Partial versus Complete Sternotomy for Aortic Valve Replacement-Multicenter Study.

BACKGROUND: The benefits of minimally invasive techniques in cardiac surgery remain poorly defined. We evaluated the short- and mid-term outcomes after surgical aortic valve replacement through partial upper versus complete median sternotomy (MS) in a large, German multicenter cohort. METHODS: A total of 2,929 patients underwent isolated surgical aortic valve replacement via partial upper sternotomy (PUS, n = 1,764) or MS (n = 1,165) at nine participating heart centers between 2016 and 2020. After propensity-score matching, 1,990 patients were eligible for analysis. The primary end point was major adverse cardiac and cerebrovascular events (MACCE), a composite of death, myocardial infarction, and stroke at 30 days and in follow-up, up to 5 years. Secondary end points were acute kidney injury, length of hospital stay, transfusions, deep sternal wound infection, Dressler's syndrome, rehospitalization, and conversion to sternotomy. RESULTS: Unadjusted MACCE rates were significantly lower in the PUS group both at 30 days (p = 0.02) and in 5-year follow-up (p = 0.01). However, after propensity-score matching, differences between the groups were no more statistically significant: MACCE rates were 3.9% (PUS) versus 5.4% (MS, p = 0.14) at 30 days, and 9.9 versus 11.3% in 5-year follow-up (p = 0.36). In the minimally invasive group, length of intensive care unit (ICU) stay was shorter (p = 0.03), Dressler's syndrome occurred less frequently (p = 0.006), and the rate of rehospitalization was reduced significantly (p < 0.001). There were 3.8% conversions to full sternotomy. CONCLUSION: In a large, German multicenter cohort, MACCE rates were comparable in surgical aortic valve replacement through partial upper and complete sternotomies. Shorter ICU stay and lower rates of Dressler's syndrome and rehospitalization were in favor of the partial sternotomy group.

A retrospective comparative study of minimally invasive extracorporeal circulation versus conventional extracorporeal circulation in emergency coronary artery bypass surgery patients: a single surgeon analysis.

OBJECTIVES: At the moment, the main application of minimally invasive extracorporeal circulation (MiECC) is reserved for elective cardiac operations such as coronary artery bypass grafting (CABG) and/or aortic valve replacement. The purpose of this study was to compare the outcome of emergency CABG operations using either MiECC or conventional extracorporeal circulation (CECC) in patients requiring emergency CABG with regard to the perioperative course and the occurrence of major adverse cardiac and cerebral events (MACCE). METHODS: We analysed the emergency CABG operations performed by a single surgeon, between January 2007 and July 2013, in order to exclude the differences in surgical technique. During this period, 187 emergency CABG patients (113 MiECC vs 74 CECC) were investigated retrospectively with respect to the following parameters: in-hospital mortality, MACCE, postoperative hospital stay and perioperative transfusion rate. RESULTS: The mean logistic European System for Cardiac Operative Risk Evaluation was higher in the CECC group (MiECC 12.1 ± 16 vs CECC 15.0 ± 20.8, P = 0.15) and the number of bypass grafts per patient was similar in both groups (MiECC 2.94 vs CECC 2.93). There was no significant difference in the postoperative hospital stay or in major postoperative complications. The in-hospital mortality was higher in the CECC group 6.8% versus MiECC 4.4% (P = 0.48). The perioperative transfusion rate was lower with MiECC compared with CECC (MiECC 2.6 ± 3.2 vs CECC 3.8 ± 4.2, P = 0.025 units of blood per patient). CONCLUSIONS: In our opinion, the use of MiECC in urgent CABG procedures is safe, feasible and shows no disadvantages compared with the use of CECC. Emergency operations using the MiECC system showed a significantly lower blood transfusion rate and better results concerning the unadjusted in-hospital mortality.

Evaluation of hemodynamic and regional tissue perfusion effects of minimized extracorporeal circulation (MECC).

Minimized extracorporeal circulation (MECC, Maquet, Cardiopulmonary AG, Hirrlingen, Germany) is an established procedure to perform coronary revascularization. Studies showed positive effects of MECC compared to conventional cardiopulmonary bypass (CCPB) procedures in terms of transfusion requirements, less inflammation reactions, and neurological impairments. Recent retrospective studies showed higher mean arterial pressure (MAP) and a lower frequency of vasoactive drug use. We addressed this issue in this study. The hypothesis was to find a higher MAP during coronary bypass grafting surgery in patients treated with MECC systems. We performed a prospective, controlled, randomized trial with 40 patients either assigned to MECC (n = 18) or CCPB (n = 22) undergoing coronary bypass grafting. Primary endpoints were the perioperative course of mean arterial pressure, and the consumption of norepinephrine. Secondary endpoints were the regional cerebral and renal oxygen saturation (rSO2) as an indicator of area perfusion and the course of hematocrit. Clinical and demographic characteristics did not significantly differ between both groups. Thirty-day mortality was 0%. At four of five time points during extracorporeal circulation (ECC) MAP values were significantly higher in the MECC group compared to CCPB patients (after starting the ECC 60 +/- 11 mmHg vs. 49 +/- 10 mmHg, p = .002). MECC patients received significantly less norepinephrine (MECC 22.5 +/- 35 microg vs. CCPB 60.5 +/- 75 microg, p = .045). The rSO2 measured at right and left forehead and the renal area was similar for both groups during ECC and significantly higher at CCPB group 1 and 4 hours after termination of CPB. Minimized extracorporeal circulation provides a higher mean arterial pressure during ECC and we found a lower consumption of vasoactive drugs in the MECC group. There was a decrease in regional tissue saturation at 1 and 4 hours post bypass in the MECC group possibly due to increased systemic inflammation and extravascular fluid shift in the CCPB group.

