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Seismocardiography measures the vibrations produced by the beating heart using an accelerometer sensor placed on the chest. We evaluated the ability of smartphone seismocardiography to distinguish between the presence and absence of spontaneous circulation.Seismocardiography signals were obtained using a smartphone placed on the sternum in a convenience sample of 60 adult patients (30 comatose patients with spontaneous circulation and 30 deceased patients). The maximum, minimum, and standard deviation (SD) of acceleration values for head-to-foot, right-to-left, and dorsoventral axes and the three axis-root mean square (RMS) of the acceleration signals were calculated. Blinded observers (n = 156) were each asked to determine the presence or absence of spontaneous circulation based on seismocardiography video clips for each of the 60 patients.The seismocardiography revealed periodic large positive peaks in the patients with spontaneous circulation, which were absent in the patients without spontaneous circulation. For each of the four output measurements (three independent axes plus the three-axis RMS), the acceleration maxima and SD were significantly higher and the minima significantly lower in the patients with spontaneous circulation than in those without spontaneous circulation (all P 0.001 except the minimum of three axis-RMS results [P = 0.009]). The observers accurately identified the seismocardiography signals from patients without spontaneous circulation, with a sensitivity of 97.6% (95% confidence interval, 97.0%-98.2%) and a specificity of 98.4% (95% confidence interval, 97.8%-99.0%).In conclusion, blinded observers accurately distinguished between seismocardiography signals from patients with and without spontaneous circulation.

The HARPOON mitral valve (MV) repair system has been shown to safely and effectively treat a degenerative MV prolapse with transventricular implantation of artificial cords on a beating heart. The low profile system is introduced and precisely steered under 3D TEE guidance towards the previously selected target on a prolapsing MV segment. It allows puncture and deployment of a knot on the leaflet. The procedure is repeated until desired number of knots are implanted and the cords are optimally tensioned to restore coaptation. The cords are then tied down on the epicardium over a felt pledget. State of the art echocardiographic imaging is a crucial part of the procedure. It starts from patients screening, pre-procedural analysis and planning, access selection, navigation, deployment, optimal cordal tensioning, and final MV assessment and is continued during the follow-up assessment. This article illustrates the specific echocardiographic aspects of the HARPOON procedure including 2D and advanced 3D TEE techniques. The echocardiographic protocol was developed based on initial experience in 60 procedures. Detailed training of the echocardiographer and surgical team, is mandatory to achieve excellent results of this procedure, being now introduced in the clinical practice., Graphical Abstract Graphical AbstractTEE navigation in orthogonal planes in a patient with P2 prolapse (left-upper panel) with a bright echo of the HARPOON device visible in the left ventricle. Anatomical drawing showing the device manipulations (right panel). Final result (left-lower panel) – bright echo of knots is visible. Good coaptation without mitral regurgitation is demonstrated in bi-plane colour Doppler study.

Introduction. One of the main unresolved problems in coronary surgery has been the search for an “ideal” graft for coronary artery bypass surgery. Surgical procedures with the use of artificial circulation can lead to high incidence of postoperative complications compared to operations on a beating heart. The aim. To study the results of total arterial myocardial revascularization on a beating heart and to evaluate the medium-term outcomes in patients with coronary heart disease. Materials and methods. Ninety eight patients with coronary heart disease were treated from 2009 to 2013. The patients underwent total arterial myocardial revascularization on a beating heart using only arterial grafts: those obtained from internal thoracic artery, radial artery, and right gastroepiploic artery. Results and discussion. No deaths were observed in the postoperative period. In 91 (92.8%) patients, the postoperative period was uneventful. After 5 years of follow-up, clinical and non-invasive methods of examination revealed no coronary circulation disorders. Conclusions. Our clinical experience showed promising short- and medium-term results. The technique of total arterial myocardial revascularization on a beating heart is a good alternative to operations performed under the condition of artificial circulation.

Purpose The aortic root pressurizing device was developed for aortic valve repair surgery. It allows echocardiographic evaluation of the aortic valve during cardioplegic arrest by mimicking diastolic afterload. Description This polyoxymethylene or polyether ether ketone–based device consists of a sealing cap nut, a sealing ring, a plug screw, and both a filling and a ventilation line. It can be easily connected to any size of aortic Dacron grafts. Evaluation The device was tested in 15 porcine hearts using a beating heart biosimulator including hemodynamic and echocardiographic monitoring. Valve competence was analyzed on both the beating and resting heart at 60 and 45 mm Hg root pressure. Aortic insufficiency was surgically induced by leaflet manipulation. Native aortic valves showed either none or trivial aortic insufficiency. After leaflet manipulation echocardiographic proof of valve insufficiency was possible in all specimen. Jet direction was identic in all cases at 60 mm Hg and 93% at 45 mm Hg root pressure. Conclusions The aortic root pressurizing device shows highly comparable results of echocardiographic aortic valve evaluation between static and dynamic settings under experimental conditions.

