Optimal Timing of Coronary Artery Bypass Grafting in Haemodynamically Stable Patients after Myocardial Infarction.

During the acute phase of myocardial infarction, the culprit artery must be revascularized quickly with angioplasty. Surgery then completes the procedure in a second stage. If emergency surgery is performed, the resulting death rate is high; 15-20% of patients are operated on within the first 48 h after the myocardial infarction. The timing of surgical revascularization and the patient's preoperative state influence the mortality rate. We aimed to evaluate the impact of surgery delay on morbimortality. Between 2007 and 2017, a retrospective monocentric study was conducted including 477 haemodynamically stable patients after myocardial infarction who underwent an urgent coronary bypass. Three groups were described, depending on the timing of the surgery: during the first 4 days (Group 1, n = 111, 23%), 5 to 10 days (Group 2, n = 242, 51%) and after 11 days (Group 3, n = 124, 26%). The overall thirty-day mortality was 7.1% (n = 34). The death rate was significantly higher in Group 1 (n = 16; 14% vs. n = 10; 4.0% vs. n = 8; 6%, p < 0.01). The mortality risk factors identified were age (OR: 1.08; CI 95%: 1.04-1.12; p < 0.001), peripheral arteriopathy (OR: 3.31; CI 95%: 1.16-9.43; p = 0.024), preoperative renal failure (OR: 6.39; CI 95%: 2.49-15.6; p < 0.001) and preoperative ischemic recurrence (OR: 3.47; CI 95%: 1.59-7.48; p < 0.01). Ninety-two patients presented with preoperative ischemic recurrence (19%), with no difference between the groups. The optimal timing for the surgical revascularization of MI seems to be after Day 4 in stable patients. However, timing is not the only factor influencing the death rate: the patient's health condition and disease severity must be considered in the individual management strategy.

Corrigendum: Robotic Cardiac Surgery in Europe: Status 2020.

[This corrects the article DOI: 10.3389/fcvm.2021.827515.].

Robotic Cardiac Surgery in Europe: Status 2020.

BACKGROUND: European surgeons were the first worldwide to use robotic techniques in cardiac surgery and major steps in procedure development were taken in Europe. After a hype in the early 2000s case numbers decreased but due to technological improvements renewed interest can be noted. We assessed the current activities and outcomes in robotically assisted cardiac surgery on the European continent. METHODS: Data were collected in an international anonymized registry of 26 European centers with a robotic cardiac surgery program. RESULTS: During a 4-year period (2016-2019), 2,563 procedures were carried out [30.0% female, 58.5 (15.4) years old, EuroSCORE II 1.56 (1.74)], including robotically assisted coronary bypass grafting (n = 1266, 49.4%), robotic mitral or tricuspid valve surgery (n = 945, 36.9%), isolated atrial septal defect closure (n = 225, 8.8%), left atrial myxoma resection (n = 54, 2.1%), and other procedures (n = 73, 2.8%). The number of procedures doubled during the study period (from n = 435 in 2016 to n = 923 in 2019). The mean cardiopulmonary bypass time in pump assisted cases was 148.6 (63.5) min and the myocardial ischemic time was 88.7 (46.1) min. Conversion to larger thoracic incisions was required in 56 cases (2.2%). Perioperative rates of revision for bleeding, stroke, and mortality were 56 (2.2%), 6 (0.2 %), and 27 (1.1%), respectively. Median postoperative hospital length of stay was 6.6 (6.6) days. CONCLUSION: Robotic cardiac surgery case numbers in Europe are growing fast, including a large spectrum of procedures. Conversion rates are low and clinical outcomes are favorable, indicating safe conduct of these high-tech minimally invasive procedures.

Aortic root remodeling with external annuloplasty for acute type A aortic dissection: Midterm results.