Minimal extracorporeal circulation and off-pump compared to conventional cardiopulmonary bypass in coronary surgery.

OBJECTIVES: Although minimal extracorporeal circulation (MECC) and off-pump surgery are equal or better alternatives to conventional cardiopulmonary bypass (CCPB) regarding perioperative morbidity, use of blood and blood products and completeness of revascularization, CCPB is still being used in the majority of coronary artery bypass grafting (CABG) operations. METHODS AND RESULTS: We investigated 1472 CABG operations in our center. A total of 1143 CABG operations were performed using CCPB, 220 using MECC and 109 were performed as off-pump coronary artery bypass (OPCAB). All patients were recorded prospectively. Perioperative follow-up was focused on the occurrence of arrhythmia, neurocognitive disorders and the need of blood and blood products. Operative mortality rates were comparable in all three groups. The mean number of distal anastomoses was 3.2+/-0.6 in the MECC group, 3.4+/-0.7 in the CCPB group and 1.9+/-0.8 in the OPCAB group (P=0.01). Arrhythmia occurred in 25% of the MECC group and in 35.6% of the CCPB group (P=0.05). Arrhythmia occurred in 21.7% of the OPCAB group. Seven patients (3%) of the MECC group suffered neurocognitive disorders perioperatively compared to 74 (7%) patients of the CCPB group (P=0.05) and three patients of the OPCAB group (3%). The median number of blood transfusions per patient was 0.8 in the MECC group, 1.8 in the CCPB group and 0.8 in the OPCAB group (P<0.0001). CONCLUSIONS: Perioperative morbidity of MECC and OPCAB is comparable to or even less in comparison to CCPB. MECC allows CABG surgery in cardiac arrest so that completeness of revascularization is being warranted and longer patency rates can be guaranteed. Furthermore, the use of blood and blood products is significantly less in MECC surgery so that MECC should be considered first choice in CABG surgery over CCPB and OPCAB.

Seventeen-year clinical results of 1,037 Mitroflow pericardial heart valve prostheses in the aortic position.

BACKGROUND AND AIM OF THE STUDY: It is generally believed that the pericardial tissue valve is associated with a greater propensity to early structural failure and subsequent valve-related complications. However, a modified valve design during recent years has considerably improved the clinical durability of this bioprosthesis. METHODS: Between April 1986 and December 2003, single Mitroflow pericardial valve prostheses were inserted in the aortic position in 1,037 patients (mean age 72.4 +/- 8.4 years). Coronary artery bypass grafting (CABG) was performed in 373 patients (36%). Preoperative echocardiographic findings of structural valve deterioration (SVD) were confirmed at reoperation. Total follow up was 5,022 patient-years (pt-yr) (mean 4.85 +/- 4.7 years) and was 99.7% complete (three patients lost). RESULTS: Early (30-day) mortality was 2.9% for elective surgery; 434 patients (41.9%) died during the follow up period. Actuarial survival at 17 years was 23.2 +/- 2%. Actuarial freedom from valve-related mortality at 17 years was 92.0 +/- 2.2%, whereas the linearized mortality rate was 0.4%/pt-yr. Linearized valve-related complications occurred at a rate of 3.6%/pt-yr (n = 122). SVD of Mitroflow bioprostheses occurred at a rate of 1.0%/pt-yr, and caused stenosis (36.7%), insufficiency (20.4%) and combined stenosis and insufficiency (42.9%). Actual freedom from SVD at 17 years was 95.3 +/- 0.7% for all patients, 96.2 +/- 0.6% for those aged > 60 years, and 99.0 +/- 0.4% for those aged > 70 years. CONCLUSION: The Mitroflow pericardial bioprosthesis, in the aortic position, provides an excellent clinical performance and a low rate of valve-related morbidity, mortality and reoperation for up to 17 years. The prosthesis also demonstrates satisfactory hemodynamic performance, and is therefore recommended for patients aged > or = 70 years and for those aged 60-69 years with comorbidities.

Cannulation of the right axillary artery for surgery of acute type A aortic dissection.

OBJECTIVE: The optimal choice of the arterial inflow site during operations for type A aortic dissection is not clearly defined. The aim of the prospective study was to identify whether cannulation of the right axillary artery instead of the femoral artery may improve the results of surgery for acute type A aortic dissection. METHODS: Seventy consecutive patients were operated on because of acute type A aortic dissection from January 2000 to February 2002. The only difference in surgical strategy was the site of arterial cannulation: the right axillary artery was used in 20 patients [axillary group] and the left femoral artery in 50 patients [femoral group]. All patients had aortic surgery with open distal anastomosis during deep hypothermic arrest and retrograde cerebral perfusion. The mean age was 58.7 +/- 12 years with a range from 28 to 88 years (axillary group, 56.6 +/- 13 years; femoral group, 59.4 +/- 12 years; P = 0.435). Preoperatively evident organ malperfusion was identified in five (25%) patients of the axillary group and in seven (14%) of the femoral group. RESULTS: There was no perioperative death. The hospital mortality rate was 5.0% for the axillary group and 22% for the femoral group (all patients, 17%). Major neurological complications occurred postoperatively in 5% of patients from the axillary group (one out of 20 patients) and in 8% of patients from the femoral group (four out of 50 patients) (all patients, 7%). CONCLUSION: Cannulation of the right axillary artery improved the outcome of surgery for acute type A aortic dissection. However, postoperative complications occurred after both axillary and femoral artery cannulation.