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Objective: To determine the effect of inverse methods and timepoints of interictal epileptic discharges (IEDs) used for high-density electric source imaging (hd-ESI) in pharmacoresistant focal epilepsies., Methods: We retrospectively evaluated the hd-ESI and [18F]fluorodeoxyglucose positron emission tomography ( 18 FDG-PET) of 21 operated patients with pharmacoresistant focal epilepsy (Engel I). Volumetric hd-ESI was performed with three different inverse methods such as the inverse solution linearly constrained minimum variance (LCMV, a beamformer method), standardized low resolution electromagnetic tomography (sLORETA) and weighted minimum-norm estimation (wMNE) and at different IED phases. Hd-ESI accuracy was determined by volumetric overlap and distance between hd-ESI source maximum, as well as 18 FDG-PET hypometabolic region relative to the resection zone (RZ)., Results: In our cohort, the shortest distances and greatest volumetric overlaps to the RZ were found in the half-rise and peak-phase for all inverse methods. The distance to the RZ was not different between the centroid of the clinical hypothesis-based cluster and the source maximum in peak-phase. However, the distance of the hypothesis-based cluster was significantly shorter compared to the cluster selected by the smallest p-value., Conclusions: Hd-ESI provides the greatest accuracy in determining the RZ at the IED half-rise and peak-phase for all applied inverse methods, whereby sLORETA and LCMV were equally accurate., Significance: Our results offer guidance in selecting inverse methods and IED phases for hd-ESI, compare the performance of hd-ESI and 18 FDG-PET and encourage future studies in investigating the relationship between interictal ESI and 18 FDG-PET hypometabolism., (Copyright © 2023 International Federation of Clinical Neurophysiology. Published by Elsevier B.V. All rights reserved.)

Introduction: Vitamin K antagonists (VKA) and non-vitamin K oral antagonist anticoagulants (NOAC) are used in the clinic to reduce risk of thrombosis. However, they also exhibit vascular off-target effects. The aim of this study is to compare VKA and NOAC on atherosclerosis progression and calcification in an experimental setup., Material and Methods: Female Apoe -/- mice (age 12 weeks) were fed Western-type diet as control or supplemented with dabigatran etexilate or warfarin for 6 or 18 weeks. Vascular calcification was measured in whole aortic arches using µCT and [ 18 F]-NaF. Atherosclerotic burden was assessed by (immuno)histochemistry. Additionally, in vitro effects of warfarin, thrombin, and dabigatran on primary vascular smooth muscle cells (VSMC) were assessed., Results: Short-term treatment with warfarin promoted formation of atherosclerotic lesions with a pro-inflammatory phenotype, and more rapid plaque progression compared with control and dabigatran. In contrast, dabigatran significantly reduced plaque progression compared with control. Long-term warfarin treatment significantly increased both presence and activity of plaque calcification compared with control and dabigatran. Calcification induced by warfarin treatment was accompanied by increased presence of uncarboxylated matrix Gla protein. In vitro, both warfarin and thrombin significantly increased VSMC oxidative stress and extracellular vesicle release, which was prevented by dabigatran., Conclusion: Warfarin aggravates atherosclerotic disease activity, increasing plaque inflammation, active calcification, and plaque progression. Dabigatran lacks undesired vascular side effects and reveals beneficial effects on atherosclerosis progression and calcification. The choice of anticoagulation impacts atherosclerotic disease by differential off target effect. Future clinical studies should test whether this beneficial effect also applies to patients., (© 2021 The Authors. Journal of Thrombosis and Haemostasis published by Wiley Periodicals LLC on behalf of International Society on Thrombosis and Haemostasis.)