Cryoenergy is the most commonly used method of lesion formation in patients who have undergone surgical ablation of atrial fibrillation. Despite frequent use, the clinical effect of cryoenergy in endocardial and epicardial approaches is unknown.To compare the effect of various cryoenergy applications on the postoperative incidence of sinus rhythm and completeness of lesions performed.A total of 55 patients underwent concomitant atrial fibrillation surgical ablation using cryoenergy under various conditions: epicardially during cardiac arrest, epicardially on beating heart, and endocardially. In the postoperative period, patients were invited to attend an electrophysiological examination to assess the completeness of surgical ablation lesions and, if necessary, to complete catheter ablation.Twenty-four patients underwent epicardial ablation on the arrested heart (group 1), 12 patients underwent epicardial ablation on the beating heart (group 2), and 19 patients underwent endocardial ablation (group 3). In the electrophysiological examination, sinus rhythm was present in 71% vs. 83% vs. 89% of patients, respectively. The completeness of pulmonary vein isolation was confirmed in 31% vs. 25% vs. 95% of patients, complete box lesions in 15% vs. 0% vs. 79% of patients, respectively.Despite the similar clinical effect of surgical ablation in all three approaches, the morphologically most effective use of cryoenergy is endocardial ablation. This approach has a very good result. Our findings further support the endocardial use of cryoenergy during surgical ablation of atrial fibrillation.Krioenergia jest najczęściej stosowaną metodą wytwarzania blizn u pacjentów poddawanych ablacji chirurgicznej z powodu migotania przedsionków. Pomimo popularności tej metody efekt kliniczny stosowania krioenergii z dostępu wsierdziowego i nasierdziowego nie jest znany.Porównanie wpływu różnych zastosowań krioenergii na pooperacyjne występowanie rytmu zatokowego i kompletność zabiegu.U łącznie 55 pacjentów wykonano jednoczesną ablację chirurgiczną migotania przedsionków z wykorzystaniem krioenergii: od strony nasierdzia po zatrzymaniu krążenia, od strony nasierdzia na bijącym sercu i od strony wsierdzia. W okresie pooperacyjnym pacjentów poproszono o zgłoszenie się na badanie elektrofizjologiczne serca, aby ocenić kompletność chirurgicznej ablacji zmian oraz w razie potrzeby uzupełnić ablację cewnikową.U 24 pacjentów przeprowadzono ablację od strony nasierdzia po zatrzymaniu krążenia (grupa 1.), u 12 pacjentów – ablację od strony nasierdzia na bijącym sercu (grupa 2.), a u 19 pacjentów – ablację z dostępu wsierdziowego (grupa 3.). W badaniu elektrofizjologicznym rytm zatokowy stwierdzono u odpowiednio 71%, 83% i 89% pacjentów. Kompletną izolację żyły płucnej potwierdzono u odpowiednio 31%, 25% i 95% pacjentów, a uszkodzenia typu „pudełka” (Pomimo zbliżonego efektu klinicznego ablacji chirurgicznej we wszystkich trzech metodach, z morfologicznego punktu widzenia najbardziej skuteczne jest stosowanie krioenergii w ablacji wsierdziowej. Technika ta daje bardzo dobry efekt. Uzyskane wyniki potwierdzają zasadność stosowania krioenergii od strony wsierdzia podczas ablacji chirurgicznej migotania przedsionków.