BACKGROUND: To evaluate the role of aortic root remodeling with external aortic annuloplasty (ARREAA) in acute type A aortic dissection (AAAD). METHODS: From May 2011 to May 2020, 59 patients out of 240 with AAAD underwent ARREAA. Data were retrospectively collected and analyzed. RESULTS: The mean age was 61.4 ± 8.6 years and 43 patients were males (73%). Hemiarch and total arch replacement were performed in 37 (62.7%) and 14 (23.7%) patients. An aortic valvuloplasty was performed in seven patients (11.8%). Five patients (8.5%) required coronary artery bypass graft. Re-exploration for bleeding was required in six patients (10.1%). The 30-day mortality rate was 18.6%. Preoperative hemodynamic instability (odds ratio [OR] = 8.57, 95% confidence interval [CI] = 1.57-46.71; p = 0.013), consciousness disorder (OR = 19.18, 95% CI = 3.02-121.72]; p = 0.002) or myocardial ischemia (OR = 6.28, 95% CI = 1.27-31.10; p = 0.013) were significantly associated with postoperative mortality. No patient was reoperated for aortic valve during the postoperative period. One patient suffered a stroke postoperatively with partial recovery. Kidney failure requiring temporary dialysis occurred in 12 patients (20.3%). At discharge, a transthoracic echocardiogram showed moderate aortic regurgitation (AR; grade 2) in two patients. During follow-up (mean = 58.4 ± 32.4 months), three patients died. The rate of mortality was 6.2%. Actuarial survival at 5 years was 76.3%. No patient required reoperation on the proximal aorta or aortic valve. At 4 years, freedom from any aortic valve or root reintervention and AR > 2 were both 100%. CONCLUSION: In a center with expertise in valve-sparing procedures, ARREAA is a reasonable option in the surgical management of AAAD in selected patients. This technique stabilizes the aortic annulus and preserves root anatomy for durable outcomes.

Concomitant Cardiac Surgery and Radiofrequency Ablation of Atrial Fibrillation: A Retrospective Single Center Study.

OBJECTIVES: Concomitant cardiac surgery and radiofrequency atrial fibrillation (AF) ablation is an established procedure recommended in guidelines. However, the results have not been as good as expected. The authors therefore searched for predictive factors of success of the ablation procedure. DESIGN: The authors carried out a retrospective cohort study. SETTING: All the included patients had cardiac surgery in the Dijon University Hospital. PARTICIPANTS: One hundred sixty-three patients with AF underwent a concomitant radiofrequency ablation between January 2009 and December 2016. INTERVENTIONS: A radiofrequency device was used to isolate the pulmonary veins creating a "Box lesion." MEASUREMENTS AND MAIN RESULTS: The primary endpoint of the study was freedom from AF at 12 months with follow-up assessed by an electrocardiogram or a 24-hour recording electrocardiogram Holter. The patient's mean age was 71 ± 9 years with a sex ratio of 1.4. Sixty-six percent of patients had paroxysmal AF and 34% nonparoxysmal AF, which includes persistent and long-standing persistent AF. Sixty-one percent of patients had an AF history for more than 1 year. The mean left atrial diameter was 47 ± 10 mm. No major ablation complications related to the procedure occurred. Overall freedom from AF rate after 1-year follow-up was 60% (n = 98). Six patients (4%) received an additional catheter-based ablation, and 10 patients (6%) had an electrical cardioversion during the follow-up period. The authors identified preoperative paroxysmal AF (odds ratio [OR] 2.54 [1.27-5.14] p = 0.008) and recent history of AF, less than 1 year, (OR 1.99 [1-4.06] p = 0.05) as statistically significant predictors for sinus rhythm maintenance at the 12-month follow-up. At the 12-month follow-up, 64% of patients who had concomitant epicardial treatment were in sinus rhythm and 57% of patients were in sinus rhythm after endocardial treatment. There were no significant differences in rhythm outcome between epicardial and endocardial radiofrequency approach, or between surgical procedures (mitral valve replacement versus coronary artery bypass grafting). The authors could not identify in a univariate analysis a significant left atrium size cutoff upon which ablation was less likely to be successful at 12 months follow-up. CONCLUSIONS: Concomitant cardiac surgery and radiofrequency AF ablation provided freedom from AF for 60% of patients after 1-year follow-up. The authors have shown that paroxysmal AF and recent AF are predictive factors of success. Nevertheless, thorough postoperative care is necessary to improve long-term results, including the use of additional catheter ablation or cardioversion.