Background: Fat tissue, and particularly visceral fat, is known to play a role in low grade systemic inflammation in COPD, and is likely to contribute to the excess cardiovascular comorbidity in COPD. Therefore, we aimed to study (18)FDG-PET-assessed inflammation of the aorta and the (visceral) fat, and evaluate its interrelations and differences in subjects with and without COPD., Methods: We retrospectively identified 42 patients (71% male, 48% current smokers, mean age 66.6 ± 8.3 years, mean BMI 25.1 ± 4.3 kg/m(2)), who underwent (18)F-FDG-PET/CT for suspected early stage bronchus carcinoma. COPD-diagnosis was based on spirometry and defined as FEV1/FVC < lower limit of normal. Inflammatory status of aortic and fat regions was defined as the average of obtained maximum target-to-background ratios (meanTBRmax). The TBR is the standardized uptake value (SUV) normalized to (18)F-FDG blood pool activity., Results: Compared to controls, patients with COPD (n = 19; 45%) had increased meanTBRmax of both the abdominal aorta (1.31 ± 0.14 vs. 1.49 ± 0.31; p = 0.02) and the abdominal visceral fat (0.28 ± 0.09 vs. 0.38 ± 0.18; p = 0.047), while inflammatory activity of the abdominal subcutaneous fat failed to show statistically significant differences (0.21 ± 0.09 vs. 0.24 ± 0.09; p = 0.345). In all patients, meanTBRmax of abdominal visceral fat was correlated with meanTBRmax of the abdominal aorta, independently of age and BMI (β = 0.590, p = 0.002)., Conclusion: Metabolic activity of the abdominal aorta and visceral fat is increased in COPD patients compared to peers. The degree of visceral fat metabolic activity is associated with aortic inflammation. More prospective research is warranted concerning the role of visceral fat in the development of vascular comorbidity in COPD., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Objectives: The aim of this study was to noninvasively detect the anti-inflammatory properties of the novel liver X receptor agonist R211945., Background: R211945 induces reversal cholesterol transport and modulates inflammation in atherosclerotic plaques. We aimed to characterize with (18)F-fluorodeoxyglucose (FDG)-positron emission tomography (PET)/computed tomography (CT) and dynamic contrast-enhanced cardiac magnetic resonance (DCE-CMR) inflammation and neovascularization, respectively, in atherosclerotic plaques with R211945 treatment compared with atorvastatin treatment and a control., Methods: Twenty-one atherosclerotic New Zealand white rabbits were divided into 3 groups (control, R211945 [3 mg/kg orally], and atorvastatin [3 mg/kg orally] groups). All groups underwent (18)F-FDG-PET/CT and DCE-CMR at baseline and at 1 and 3 months after treatment initiation. Concomitantly, serum metabolic parameters and histology were assessed. For statistical analysis, continuous DCE-CMR and PET/CT outcomes were modeled as linear functions of time by using a linear mixed model, whereas the histological data, animal characteristics data, and nonlinear regression imaging data were analyzed with a 2-tailed Student t test., Results: (18)F-FDG-PET/CT detected a decrease in mean and maximum standard uptake values (SUV) over time in the R211945 group (both p = 0.001), indicating inflammation regression. The atorvastatin group displayed no significant change (p = 0.371 and p = 0.600, respectively), indicating no progression or regression. The control group demonstrated an increase in SUV (p = 0.01 and p = 0.04, respectively), indicating progression. There was a significant interaction between time and group for mean and maximum SUV (p = 0.0003 and p = 0.0016, respectively) . DCE-CMR detected a trend toward difference (p = 0.06) in the area under the curve in the atorvastatin group, suggesting a decrease in neovascularization. There was no significant interaction between time and group (p = 0.6350 and p = 0.8011, respectively). Macrophage and apolipoprotein B immunoreactivity decreased in the R211945 and atorvastatin groups (p < 0.0001 and p = 0.0004, respectively), and R211945 decreased oxidized phospholipid immunoreactivity (p = 0.02)., Conclusions: Noninvasive imaging with (18)F-FDG-PET/CT and DCE-CMR and histological analysis demonstrated significant anti-inflammatory effects of the LXR agonist R211945 compared with atorvastatin. The results suggest a possible role for LXR agonists in the treatment of atherosclerosis., (Copyright © 2012 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: The aim of this feasibility study was to evaluate [(18)F]-2-Fluoro-A85380 for in vivo imaging of arterial nicotinic acetylcholine receptors (nAChRs) in humans. Furthermore, potentially different vascular uptake patterns of this new tracer were evaluated in healthy volunteers