Background Transapical beating-heart neochord implantation (Neochord) to repair mitral valve regurgitation has been demonstrated to be a safe and effective minimally invasive alternative to open surgical repair in selected patients with mitral leaflet prolapse. Successful neochordae implantation depends on accurate localization of the site of regurgitation and careful assessment of MV morphology. The objective of this study is to demonstrate that 3D-transesophageal echocardiography (3D-TEE) has become a fundamental tool, essential in both the preoperative study and to guide the procedure and for follow-up. Methods All consecutive patients with severe symptomatic DMR due to prolapse or flail of one or both mitral leaflets that underwent the NeoChord procedure between March 2017-Jan 2021 were included. Patients were categorized according to MV anatomy by 3D-TEE; Type A isolated central posterior leaflet prolapse and/or flail, Type B posterior multi-segment prolapse and/or flail, Type C anterior and/or bi-leaflet prolapse or flail, Type D paracommissural prolapse and/or flail and/or significant leaflet and/or annular calcifications. Results 43 patients were included. Median age was 67.7±13.4 y. Median EuroSCOREII 2.7%±1.91. There were 35 Type A patients (81.4%), 4 Type B (9.3%), 1 Type C (2.3%), and 3 Type D (7%). Type A was considered the more favorable morphology. 2D/3D TEE were employed for guiding the device from the apex of the left ventricle across the mitral annulus (Figure 1, A–C), orientation of the tip of the device with regards to the prolapsing segment of the leaflet positioning and leaflet grasping (Figure 1, D, E) and evaluation of the final length and tension of the neochordae to obtain a satisfactory mitral valve competence. (Figure 1, F). Procedural success was achieved in 38 patients (88,4%). 5 patients, 2 type A and 3 type D, underwent conversion to open surgery for immediate failure. 1 high-risk patient considered inoperable died before discharge. At 19 (IQR 13–23) months median follow-up, MR ≤II was present in 29 (76.3%). Overall 2 year survival was 100%. Freedom from reintervention was 89% for overall population. Conclusions TEE-Guided Transapical beating-heart neochord implantation is a feasible, low-risk technique. 2D and 3D TEE are the fundamental and essential diagnostic tools for the correct selection and monitoring of the procedure, as well as its possible complications. Funding Acknowledgement Type of funding sources: None. Figure 1

Off-pump coronary artery bypass grafting (OPCAB), although devoid of the morbidity associated with cardiopulmonary bypass (CPB), has its own technical difficulties. Achieving optimum tissue stabilization on a beating heart along with hemodynamic fragility due to extreme positioning also complicates the anesthetic management. In addition, it is difficult to obtain a clear surgical field in the presence of arteriotomy. The use of catheter-directed high-flow gas blower (mister blower) helps achieve a clear surgical field to a great extent. However, there have been reported cases of arterial and pulmonary embolism caused by these high-flow gas blowers. The present case reports a case of massive venous air embolism caused by the use of mister blower.

We present a case to demonstrate the feasibility of transapical beating heart mitral valve repair in a patient with dextrocardia. This minimally invasive technique provides simple, safe and satisfactory mitral repair. The surgical technique, outcome and prognosis are not affected by the condition.

Background: Functional tricuspid regurgitation (FTR) treatment is challenging and most therapies targeting tricuspid valve (TV) annulus have shown limited durability with high rate of resid...

Aim.To assess the cytokine profile and the level of endothelial dysfunction in patients with coronary artery disease (CAD) and different outcomes of coronary artery bypass grafting (CABG).Materials and methods.The study included 95 people, with 22 of them being practically healthy (without CAD). The CAD patients (73) were retrospectively divided into 2 subgroups according to the presence of complications within the first month after the CABG. The first subgroup consisted of 25 patients suffering from complications after CABG, with 48 people making up the second subgroup (no complications after CABG). CABG was performed on a beating heart; bypass grafts were attached during revascularisation. The serum levels of IL-4 and IFN-γ were determined through the enzyme-linked immunosorbent assay (ELISA) using appropriate test systems manufactured by BCM Diagnostics and a Zenyth 340 microplate photometer (Biochrom Ltd). In order to determine the content of endothelin-1 in blood serum, ELISA test systems manufactured by Biomedica were used. The statistical analysis of study results was performed employing the descriptive statistics module of Statistica 12.0 (StatSoft, USA). The mean (M), its error (m), median (Me) and the interquartile range [Q25; Q75] were calculated. In cases when p ≤ 0.05, the results were considered statistically significant.Results.It was revealed that, in the preoperative period, CAD patients from both subgroups exhibited increased levels of endothelin-1 (p = 0.0001) and IFN-γ (p = 0.0001), whereas an increase in IL-4 production was noted only in the first subgroup (p = 0.0001), as compared to the control group. The follow-up revealed that CAD patients with complications after CABG exhibited stable high levels of IL-4 (p > 0.05) and IFN-γ (p > 0.05) during the entire observation period, as compared to the initial values. The content of endothelin-1 in both subgroups increased significantly on the 4th day of observation (p > 0.05) and returned to its initial high values after 1 month.Conclusion.Immune response in CAD patients suffering from complications after CABG develops mainly along the pro-inflammatory pathway and is accompanied by endothelial dysfunction.

