard ratio = 1.05 [1.01-1.10], p<0.025). CONCLUSIONS: Postoperative peak arterial lactate level in patients undergoing cardiac surgery is an independent predictor for both early and late mortality.

Mid-term haemodynamic and clinical results after aortic valve replacement using the Freedom Solo stentless bioprosthesis versus the Carpentier Edwards Perimount stented bioprosthesis.

OBJECTIVES: The aim of this study was to investigate the mid-term haemodynamic and clinical results after aortic valve replacement (AVR) using the Sorin Freedom Solo (SFS) stentless bioprosthesis, compared with the standard Carpentier Edwards Perimount (CEP) stented bioprosthesis. METHODS: In this retrospective cohort study of prospectively collected data, 116 patients were included in the SFS group (53 males; median age 74 years, range 56-85 years), and 122 patients in the CEP group (85 males; median age 73 years, range 43-88 years) between July 2007 and January 2013. Echocardiography was performed at 6 weeks after surgery in our centre, and the most recent echocardiography (in our centre or in referring cardiology departments) was requested. Between September 2013 and April 2014, all patients were called by the same researcher to gain clinical follow-up data. RESULTS: Mid-term mortality was 16.4% in the SFS group (19 patients) and 21.3% in the CEP group (26 patients); (P = 0.3). The mean transvalvular gradient was 7.4 ± 3.1 mmHg in the SFS group, and 11.6 ± 3.2 mmHg in the CEP group at 6 weeks postoperatively (P < 0.001). When stratified by labelled valve size, mean gradients were significantly lower in the SFS group for every size (P ≤ 0.03). After 3.3 ± 1.4 years of follow-up, the mean gradient was still significantly lower in the SFS group than that in the CEP group (P < 0.001). Clinical follow-up showed relatively low complication rates. CONCLUSION: These data suggest that the Sorin Freedom Solo stentless bioprosthesis is as safe as the Carpentier Edwards bioprosthesis, and provides better short- and mid-term haemodynamic performance than the Carpentier Edwards bioprosthesis.

Long-term follow-up of 82 patients after surgical excision of atrial myxomas.

OBJECTIVES: Literature reporting on large patient groups with the long-term follow-up is limited due to the low incidence of myxomas. This single-centre, retrospective study reports on the long-term follow-up (e.g. complications, recurrence and survival) of a substantial patient group operated for cardiac myxomas. METHODS: Patients were retrospectively selected from a prospectively obtained database comprising patients who had undergone cardiac surgery in the Catharina Hospital from 1990 onwards. Baseline characteristics and perioperative data were obtained from the database. In case of insufficient information, medical reports were analysed. The echocardiogram and clinical follow-up data were collected at outpatient clinics. RESULTS: Eighty-two patients were included, of which 48 were females with a mean age of 61.3 years (±13.8). The main presenting symptom was dyspnoea (29.3%), followed by chest pain (24.4%), palpitations (19.5%) and embolism (15.9%). Atrial fibrillation was the most frequent complication; directly postoperative (22%) and at the long-term follow-up (26.3%). The follow-up was completed in 95.1%, with a mean echocardiographic follow-up time of 72 months and with a longest follow-up of almost 23 years. There were no myxoma recurrences. Thirteen patients (16.5%) deceased during the follow-up, with a mean time of 9 years after surgery. CONCLUSIONS: Myxomas carry the risk of severe complications. Surgical excision is the only option of treatment and gives excellent early and long-term results. Recurrence rates are low in case of non-hereditary myxomas, even in case of irradical excision. The echocardiographic follow-up therefore could be called into question.

Conventional Aortic Valve Replacement after Displacement of a Percutaneously Implanted Aortic Prosthesis: Case Report.

A case is described of aortic stenosis that was initially treated with transcatheter aortic valve implantation (TAVI) due to a high-risk profile. Following dysfunction of the TAVI prosthesis, conventional aortic valve replacement (AVR) was successfully performed; the subsequent postoperative course was uneventful. In conclusion, the target population for TAVI must be more accurately specified, with further research helping to define whether AVR or TAVI is the best treatment option for 'intermediate-risk' patients.