and in patients with neurodegenerative disorders., Background: [(18)F]-2-Fluoro-A85380 was developed for in vivo positron emission tomography (PET) imaging of nAChR subunits in the human brain. These nAChRs are also found in arteries and seem to mediate the deleterious effects of nicotine as a part of tobacco smoke in the vasculature. It has been previously shown that uptake patterns of the radiotracer in the brain differs in patients with neurodegenerative disorders compared with healthy controls., Methods: [(18)F]-2-Fluoro-A85380 uptake was quantified in the ascending and descending aorta, the aortic arch, and the carotids in 5 healthy volunteers and in 6 patients with either Parkinson's disease or multiple system atrophy, respectively, as the maximum target-to-background ratio. The maximal standardized uptake value values, the single hottest segment, and the percent active segments of the [(18)F]-2-Fluoro-A85380 uptake in the arteries were also assessed., Results: [(18)F]-2-Fluoro-A85380 uptake was clearly visualized and maximum target-to-background ratio uptake values corrected for the background activity of the tracer showed specific tracer uptake in the arterial walls. Significantly higher uptake values were found in the descending aorta. Comparison between volunteers and patients revealed significant differences, with lower [(18)F]-2-Fluoro-A85380 uptake in the patient group when comparing single arterial territories but not when all arterial territories were pooled together., Conclusions: [(18)F]-2-Fluoro-A85380 can provide specific information on the nAChR distribution in human arteries. Vascular nAChR density seems to be lower in patients with Parkinson's disease or multiple system atrophy. Once confirmed in larger study populations and in the experimental setting, this approach might provide insights into the pathogenic role of nAChRs in the human vasculature., (Copyright © 2012 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: We investigated the prevalence and clinical risk factors of carotid vessel wall inflammation by means of 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) in a population consisting of coronary artery disease (CAD) patients., Background: The atherosclerotic disease process is characterized by infiltration and retention of oxidized lipids in the artery wall, triggering a disproportionate inflammatory response. Efforts have been made to use noninvasive imaging to quantify this inflammatory response in the vessel wall. Recently, carotid FDG-PET has been shown to reflect the metabolic rate of glucose, a process known to be enhanced in inflamed tissue., Methods: Carotid inflammation was quantified in 82 CAD patients (age 62 ± 10 years) as the maximum target-to-background ratio ((wholevessel)TBR(max)). Furthermore, we assessed the maximal standardized uptake value values ((wholevessel)SUV(max)), the single hottest segment (SHS), and the percent active segments (PAS) of the FDG uptake in the artery wall, measured by FDG-PET., Results: Whole-vessel TBR(max) >1.8 was present in 67%, >2.0 in 39%, >2.2 in 23%, and >2.4 in 12% of the population. Multiple linear regression analysis with backward elimination revealed that body mass index (BMI) ≥30 kg/m2 (p < 0.0001), age >65 years (p = 0.01), smoking (p = 0.02), and hypertension (p = 0.01) were associated with (wholevessel)TBR(max). The number of components of the metabolic syndrome was also associated with (wholevessel)TBR(max) (p = 0.02). In similar analyses, (wholevessel)SUV(max) was associated with BMI ≥30 kg/m2 (p < 0.0001), age >65 years (p = 0.004), male gender (p = 0.02), and hypertension (p = 0.04); SHS with BMI ≥30 kg/m2 (p < 0.0001), age >65 years (p = 0.02), smoking (p = 0.04), and hypertension (p = 0.05); PAS with BMI ≥30 kg/m2 (p = 0.001), smoking (p = 0.03), and hypertension (p = 0.01)., Conclusions: Carotid inflammation as revealed by FDG-PET is highly prevalent in the CAD population and is associated with obesity, age over 65 years, history of hypertension, smoking, and male gender. Artery wall FDG uptake increased when components of the metabolic syndrome clustered., (Copyright © 2011 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Malignant fibrous histiocytomas are rare soft-tissue sarcomas of uncertain histogenesis but represent the most common soft-tissue sarcomas in adults. In this report of a 70-year-old male patient suffering from this rare malignant disease, we describe the diagnostic benefits of combined functional and morphological imaging as realized in positron emission tomography and computed tomography, helping to avoid invasive diagnostic methods and, most importantly, harmful and quality-of-life-reducing, oncologically ineffective therapies.