Posthypoxic encephalopathy is a frequent complication after coronary artery bypass surgery (CABG), which includes stroke, early postoperative delirium, and postoperative cognitive dysfunction (PCD). The more pronounced prevalence and severity of the latter during surgery using extracorporeal circulation are currently being discussed.Objective: to analyze various types of cerebral dysfunction in patients undergoing CABG and to determine the role of perioperative factors in its development.Patients and methods. The investigation enrolled 53 patients who had undergone elective CABG for coronary heart disease. Group 1 included 20 patients who had undergone beating-heart surgery; Group 2 comprised 33 patients, in whom CABG had been performed using extracorporeal circulation (ECC). Neuropsychological testing and brain magnetic resonance imaging (MRI) (structural and functional techniques) were carried out.Results and discussion. Posthypoxic encephalopathy was diagnosed in 10 and 67% of patients in Group 1 and 2, respectively (p=0.05); these were precisely all the three types of brain dysfunction which were observed in Group 2 patients. Factors, such as over 70 years of age; median level of education; smoking; body mass index >30 kg/m2 ; ejection fraction 210-min surgery duration; >55-min aortic ligation; and >115-min ECC, showed a statistically significant association with the onset of PCD (pConclusion. Surgical myocardial revascularization using ECC is associated with a greater likelihood of PCD than beating-heart CABG. The factors that favored the development of PCD, such as increased age, low preoperative cognitive status, smoking, and long-term use of ECC, were identified when applying ECC.

Coronary artery bypass graft (CABG) surgery is one of the treatment modalities of coronary artery disease (CAD) patients. There are multiple selection criteria for CABG and multiple procedures like conventional CABG, on pump beating heart CABG and off pump beating heart CABG (OPCAB). This study was intended to compare between conventional CABG and on pump beating heart CABG. Total 60 patients were selected for the study, of which 30 patients had undergone conventional CABG and 30 had undergone on pump beating heart CABG. Different preoperative and postoperative variables shows clear and significant superiority of on pump beating heart CABG. So it may be an alternative surgical procedure where OPCAB is not feasible in poor left ventricular (LV) .function. Journal of Surgical Sciences (2014) Vol. 18 (1) : 20-27

Background: Current cardioplegic technique during conventional coronary artery bypass grafting (CABG) does not consistently avoid myocardial ischemic damage in high risk patients. Alternatively revascularization without CPB is not always technically feasible. The on-pump beating technique eliminates global myocardial ischemia and thus reduce the mortality and morbidity in high risk patients. This study evaluates the early surgical outcomes of on-pump beating-heart CABG in comparison to conventional CABG. Methods: In this prospective study 60 high risk patients with EURO-SCORE of 6 and above were prospectively allocated into two groups in non-randomized way. Among them 30 patients underwent on-pump beating-heart CABG and 30 patients underwent conventional CABG. The early surgical clinical outcomes were compared between the groups. Results: On-pump beating heart CABG significantly reduced the duration of operation time, cardiopulmonary bypass time, postoperative ventilation time and intensive care unit (ICU) stay. Total blood loss and transfusion requirement were less with reduced Peak Creatine-Kinase level in On-pump beating heart CABG. 30 day mortality was less in On-pump beating heart CABG group (6.7% versus 13.3%). No significant differences between the groups were found in morbidity regarding stroke, renal failure, mediastinitis and atrial arrhythmia. Conclusion: On-pump beating heart CABG can be performed safely in high risk patients. It is still associated with the detrimental effect of CPB but eliminates intra-operative global myocardial ischemia. Cardiovasc. j. 2019; 12(1): 13-19

Aim. To evaluate the results of surgical treatment of post-infarction left ventricular aneurysms with on-pump beating heart technique. Methods. In our center from April, 2009 to January, 2014 169 patients had reconstruction of the left ventricle with on-pump beating heart technique. Among the patients 159 were males (94.1%) and 10 of them were females (5.9%), average age 53.8±8.9 years (39 to 72 years). Angina pectoris class I (according to the classification of Canadian Heart Association) was established in 7 (4.1%) patients, class II - in 49 (29.0%), class III - in 107 (63.3%), class IV - in 4 (2.4%), unstable angina in 2 (1.2%) patients. Chronic heart failure class I (according to New York Heart association functional classification) was diagnosed in 5 (3.0%) patients, class II in 37 (21.9%), class III in 124 (73.4%), class IV in 3 (1.8%) patients. Average ejection fraction of the left ventricle was 38.6±7.9% (25 to 67%). Mitral valve insufficiency stage 2-3 was revealed in 23 (13.6%) patients. Results. Endoventriculoplasty of the left ventricle by Dor's technique was performed in 49 (29.0%) patients, auto-septoplasty of the left ventricle - 59 (34.9%) patients, linear repair in 40 (23.7%) patients. Combined surgical interventions were performed in 21 (12.4%) patients. In-hospital lethality was 2.4% (n=4). Conclusion. Left ventricular reconstruction with on-pump beating heart technique without cardioplegic arest is effective and safe; the method allows performing remodelling of the left ventricle and reaching the target volume parameters.

