Search

Background:  The long-term outcomes of combined rapid-deployment aortic valve replacement (RDAVR) with coronary artery bypass graft surgery (CABG) are not well explored. We report 3-year results from the INCA registry on combined RDAVR with CABG., Methods:  INCA is a prospective, multicenter registry that enrolled 224 patients undergoing RDAVR with CABG at 10 cardiac institutions in Germany. Prosthetic valve hemodynamics, clinical outcomes, and quality of life (QoL) up to 3 years were assessed., Results:  The mean age of patients was 73.6 ± 6.1 years, and the mean logistic EuroSCORE was 7.8 ± 6.0%. The mean number of distal arterial and venous anastomoses was 3.13 ± 1.56, aortic cross-clamp time was 79.4 ± 24.1 minutes, cardiopulmonary bypass time was 109.6 ± 34.5 minutes, and operation time was 224.2 ± 62.7 minutes. The majority of implanted valve size was 25 mm. At baseline, 11 patients (4.9.%) had a permanent pacemaker. Postoperatively, 17 patients (7.6%) required a new pacemaker implantation (5.4% valve-related). All-cause mortality at 30 days was 2.2%, and 11.2% at 3 years. Patient QoL (SF-12v2) was significantly restored and maintained for up to 3 years ( p  < 0.001). Five patients (0.9%) underwent reoperation related to endocarditis. The postimplant mean gradient was 9.2 ± 3.7 at discharge and 8.9 ± 4.6 mm Hg at 3 years., Conclusion:  Combined RDAVR with CABG procedure is safe and effective over time. It offers stable and low transvalvular gradients with satisfactory clinical outcomes at 3 years. The pacemaker rate appears to be slightly increased, with no significant clinical effect at 3 years., Competing Interests: None declared., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Background:  To minimize the surgical damage, minimally invasive mitral valve surgery (MIMVS) has become the therapy of choice. However, this approach is technically more challenging, especially in endocarditis. The data on MIMVS in endocarditis are scarce, we therefore retrospectively analyzed the result at our institute., Methods:  From January 2011 and July 2017, 420 MIMVS were performed, out of which 44 (10%) were for endocarditis. Mean age was 55 ± 17 years and 41% ( n  = 18) were male., Results:  Euroscore II was 7.3 (range: 2-38). Operation times, cardiopulmonary bypass times, and clamp times were 230 (±77), 158 (±56), and 84 (±39) minutes, respectively. Seven cases (16%) were cardiac redo operations. Mitral valve repair and replacement was performed in 46 ( n  = 20) and 54% ( n  = 24) of patients, respectively. Overall in-hospital mortality, apoplexy, and reoperation rates (all for bleeding) were 7 ( n  = 3), 0 ( n  = 0), and 11% ( n  = 5), respectively. New onset of dialysis was required in three patients (7%). No patient developed superficial wound infection. Overall intensive care unit and hospital stay was 3 (±3) and 24 (±32) days, respectively., Conclusion:  MIMVS can be performed with acceptable outcome and low perioperative morbidity in patients with mitral valve endocarditis. Especially absence of any postoperative wound infections and low rate of endocarditis recurrence; use of MIMVS must be encouraged as an eligible approach in most cases., Competing Interests: None., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: Minimally invasive mitral valve surgery (MIMVS) is superior to "classical" mitral valve surgery via a sternotomy regarding wound healing and postoperative pain. It is however a more challenging procedure. Patients' preference is leading clearly toward minimally invasive approaches, and surgeons are driven by upcoming new technologies in interventional procedures such as the MitraClip. Especially in re-do cases, the access via right mini-thoracotomy, as previously non-operated situs, is a possible advantage over a re-sternotomy. We therefore retrospectively analyzed our result regarding MIMVS in re-do cases at our institute., Methods: From January 2011 and June 2016, 33 operations were MIMVS re-do procedures. Mean age was 60 years (±16 years), and 51% were male., Results: Sixty-one percent were elective cases, 29% were urgent cases, and 9% were emergency operations. Operation times, cardiopulmonary bypass (CPB) times, and clamp times were 235 minutes (±51 min), 149 minutes (±42 min), and 62 minutes (±45min), respectively. Mitral valve repair and replacement was performed in 24% ( n  = 8) and 76% ( n  = 25), respectively. Overall in-hospital mortality, apoplexy, and re-operation rates (all for bleeding) were 0% ( n  = 0), 3% ( n  = 1), and 9% ( n  = 3). New onset of dialysis was required in two (6%) patients. Two (6%) patients developed superficial wound infection. Overall intensive care unit (ICU) and hospital stay was 3 days (±4 days) and 15 days (±7 days), respectively., Conclusion: MIMVS for re-do cases can be performed with minimal mortality and morbidity and therefore represents a safe alternative to conventional mitral valve surgery in cardiac re-do operations. However, postoperative morbidity is highly dependent on preoperative patient status., Competing Interests: None declared., (Georg Thieme Verlag KG Stuttgart · New York.)