Comparison of automated fastener device Cor-Knot versus manually-tied knot in minimally-invasive isolated aortic valve replacement surgery.

BACKGROUND: The aim of our prospective study was to evaluate the efficacy and the safety of the Cor-Knot device in isolated aortic valve replacement by right anterior minithoracotomy. METHODS: A single-center, prospective study was conducted between September 2009 and June 2018. Four hundred and forty patients were operated on for aortic valve replacement by right anterior minithoracotomy. Of these patients, 221 underwent isolated AVR surgery with stented prosthesis. Sutures were secured using the Cor-Knot titanium fastener in 63 patients (28.5%) and knots were hand-tied in 158 (71.5%). Statistical analyses were done using a propensity score with 1:1 matching for the automatically tied (AT) and manually tied (MT) patients. RESULTS: The aortic cross-clamping and cardiopulmonary bypass times were significantly decreased in the AT group (74±13.8 minutes vs. 90.4±23.7 minutes, P<0.0001, and 100.8±20.6 minutes vs. 117.6±33.1 minutes, P<0.0001), compared with the MT group. Clinical outcomes were similar in the two groups, whether in the analysis of non-matched or matched groups. There was no difference in 30 day-mortality (1.2% vs. 0%, P=0.37), and the stroke and transient ischemic attack rates were comparable (2.5% vs. 1.6%; P=0.67). There was no significant increase in pacemaker implantation in the AT group (1.3% vs. 0%, P=0.36), and the rate of aortic regurgitation ≥ 2 was lower (3.9% vs. 0%; P=0.11) but not statistically significant. CONCLUSIONS: The automated Cor-Knot fastener is an easy-to-use, time-saving device which does not increase perioperative morbidity and mortality in patients undergoing aortic valve replacement by right anterior minithoracotomy.

Serratus anterior plane block for minimal invasive heart surgery.

BACKGROUND: Minimal invasive heart surgery (MIHS) presents several benefits, but provides intense and prolonged post-operative pain. Our objective was to compare efficacy of serratus anterior plane block (SAPB) with continuous wound infiltration (CWI) for management of post-operative pain following MIHS. METHODS: It's retrospective, monocentric study between November 2016 to April 2017. The study was performed at the University hospital of Dijon, Burgundy, France. All patients scheduled for MIHS was included. Data was collected retrospectively. During this period, 20 patients had SAPB and 26 had CWI. SAPB was performed before extubation with a single injection of 0.5 mg/kg of ropivacaïne (5 mg/ml). In the CWI group, catheter was inserted in the subcutaneous space by the surgeon at the end of the procedure. A 10 ml bolus of ropivacaïne (7.5 mg/mL) was followed by a continuous infusion (2 mg/ml) between 7 and 12 ml/h for 48 h. Morphine consumption and visual analog score (VAS) were recorded for 48 h. Length of stay in intensive care unit and hospital was also collected. RESULTS: Morphine consumption and VAS score were significantly lower in SAPB group (p < 0.01). Length of stay in intensive care and hospital was significantly was decreased in SAPB group. CONCLUSION: SAPB appears effective in reducing postoperative MIHS pain.

Technical points for aortic valve replacement through right anterior minithoracotomy.