IntroductionHeart-type fatty acid-binding protein (H-FABP) is a novel indicator of myocardial damage. The aim of the study was to compare the levels of H-FABP in off-pump and on-pump coronary artery bypass grafting (CABG).Material and methodsThirty non-randomised 30 patients who underwent CABG between January 2009 and January 2010 were enrolled in the study. Patients were divided into two equal size (n = 15) groups as group A (off-pump CABG group) and group B (on-pump CABG group). Three arterial blood samples were obtained for H-FABP after sternotomy (H-FABP 1), after the last distal anastomosis in group A and immediately after the cross clamp was removed from the aorta in group B (H-FABP 2) and 24 h after the operation (H-FABP 3). Renal and liver functions and circulating fatty acid binding protein (FABP) levels were also assessed in blood samples obtained 24 h before and 1 h after the operation.ResultsAt all three assessment points patients in group B had significantly higher H-FABP values when compared with group A. Preoperative renal and liver functions were similar in both groups and they did not differ significantly in group A and group B when preoperative and postoperative values were compared. In both groups circulating FABP levels increased in the postoperative period, and the increase was more pronounced in the on-pump CABG group.ConclusionsOn-pump surgery resulted in higher levels of H-FABP as an ischaemic marker in patients receiving coronary artery bypass surgery.

Background: A longer-arm clip design for transcatheter edge-to-edge repair of mitral and tricuspid valves could be beneficial in treating complex valve pathologies. Its hemodynamic effects and usab...

Background: To avoid harmful effect of cardiopulmonary bypass (CPB) used in off-pump coronary artery bypass graft (CABG) surgery, cardiac surgeons are now inclined to on-pump beating heart surgery (ONBEAT). However, the superiority of ONBEAT over Off-pump has not yet been conclusively established. This study compares the outcomes between off-pump and on pump beating heart CABG surgery. Methods: A total 249 consecutive patients who underwent non-emergency, primary isolated CABG from January 2014 to December 2017 by a single surgeon were included. The selected patients were assigned to either OPCAB group (Patients who received Off-pump beating heart CABG surgery, n=193) or to ONBEAT group (patients who received On-pump beating heart CABG surgery, n=56). The clinical outcomes were investigated and compared. Result: Forty percent of the patients were in their 5th decade of life. A male predominance was also observed. The two study groups were almost identical in terms of age and sex (p=0.983 and p=0.153 respectively). None of the conventional risk factors of ischemic heart disease (smoking, diabetes, hypertension and dyslipidaemia) were any different between the study groups (p > 0.05). Cerebrovascular disease, recent MI, congestive heart failure and left main disease were significantly higher in the on-pump beating heart group compared to those in the off-pump beating heart group (p < 0.05). The left ventricular ejection fraction (LVEF) was significantly lower in the former group than that in the latter group (p= 0.007). Both groups required 3 grafts on an average. Two patients in the on-pump group required Intra-Aortic Balloon Pump (IABP) support as opposed to none in the off-pump group (p=0.050). The mean cardiopulmonary bypass (CPB) time was 105.8 ± 46.5 in the on-pump group. Fourteen patients (25%) from off-pump group needed urgent switching to on-pump group. Postoperative drainage in the first 24 hours was significantly voluminous in the on-pump group (p < 0.001). The incidence of pneumonia, respiratory failure, arrhythmia, renal failure requiring haemodialysis and perioperative MI were significantly higher in the on-pump group (p < 0.001, p < 0.001, p=0.037, p < 0.001 and p=0.050 respectively). The patients with prolonged mechanical ventilation were also more in the on-pump group. The left ventricular ejection fraction (LVEF) was much lower and Intensive Care Unit (ICU) stay was longer in the on-pump group compared to those in the off-pump group (p < 0.001). The incidence of in-hospital mortality was also higher in the former group (p=0.037). Conclusion: OPCAB was associated with lower operative morbidity compared to ONBEAT cardiac surgery. However, the increased morbidity in ONBEAT group might have been influenced by a sizable proportion of patients from OPCAB group being switched to ONBEAT group due to their haemodynamic deterioration and frequent ventricular fibrillation. But on-pump CABG can be performed safely on high risk patients. Use of cardiopulmonary bypass and elimination of cardioplegic arrest may be beneficial to hemodynamically unstable patients. Ibrahim Card Med J 2017; 7 (1&2): 15-22