Papillary carcinoma is the most common malignancy of the thyroid gland with initial lymphogenic metastatic spread in many cases. Hematogenous spread may affect the lung, bone and brain. We present a case of hematogenous metastases of papillary thyroid carcinoma both in the choroid and the skin, which are reported in the literature to be rare sites of metastases in primary differentiated thyroid carcinoma. This finding is even more remarkable, as the reported patient presented without any other disseminated hematogenous metastases at the time of diagnosis of both of these metastases. With this background, papillary carcinoma of the thyroid should be considered in the differential diagnosis of choroidal or skin metastasis of unknown origin.

Background: As single-head data acquisition for thallium-201 myocardial SPECT is a frequently used method mainly in the outpatient medical care as well as in smaller hospitals, comparison to dual-head data collection is a still discussed issue mainly with regard to quality control and -assurance., Methods: A total of 1334 patients undergoing thallium-201 myocardial SPECT for diagnosis of myocardial ischemia and/or viability have been retrospectively analyzed. In 554 patients, a single-head gamma camera (360 degrees rotation) has been applied, whereas a dual-head gamma camera (180 degrees rotation) has been used in 780 patients. Four hundred twenty-six patients received both myocardial SPECT as well as coronary angiography. The diagnostic value of both applied acquisition techniques has been analyzed., Results: Regarding myocardial viability, positive predictive value for the diagnosis of myocardial scar tissue was significantly higher for dual-head- as compared to single-head acquisition. Among the 426 patients undergoing diagnosis of myocardial ischemia, significant differences have only been found with regard to specificity being higher in the single-head acquisition. Diagnosis of myocardial ischemia related to a distinct myocardial perfusion region showed a significantly higher sensitivity of dual-head acquisition for the left anterior descending perfusion area, whereas specificity was significantly higher for single-head acquisition., Conclusions: Our results indicate a beneficial effect of dual-head data collection with regard to sensitivity of the diagnosis of myocardial ischemia. In contrast, single-head data acquisition was superior with regard to specificity. However, it is justified to preferably apply dual-head data collection in clinical routine due to the shorter acquisition time leading to an evident time benefit of this acquisition technique.

Nicotinic acetylcholine receptors (nAChR) are involved in many physiological functions and appear to be affected in neurodegenerative diseases like Alzheimer's disease and Parkinson's disease (PD). Here, we describe the in vitro evaluation of nAChRs in PD with 2-[18F]F-A85380, a ligand with high affinity to the beta2 nAChR subunit. Autoradiography with 2-[18F]F-A85380 in untreated rat brain corresponded to the known distribution of alpha4beta2 nAChRs with high uptake in the thalamus, moderate uptake in the striatum and cortex and low uptake in the cerebellum (47%, 43% and 19% of the thalamus, respectively). The localization of alpha4beta2 nAChRs in the striatum was investigated in rodents with unilateral lesion of the substantia nigra. 2-[18F]F-A85380 binding was significantly reduced in the striatum ipsilateral to the lesion side (to 64% of the contralateral side), indicating that a fraction of alpha4beta2 nAChRs is located on dopaminergic terminals, whereas another fraction resides on striatal interneurons or cortical afferents. Similarly, in human brain sections of PD patients, 2-[18F]F-A85380 uptake was significantly reduced not only in the caudate and putamen but also in the thalamus (approximately 30% of the binding of control brain in all three regions); within the striatum, nAChRs in the putamen were significantly more severely affected as in the caudate. The observed pattern of alpha4beta2* nAChR loss demonstrates the potential of 2-[18F]F-A85380 for further investigations of this positron emission tomography ligand for in vivo studies of alpha4beta2* nAChRs in PD.