After 8 years of practice and over 400 operated patients, we present a technique of minimally invasive aortic valve replacement that can be used by all surgeons on many patients. The access to the aorta is via the 2nd or 3rd right anterior intercostal space. Cardiopulmonary bypass is provided using the femoral artery and vein. The aorta is clamped directly. One shot of Custodiol (EUSA Pharma, Limonest, France) is the most commonly used cardioplegia. Aortic valve replacement is performed in the regular way. To reduce the aortic cross-clamping time, sutureless or rapid-deployment valves, as well as the Cor-Knot (LSI Solutions, Inc., Victor, NY, USA) automatic knotting system, are excellent options. Right anterior minithoracotomy for aortic valve replacement is safe and reproducible.

Comparable Outcome of Out-of-Hospital Cardiac Arrest and In-Hospital Cardiac Arrest Treated With Extracorporeal Life Support.

Extracorporeal life support (ECLS) has shown benefits in the management of refractory in-hospital cardiac arrest (IHCA) by improving survival. Nonetheless, the results concerning out-of-hospital refractory cardiac arrests (OHCA) remain uncertain. The aim of our investigation was to compare survival between the two groups. We realized a single-center retrospective, observational study of all patients who presented IHCA or OHCA treated with ECLS between 2011 and 2015. Multivariate analysis was realized to determine independent factors associated with mortality. Over the 4-year period, 65 patients were included, 43 in the IHCA group (66.2%), and 22 (33.8%) in the OHCA group. The duration of low flow was significantly longer in the OHCA group (60 vs. 90 min, P = 0.004). Survival to discharge from the hospital was identical in the two groups (27% in the OHCA group vs. 23% in the IHCA group, P = 0.77). All surviving patients in the OHCA group had a cerebral performance categories score of 1-2. In multivariate analysis, we found that the initial lactate level and baseline blood creatinine were independently associated with mortality. We found comparable survival and neurological score in patients who presented IHCA and OHCA treated with ECLS. We believe that appropriate selection of patients and optimization of organ perfusion during resuscitation can lead to good results in patients with OHCA treated with ECLS.

Aortic root remodeling and external aortic annuloplasty to treat sinus of Valsalva aneurysm in a patient with complete situs inversus.

BACKGROUND: Sinus of Valsalva aneurysm is an uncommon anomaly of the aorta. It occurs most frequently in the right sinus of Valsalva. Complications depend on its size and location. Situs inversus totalis is a rare condition wherein organs are reversed from their normal positions (mirror image). CASE PRESENTATION: We report the case of a 69-year-old man who presented situs inversus totalis known since his childhood and a sinus of Valsalva aneurysm in the right coronary sinus discovered by echocardiography following a history of infection. This was confirmed by CT-scan and MRI. Valve sparing surgery was performed using the remodeling technique associated with external aortic annuloplasty CONCLUSIONS: The remodeling technique with exteranl aortic annuloplasty is usual technique to treat SVA.

Incidence and Predictors of New-Onset Silent Atrial Fibrillation after Coronary Artery Bypass Graft Surgery.

AIMS: We investigated the incidence, risk factors, and prognostic impact of silent atrial fibrillation (AF) after coronary artery bypass graft (CABG) surgery. METHODS: This observational study prospectively included 100 patients referred for CABG surgery. Holter ECG monitoring was used to record every arrhythmic event for 7 days. AF was defined as at least one episode >30 s. Episodes recorded on Holter ECG monitoring but not clinically identified were classified as silent AF. RESULTS: Among 34 patients who developed new-onset AF, 13 had silent AF. Compared with patients with maintained sinus rhythm (SR), silent AF patients had a significantly higher logistic EuroSCORE (2.9 (1.5-5.2) versus 2.3 (1.4-3.7), p = 0.017) and were more likely to have previous sleep apnea (31% versus 8%, p = 0.016) and left atrial diameter >45 mm (36% versus 5%, p = 0.002). At one-year follow-up, 30% of silent AF patients had developed symptomatic AF versus 7% in the SR group (p = 0.03) and 11% in the clinical AF group (p = 0.21). CONCLUSION: After CABG surgery, silent AF is common and may be associated with a higher incidence of recurrences at one-year follow-up than clinical AF. Improved screening for silent AF may help to reduce thromboembolic events in this high-risk population.