Objective: The objective of the present study was to see the effect of magnesium in preventing cardiac arrhythmias in patients undergoing coronary artery bypass grafting (CABG) surgery. Methods: This study was carried out in the Department of Anesthesia, Analgesia and Intensive Care Medicine (Cardiac Anesthesia Wing) of Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka who underwent CABG surgery under general anaesthesia. A total of 60 patients scheduled for CABG were consecutively selected and were randomly divided into study group and control group. Patients aged 35-70 years irrespective of sex, ASA grade I & II, NYHA functional class I & II and ejection fraction 35-65% were included in the study. The study group was treated by vecuronium, fentanyl and magnesium sulphate infusion, while the control group was treated by vecuronium and fentanyl infusion. The demographic variables, preoperative clinical characteristics, peroperative variables and haemodynamic findings were observed at different time intervals. Results: The mean ages of the study and control groups were 51.0 ± 6.9 years and 53.8 ± 6.2 years respectively. Males demonstrated their predominance in both magnesium (83.3%) and control (76.7%) groups. The distribution of preoperative confounding factors like diabetes, previous MI, hypertension and ejection fraction were not statistically different between the study groups. Two-thirds (67.7%) of the patients in magnesium group and 53.3% in the control group required 3 grafts. Number of 4 grafts in magnesium and control groups was 20% and 30% respectively and that of 2 grafts was 13.3% and 16.7% respectively. In the study group, out of 30 patients, 3(10%) developed arrhythmia, while in the control group out of 30 patients, 5(16.7%) developed arrhythmia (p = 0.353).The haemodynamic parameters in patients receiving magnesium were more stable during the whole period of observation. Conclusion: The findings of the study suggest that magnesium could reduce the development of arrhythmia to an acceptable level in patients undergoing beating heart CABG surgery. However, further study with large sample is recommended to achieve a conclusive remark. Ibrahim Card Med J 2017; 7 (1&2): 37-43

This study compared monophasic 100-μs pulses with high-frequency electroporation (HF-EP) bursts using an in vivo animal model. Myocardial damage was evaluated by histologic analysis. Compared with 10 monophasic pulses, 20 bursts of HF-EP at 100 and 150 kHz were associated with less damage. However, when the number of HF-EP bursts was increased to 60, myocardial damage was comparable to that of the monophasic group. HF-EP protocols were associated with attenuated collateral muscle contractions. This study shows that HF-EP is feasible and effective and that pulse frequency has a significant effect on extent of ablation. Funded by the Nicholas and Elizabeth Shlezak Super Center for Cardiac Research and Biomedical Engineering at Tel Aviv University; Mayo Clinic–Sheba innovation grant; project (PID2019-110120RBI00/AEI/10.13039/501100011033) from the Ministry of Science, Innovation, and Universities; and the State Research Agency of the Spanish government and by the Beatriu de Pinos program from the Ministry of Business and Knowledge of the Government of Catalonia (grant identifier: 2017 BP 00032). Dr Ivorra gratefully acknowledges financial support by the Catalan Institution for Research and Advanced Studies (ICREA) under the ICREA Academia program.

The intra-operative real-time assessment of tissue viability can potentially improve therapy delivery and clinical outcome in cardiovascular therapies. Cardiac ablation therapy for the treatment of supraventricular or ventricular arrhythmia continues to be done without being able to assess if the intended lesion and lesion size have been achieved. Here, we report a method for continuous measurements of cardiac muscle microcirculation to provide an instrument for real-time ablation monitoring. Methods: We performed two acute open chest animal studies to assess the ability to perform real-time monitoring of creation and size of ablation lesion using a standard RF irrigated catheter. Radiofrequency ablation and laser Doppler were applied to different endocardial areas of alive open-chest pig. Results: We performed two experiments at three different RF ablation energy setting and different ablation times. Perfusion signals before and after ablation were found extensively and distinctively different. By increasing the ablation energy and time, the perfusion signal was decreasing. Conclusion: In vivo assessing the local microcirculation during RF ablation by laser Doppler can potentially be useful to differentiate between viable and nonviable ablated beating heart in real time.

Cardiac haemangiomas are rare entities and very few cases have been reported where they originate from the main arteries of the heart. We present a case of haemangioma arising from the main PA, which was completely resected with clear margins on the beating heart.