Background: Female gender has been associated with a high prevalence of perioperative morbidity and mortality in coronary artery bypass grafting surgery (CABG). We attempted to determine a potential benefit of off-pump CABG as compared with on-pump CABG (OPCAB) with regard to perioperative outcome in female patients., Methods: Data were prospectively gathered on 2,182 consecutive female patients undergoing CABG either with or without cardiopulmonary bypass from 1996 to 2001. The associations between OPCAB surgery in addition with 22 further preoperative patient-related or treatment-related variables and 26 perioperative outcome variables were assessed with multivariable logistic regression analysis., Results: One hundred fifty-two (7.0%) female patients underwent OPCAB surgery during the study period. Women undergoing OPCAB had higher ejection fractions and received fewer coronary artery bypass grafts than CABG patients. Surgery using OPCAB was associated with shorter hospital stays, less bleeding, less transfusion requirements, and lower mortality than CABG. Furthermore, OPCAB surgery was independently associated with a lower prevalence of high perioperative transfusion requirement, postoperative respiratory insufficiency, postoperative renal insufficiency, and dialysis. Prevalence of postoperative blood loss of at least 500 mL was significantly higher after OPCAB surgery., Conclusions: OPCAB in female patients undergoing coronary artery bypass surgery is safe and seems to be beneficial with regard to perioperative outcome as compared with conventional on-pump CABG. For that reason, off-pump surgery may be an effective method of lowering morbidity and mortality in these relatively high-risk patients.

Background: Despite refinements in perioperative patient management postoperative renal failure requiring hemofiltration or dialysis is still a common complication after coronary artery bypass grafting associated with impaired patient outcome., Methods: Prospective data on 9,631 patients receiving myocardial revascularization with (coronary artery bypass grafting [n = 8,870]) or without cardiopulmonary bypass (off-pump coronary artery bypass grafting [n = 761]) between April 1996 and August 2001 were evaluated by univariate and multivariate logistic regression analysis., Results: Overall prevalence of postoperative continuous renal replacement therapy was 4.1% (coronary artery bypass grafting, 4.3%; off-pump coronary artery bypass grafting, 1.8%; p = 0.001). Thirty of 40 selected preoperative and intraoperative patient and treatment related variables had a high association with the requirement for postoperative renal replacement therapy; fifteen of these variables were independent predictors in the whole study population. Off-pump coronary artery bypass surgery was identified as having a significantly lower predictive value for postoperative continuous renal placement therapy. In the subgroup of patients undergoing off-pump coronary artery bypass grafting surgery, a second multivariate logistic regression model revealed preoperative cardiogenic shock, urgent operation, intraoperative low cardiac output, and high transfusion requirement as independent predictors for postoperative renal replacement therapy., Conclusions: Patients with preoperative nondialysis dependent renal insufficiency are at a high risk for further decline in renal function requiring postoperative continuous renal replacement therapy. Off-pump coronary artery bypass surgery is associated with a lower prevalence of postoperative renal replacement therapy after coronary artery bypass grafting.

Background: Postcardiotomy cardiogenic shock occurs in approximately 1% of patients. We prospectively evaluated the early and long-term outcome as well as predictors of survival when using temporary extracorporeal membrane oxygenation (ECMO) support., Methods: During 5 years 219 of 18150 patients (1.2%) undergoing cardiac surgery (coronary artery bypass grafting, n = 119; aortic valve replacement, n = 24; coronary artery bypass grafting and aortic valve replacement, n = 21; coronary artery bypass grafting and mitral valve replacement, n = 11; other procedures, n = 44) required temporary postoperative ECMO support. The ECMO implantation was performed through the femoral vessels or through the right atrium and ascending aorta. Additional intraaortic balloon counterpulsation was employed in 144 patients to improve coronary blood flow., Results: Mean duration of ECMO support was 2.8 +/- 2.2 days. One hundred thirty-four patients (60%) were successfully weaned from ECMO. Of these, 52 patients (24%) were discharged from the hospital after 29.9 +/- 24 days. The main cause of death was myocardial failure. Five-year follow-up is 96% complete; 37 patients (74%) were alive with reasonable exercise capacity., Conclusions: Extracorporeal membrane oxygenation is an acceptable technique for short-term treatment of refractory postoperative low cardiac output. It can save the lives of a group of very high risk patients.