Pre-operative growth differentiation factor 15 as a novel biomarker of acute kidney injury after cardiac bypass surgery.

BACKGROUND: Pre-operative GDF-15 plasma levels significantly improve the prognostic value of the EuroSCORE for mortality after cardiac surgery. However, despite the strong correlation between GDF-15 and renal function, no data are available regarding the potential interest of pre-operative GDF-15 levels to improve the prediction of acute kidney injury (AKI) after cardiac artery bypass graft (CABG) surgery. METHODS: All patients operated on by 2 surgeons for CABG surgery at our university hospital from September 2011 to March 2013 were screened for participation in this prospective, observational study. EXCLUSION CRITERIA: age <18years or >80years, previous atrial fibrillation/flutter, previous severe renal failure, previous cardiac surgery, emergency surgery. AKI was defined according to KDIGO criteria. GDF-15 levels in plasma were measured before induction and 12h after surgery. RESULTS: 134 patients were included in this study. 42 (31%) developed post-operative AKI. AKI patients had a significantly higher pre-operative log-GDF-15 level (OR=3.64; 95% CI=1.41-9.40, p=0.008), a lower pre-operative eGFR (OR=0.98; 95% CI=0.96-0.99; p=0.026), and most often underwent on-pump surgery (OR=2.60; 95% CI=1.14-5.96, p=0.024). On ROC curves, GDF-15 before induction was found to be the best pre-operative biomarker to predict AKI (AUC=0.83; CI=0.75-0.89), compared with eGFR (AUC=0.67; 95% CI=0.59-0.75), p=0.003 and NT-proBNP (AUC=0.62; CI=0.51-0.72), p<0.001. Pre-operative GDF-15 was also significantly better than the EuroSCORE in predicting AKI (AUC 0.62, 95% CI=0.54-0.70), p<0.001. CONCLUSIONS: Pre-operative GDF-15 plasma levels are associated with post-operative AKI in CABG patients. If confirmed in larger cohorts, pre-operative GDF-15 may be of value to improve pre-operative risk stratification among candidates for surgery.

Low Circulating Levels of Growth Differentiation Factor-15 Before Coronary Artery Bypass Surgery May Predict Postoperative Atrial Fibrillation.

OBJECTIVES: To assess the role of growth differentiation factor-15 (GDF-15) as a potential new predictor of postoperative atrial fibrillation (POAF) after off-pump (OFP) and on-pump (ONP) coronary artery bypass graft (CABG) surgery. DESIGN: Prospective, single-center, observational study. SETTING: University teaching hospital. PARTICIPANTS: The first 50 patients planned for OFP surgery and the first 50 patients planned for ONP surgery among patients referred for CABG with the following exclusion criteria: age<18 or>80 years, previous atrial fibrillation/flutter, previous treatment with amiodarone, previous cardiac surgery, and emergency surgery. INTERVENTIONS: Included patients were equipped with long-duration (7 days) Holter-ECG monitoring. MEASUREMENTS AND MAIN RESULTS: POAF was defined as an AF episode lasting>30 seconds. All patients underwent preoperative echocardiography to assess left ventricular ejection fraction and left atrial diameter. GDF-15 levels were assessed after induction of anesthesia and 12 hours after arrival at the intensive care unit. Among the 100 patients, 34 (34%) developed POAF. In Cox multivariate regression analysis, the EuroSCORE, left atrial diameter>45 mm, and low GDF-15 levels at induction were associated independently with the onset of POAF. In contrast, preoperative NT-proBNP levels did not predict POAF. The use of ONP surgery was not associated with a higher incidence of POAF, even though baseline and follow-up characteristics in ONP and OFP patients were identical. CONCLUSIONS: In patients with no history of AF, a low plasma level of GDF-15 before CABG surgery was a strong independent predictor of POAF. Moreover, preoperative plasma GDF-15 levels added an incremental predictive value to classic risk factors of POAF.