OBJECTIVES The objective of this study was to evaluate the safety and performance of a novel, beating heart procedure that enables echocardiographic-guided beating heart implantation of expanded polytetrafluoroethylene (ePTFE) artificial cords on the posterior mitral leaflet of patients with degenerative mitral regurgitation. METHODS Two prospective multicentre studies enrolled 13 (first-in-human) and 52 subjects, respectively. Patients were treated with the HARPOON beating heart mitral valve repair system. The primary (30-day) end point was successful implantation of cord(s) with mitral regurgitation reduction to ≤moderate. An independent core laboratory analysed echocardiograms. RESULTS Of 65 patients enrolled, 62 (95%) achieved technical success, 2 patients required conversion to open surgery and 1 procedure was terminated. The primary end point was met in 59/65 (91%) patients. Among the 62 treated patients, the mean procedural time was 2.1 ± 0.5 h. Through discharge, there were no deaths, strokes or renal failure events. At 1 year, 2 of the 62 patients died (3%) and 8 (13%) others required reoperations. At 1 year, 98% of the patients with HARPOON cords were in New York Heart Association class I or II, and mitral regurgitation was none/trace in 52% (n = 27), mild in 23% (n = 12), moderate in 23% (n = 12) and severe in 2% (n = 1). Favourable cardiac remodelling outcomes at 1 year included decreased end-diastolic left ventricular volume (153 ± 41 to 119 ± 28 ml) and diameter (53 ± 5 to 47 ± 6 mm), and the mean transmitral gradient was 1.4 ± 0.7 mmHg. CONCLUSIONS This initial clinical experience with the HARPOON beating heart mitral valve repair system demonstrates encouraging early safety and performance. Clinical registration numbers NCT02432196 and NCT02768870.

The lack of blood flow to the brain during a cardiac arrest can cause irreparable damage. Thus, after restoring normal rhythm and circulation, patients can end up with a beating heart in a brain-dead or a severely damaged body. Thus, preservation of the brain from hypoxic-ischemic encephalopathy has assumed paramount importance post-cardiac arrest. In this chapter, the author presents an illustrative case and briefly discusses hypothermia post-cardiac arrest for brain preservation.

Introduction: Beating-heart transapical mitral valve repair represents a significant advancement in the minimally invasive treatment of mitral regurgitation. However, current techniques require increased artificial chordae length and altered anchoring position, which may increase the stresses on the suture. We hypothesized that artificial chordae manufactured with increased elasticity will dampen sharp increases in force, thus theoretically increasing durability. Methods: Porcine mitral valves (n=3) were mounted in a heart simulator and isolated mitral regurgitation was induced by cutting posterior primary chordae. Each valve was first repaired with standard CV-5 polytetrafluoroethylene (PTFE) suture affixed to a 3D-printed anchor with an embedded high-resolution Fiber Bragg Grating sensor to measure forces (Fig A). The repair was then repeated with an elastic suture manufactured using a biocompatible silicone and designed with a cross-sectional area of 0.56mm 2 , a geometry calculated to result in a desired 10-15% strain at relevant forces (Fig B). Results: Both materials allowed for successful repairs: mitral leakage volume was reduced from 28.29±4.83ml to 1.26±0.99ml ( p =0.009) with PTFE suture, and to 1.78±0.88ml ( p =0.008) with the elastic suture, with no significant difference between the repairs. Normalized force tracings (Fig C, standard deviation is shaded) revealed that the elastic suture resulted in a significantly lower peak systolic force when compared to PTFE suture (0.23±0.04N vs 0.32±0.03N, p =0.007). Conclusions: Artificial chordae with increased elasticity compared to traditional PTFE suture can dampen sharp peaks in force, thus offering a promising advancement in improving transapical repair durability. This proposal has the potential to apply to open-heart artificial chordae implantation as well. Future work to optimize suture material and manufacturability will help translate this development into clinical use.

Studies on reptile hearts date back to 350 BC with Aristotle, who described the presence of the heart and blood vessels in multiple animal species, including turtles and snakes. In the early seventeenth century, Harvey described blood flow and the beating heart of various reptiles, noting the loss of crimson color to the ventricle with each heartbeat. Detailed study from multiple researchers over the last century have been built on these foundations, greatly enhancing our current knowledge of reptilian cardiovascular anatomy and physiology. Unlike mammalian hearts where the myocardium receives its entire oxygen supply from the coronary vessels, the reptilian myocardium receives oxygen from both coronary circulation and venous blood held within the chambers. Cardiovascular diseases are underdiagnosed in reptiles and can be attributed to multiple causes. A method to organize these causes is by using the DAMNIT mnemonic: Degenerative, Deposition, Developmental Anomalies, Metabolic, Neoplastic, Nutritional, Idiopathic, Infectious, and Traumatic.