Purpose: Recently surgical treatment of atrial fibrillation has gained more popularity and presently is being performed in large numbers of patients. This report describes our early experience in treatment of patients with chronic or paroxysmal atrial fibrillation with a new tool for left atrial cryoablation., Description: From July 2002 through January 2003, 28 patients underwent left atrial cryoablation with the Surgifrost CryoCath. Patients underwent cryotherapy as an isolated procedure (n = 1), in combination with mitral valve surgery (n = 13), or with other surgical procedures (n = 14). In all patients contiguous lesion lines to the orifices of the pulmonary veins connected to the mitral annulus and the atriotomy were created. Surgery was performed through a conventional sternotomy in 8 patients (29%) and a right lateral minithoracotomy using video-assistance in 20 patients (71%)., Evaluation: Postoperatively sinus rhythm was restored in 27 patients (96%). At discharge 82% (23/28) of patients were in sinus rhythm and 18% (5/28) were in atrial fibrillation. Four patients (14%) required pacemaker implantation. There was no in-hospital mortality. At 6-months follow-up (19/28 patients) all were alive and 74% were in stable sinus rhythm, New York Heart Association functional class was 1.2 +/- 0.4., Conclusions: As indicated by our small and early patient cohort left atrial cryoablation with the Surgifrost argon cryocatheter is effective for the treatment of atrial fibrillation. This new device is technically easy to handle, it can be applied through a median sternotomy or lateral minithoracotomy. Long-term follow-up is necessary to evaluate further rhythm outcome.

Background: Surgical closure of secundum atrial septal defect (ASD) is a standard procedure associated with very low mortality and morbidity. We evaluated outcomes in the era of catheter-based interventional closure and minimally invasive techniques., Methods: From May 1996, February 2002, 177 patients with a body weight of more than 30 kg underwent surgical ASD closure. A right lateral minithoracotomy (LMT) was used in 122 patients and a conventional approach, in 55. Diagnoses included secundum ASD in 106 patients in the LMT group and 40 in the conventional group, sinus venosus ASD in 13 patients in each group, and status post interventional closure in 3 and 2 patients, respectively. Mean age was 37 +/- 17 years in the LMT group and 43 +/- 20 years, in the conventional group and mean body weight was 66 +/- 17 kg and 70 +/- 16 kg, respectively. In the LMT group, femoral cannulation was performed for cardiopulmonary bypass., Results: Direct ASD closure was carried out in 67.2% of patients in the LMT group and 58.2% of those in the conventional group. The remaining patients had pericardial patch closure. There was one death: A patient in the conventional group who required explantation of an Amplatzer device because of infection died postoperatively. Average stay in the intensive care unit was 1.2 +/- 0.5 days. Two patients required reoperation for residual ASD after direct closure; 1 sustained a temporary neurological deficit that resolved completely. On postoperative echocardiography, a minimal residual shunt was seen in only 3 patients. All patients were in good clinical condition with improved functional status at discharge from the hospital., Conclusions: Secundum ASD closure by LMT has become as standard and safe an operation as the conventional technique and achieves good perioperative results and satisfactory long-term outcomes. Thus LMT is an attractive option for patients who are not suitable for closure using catheter-based devices.