Objective: Pleural tubes after coronary artery bypass graft (CABG) surgery usually cause pain resulting interalia in an impact of postoperative breathing. Therefore, the influence of intrapleural lidocaine application through special double-lumen chest tubes with respect to pain relief and lung function was investigated and compared with placebo., Methods: In this study, 40 patients who underwent CABG got intrapleural injection either with 2% lidocaine ( n  = 20) or placebo (0.9% saline solution) ( n  = 20) on the first 2 days after surgery. Pain was measured by pain intensity numeric rating scale (NRS) (0 = no pain; 10 = the most intense pain) and lung function by portable spirometer., Results: On the first postoperative day (POD1), mean pain reduction was NRS 1.9 for the lidocaine group with an improvement of the forced expiratory volume in 1 second (FEV1) of 0.51 L. Similar results were shown on the second postoperative day (POD2) with a decreased pain level of mean NRS 1.65 and an FEV1 improvement of 0.26 L. In comparison, results of the placebo group showed no significant pain reduction, neither on the POD1 (NRS 0.35; p  = 0.429) nor on the POD2 (NRS 0.55; p  = 0.159). Also, there was no significant influence of FEV1 after placebo on the POD1 (FEV1 = 0.048 L; p  = 0.70) or on the POD2 (FEV1 = 0.0135 L; p  = 0.925)., Conclusion: Intrapleural application of lidocaine is a safe and feasible method to reduce drainage-related pain and improving lung function after CABG., Competing Interests: None declared., (Georg Thieme Verlag KG Stuttgart · New York.)

Objectives  Coronary artery bypass grafting (CABG) is the "gold standard" for patients with multiple vessel coronary artery disease (CAD). However, there is no "gold standard" to control bypass patency immediately postoperatively. "Post-completion" control angiogram (CA) is not routinely performed. We retrospectively analyzed the data of all patients undergoing urgent coronary angiogram post-CABG at our center. Methods  Between January 2005 and June 2011, a total of 6,025 patients underwent CABG (isolated or combined) for CAD in our hospital. In patients who underwent urgent postoperative CA, high serum cardiac enzymes (>100 CK-MB), severe new ECG changes, or unexpected low left ventricular function were present. Results  A total of 106 patients (1.8%) underwent post-CABG urgent coronary angiogram. Overall 30-day mortality in this cohort was 8.5%. The average time between the cardiac operation and the coronary angiogram in these patients was 3.41 ± 5.68 days. The rates for an urgent coronary angiogram were 1.3% ( n  = 25), 2% ( n  = 65), and 1.8% ( n  = 16) for total arterial, combined arterial, and venous and solely venous CABG, respectively. Twenty-four percent of patients underwent CABG bypass revision, while 32% of the patients underwent PTCA, stenting, or both. Younger patients, female patients, smaller patients, and patients receiving a combined arterial and venous revascularization were at a higher risk for an unplanned postoperative CA in the multivariate risk analysis. Conclusion  This study shows that the necessity for urgent post-CABG coronary angiogram is low (1.8%). However, more than half of the patients undergoing postoperative coronary angiogram needed reintervention, and, in spite of it, had high mortality. "Completion" control angiogram is not always feasible, patients at higher risk (e.g., female patients) should be identified and post-CABG coronary angiogram performed as soon as possible without undue delay, or a primary hybrid approach with an intraoperative CA should be applied., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Georg Thieme Verlag KG Stuttgart · New York.)

Background:  Total arterial revascularization (TAR) has become a standard procedure for the treatment of coronary multivessel disease, due to the superior long-term patency rates of arterial grafts as compared with saphenous vein graft material. Controversies about the use of TAR in patients with left main coronary artery disease exist. Hence, we ought to determine whether left main coronary artery disease is a risk factor for early postoperative mortality and morbidity after TAR using the in situ left internal thoracic artery (LITA) and radial artery as composite T-graft., Methods:  A total of 904 consecutive patients were included in this retrospective study. They underwent first-time coronary artery bypass grafting surgery in our institution, receiving TAR using the in situ LITA and RA T-graft. Of these patients, 247 (27%) had left main coronary artery disease (Group LMSS) and 657 (73%) had no significant left main coronary artery stenosis (Group nLMSS)., Results:  Results were comparable. Mortality and perioperative myocardial infarction rates were 0.4% LMSS versus 0.3% nLMSS, p = 1, and 2% LMSS versus 2% nLMSS, p = 0.81, respectively. Stroke rate, acute renal failure rate, and reoperation rates were 2% LMSS versus 1% nLMSS, p = 0.36, 7% LMSS versus 8% nLMSS, p = 0.41, and 2% LMSS versus 3% nLMSS, p = 0.5, respectively. Postoperative stay was shorter in the LMSS group (8.1 ± 4.3 days vs. 8.9 ± 6.1 days nLMSS, p = 0.048)., Conclusion:  Our perioperative results indicate that TAR in patients with left main stenosis is safe and feasible. Long-term results will have to be awaited to further evaluate prognostic outcome., (Georg Thieme Verlag KG Stuttgart · New York.)

Introduction: The "ideal" treatment of acute aortic dissection type A (AADA) with dissected and dilated root is controversial. We compared the outcome of classical Bentall procedure (biological and mechanical) with valve-sparing David procedure., Methods: Between January 2002 and July 2011, 119 patients with AADA and aortic root involvement underwent surgery at our center. Thirty-one patients (group 1) received biological conduits, 41 (group 2) received mechanical conduits, and 47 (group 3) underwent David procedures., Results: Cross-clamp, cardiopulmonary bypass, and circulatory arrest times were 151 ± 52, 232 ± 84, and 36 ± 30 minutes (group 1); 148 ± 44, 237 ± 91, and 45 ± 29 minutes (group 2); and 160 ± 46, 231 ± 63, and 35 ± 17 minutes (group 3), respectively. The 30-day mortality rates were 32.3% (group 1), 22% (group 2), and 12.8% (group 3). The 1-year rates for freedom from valve-related reoperation were 100% (group 1), 92.5% (group 2), and 95.2% (group 3) (p = 0.172). The 1-year survival rates were 61% (group 1), 61% (group 2), and 84.1% (group 3) (p = 0.008)., Conclusion: Even in AADA patients with root involvement, David procedure has acceptable results. David procedure (if possible) or a Bio-Bentall (for pathological valves) seems to be the optimal technique., (Georg Thieme Verlag KG Stuttgart · New York.)