Background: Stroke remains a devastating complication after cardiac surgical procedures despite advances in perioperative monitoring and management. The purpose of this study was to determine the predictors of stroke in a large, contemporary cardiac surgery population., Methods: Prospective data on 16,184 consecutive patients undergoing cardiac surgery (coronary artery bypass grafting [CABG], n = 8,917; beating heart CABG, n = 1,842; aortic valve surgery, n = 1,830; mitral valve surgery, n = 708; double or triple valve surgery, n = 381; CABG and valve surgery, n = 2,506) between April 1996 and August 2001 were subjected to univariate and multivariate analysis. Stroke was defined as any new permanent (manifest stroke) or temporary neurologic deficit or deterioration (transient ischemic attack or prolonged reversible ischemic neurologic deficit) and was confirmed by computed tomography or magnetic resonance imaging whenever possible., Results: Overall incidence of stroke was 4.6% and varied between surgical procedures (CABG 3.8%; beating-heart CABG 1.9%; aortic valve surgery 4.8%; mitral valve surgery 8.8%; double or triple valve surgery 9.7%; CABG and valve surgery 7.4%). Of 63 patient-specific and treatment variables, 54 were found to have a significant univariate association with postoperative stroke. Multivariable analysis revealed 10 variables that were independent predictors of stroke: history of cerebrovascular disease, peripheral vascular disease, diabetes, hypertension, previous cardiac surgery, preoperative infection, urgent operation, CPB time more than 2 hours, need for intraoperative hemofiltration, and high transfusion requirement. Beating heart CABG was associated with a lower incidence of stroke in this multivariable analysis., Conclusions: Identification of predictors for stroke is important for understanding the pathogenesis of this devastating complication as well as for developing preventative strategies. Although retrospective analyses can be subject to selection bias we believe beating heart CABG is associated with a lower incidence of stroke and may therefore improve patient outcomes.

Background: The aim of this study was to compare outcomes in patients undergoing minimal access versus conventional aortic valve replacement (AVR)., Methods: We reviewed prospectively gathered data on all patients who were undergoing first-time AVR, with or without replacement of the ascending aorta, over a 1-year period at our institution., Results: A total of 176 patients underwent minimal access and 258 underwent conventional AVR. The conventional group was older, had more incidence of diabetes, and more aortic stenosis (all p < 0.05). Eight minimal access AVR patients (2%) required conversion to a complete sternotomy. Minimal access AVR patients had longer aortic crossclamp times than conventional AVR patients (60 +/- 22 vs 55 +/- 23 minutes, p = 0.03) but similar CPB times (93 +/- 38 vs 88 +/- 42 minutes, p = 0.20). Postoperative creatine kinase-MB levels were similar for the two groups. Total postoperative blood loss was significantly lower in the minimal access group, and these patients received less red blood cell and fresh frozen plasma transfusions. Minimal access AVR patients were less likely to have postoperative respiratory failure (3% vs 10%); they had shorter intensive care unit stays (3.7 +/- 5.4 vs 4.5 +/- 5.6 days) and shorter hospital stays (10 +/- 6 vs 12 +/- 7 days, all p < 0.05). Mortality was lower in patients undergoing minimal access surgery (3% vs 9%, p = 0.008) by univariate analysis. Multivariate predictors of mortality were age, hypertension, and CPB time., Conclusions: Although patient selection may have influenced some of the observed differences between our patient groups, minimal access surgery appears to be associated with decreased morbidity and resource use when compared to conventional AVR.

Background: The aim of this study was to evaluate postoperative pain levels after endoscopic versus conventional internal thoracic artery (ITA) dissection for minimally invasive direct coronary artery bypass graft surgery (MIDCABG) surgery. Results were compared with pain levels associated with conventional cardiac bypass operations through a median sternotomy., Methods: Of 190 patients included in this prospective study, 24 patients had endoscopic ITA takedown (MIDCABG-endo) using the da Vinci telemanipulator followed by a manual coronary anastomosis through a left minithoracotomy. A conventional MIDCABG operation (MIDCABG-conv) was performed in 73 patients with ITA preparation under direct vision. Postoperative pain levels after conventional CABG through a median sternotomy (CABG-conv, n = 93) served as controls. A standarized questionnaire including visual analog scale (VAS) was used for prospective pain assessment from POD 1 to 7., Results: Pain levels (VAS) declined in all groups from POD 1 to 7. Overall pain levels were significantly lower in the MIDCABG-endo group as compared with MIDCABG-conv and CABG-conv groups, respectively (p < 0.001, general linear model). There was no significant difference between the MIDCABG-conv and CABG-conv (p = not significant, general linear model) groups. Furthermore, patients after MIDCABG-endo required fewer nonsteroidal anti-inflammatory drugs and opioid medications, postoperatively., Conclusions: An endoscopic ITA takedown in MIDCABG surgery leads to significantly reduced postoperative pain levels possibly because of less rib retraction.