Objectives Transapical beating heart neochordae implantation is an innovative mitral valve repair technique that has demonstrated promising clinical results in patients with primary mitral regurgitation. However, as clinical experience continues to increase, neochordae implantation criteria have not been fully standardized. The aim of this study was to investigate the biomechanical effects of selecting an antero-lateral apical access site compared with a postero-lateral site, and suboptimal neochordae length compared with optimal suture length, on restoring physiologic left heart dynamics. Methods Transapical neochordae implantation using 3 and 4 sutures was computer simulated under 3 posterior mitral leaflet prolapse conditions: isolated P2, multiscallop P2/P3 and multiscallop P2/P1. Physiologic, pre- and postrepair left heart dynamics were evaluated using a fluid-structure interaction modeling framework. Results Despite the absence of residual mitral regurgitation in all postrepair models with optimal neochordae length, selecting an antero-lateral apical entry site for the treatment of P2/P3 prolapse generated a significant increase (>80%) in neochordae tension and P2 peak stress, with respect to a postero-lateral entry site. During isolated P2 prolapse repair, although neochordae overtension by 5% led to minimal hemodynamic changes in the regurgitant volume compared with using an optimal suture length, a significant increase in systolic and diastolic neochordae tension (>300%) and posterior leaflet average stress (70%-460%) was quantified. On the other hand, neochordae undertension by 5% led to worsening of regurgitation severity. Conclusions This parametric computer study represents a further step toward an improved understanding of the biomechanical outcomes of transapical neochordae technologies.

Background: Various methods have been developed to overcome the deleterious effects of ischemia/ reperfusion injury that occurs after cardioplegic arrest. The aim of the study was to assess the safety, efficacy, and applicability of the beating-heart mitral valve replacement (MVR) compared to the conventional MVR. Methods: Forty patients scheduled for mitral valve replacement were randomly assigned into two groups, conventional MVR as the control group (n= 20) and beating-heart MVR with continuous antegrade coronary perfusion as the study group (n=20). Three patients in the beating-heart group were converted to the conventional technique because of the blood-flooded field and excluded from the analysis. Results: The preoperative clinical and echocardiographic variables were comparable between both groups. There was no significant difference between both groups regarding cardiopulmonary bypass time (79.4± 14 vs. 75.7± 10.9 minutes; p= 0.398) and total operative time (200± 55.6 vs. 183.9± 67.5 min; p= 0.458) in the conventional and beating-heart group, respectively. Serum troponin I level was significantly higher in the conventional MVR group 6 hours postoperatively (4.9±4 vs. 2.7±1.2 ng/ml; p= 0.036), while there was no significant difference between both groups regarding total CK and CK-MB (p= 0.565 & 0.597 respectively). Eight patients (44%) in the conventional MVR group needed inotropic support compared to 3 patients (19%) in the beating-heart MVR group (P = 0.11). There was no operative mortality or major morbidity in both groups. At 6-months follow-up, there was no difference in NYHA class (1.3±0.3 vs. 1.2±0.3; p= 0.336) and the ejection fraction (60.0±6.3 vs. 63.2±6 %; p= 0.139) in the conventional vs. beating-heart group. Conclusion: Beating-heart MVR is a safe alternative to the conventional method with comparable outcomes. There is a relatively blood-filled field compared to the conventional technique.

The AngioVac System has already proved to be effective and safe in the treatment of thrombotic and endocarditic formations concerning the venous district and the tricuspid valve. We describe an innovative use of the AngioVac System to treat a left-sided heart mass. In a high-surgical-risk patient, we used a micro-invasive transapical access and a modified extracorporeal membrane oxygenation circuit to remove the mass from the mitral bioprosthesis without having to replace it. Further experiences are required to confirm the safety of this technique in high-risk patients.

3D imaging, modeling, and printing of congenital heart disease (CHD) have revolutionized the ability to visualize complex hearts. Printed 3D and virtual computer heart models have a number of limitations, including often lacking valve anatomy and representing only one time point in the cardiac cycle. 3D visualization of the beating heart has been limited to echocardiography, and multi-planar and topographical images from CT and MRI. Presented here are video capture images of a high resolution, dynamic 3D (‘4D’) model from a cardiac MRI study representing the endocardial surface “contracting” throughout the cardiac cycle in a 4 month old infant with Tetralogy of Fallot, double aortic arch, and vertical vein from the left upper pulmonary vein to innominate vein.

Coronary artery bypass grafting techniques have been unchangeable for many years, whereas development and enhancement of myocardial protection methods in coronary bypass grafting for patients with ischemic heart disease are still actual issues of current coronary surgery. Coronary artery bypass grafting techniques include the traditional/conventional technique with cardiopulmonary bypass, aortic cross-clamping and cardioplegia, off-pump and on-pump beating heart coronary artery bypass grafting. Coronary artery bypass grafting with cardiopulmonary bypass and cardioplegia remains the most common method of coronary revascularization. However the cardiac arrest inevitably leads to global cardiac ischemia, and current cardioplegias do not prevent ischemic damage to the myocardium in all cases, especially in high-risk surgical patients. Off-pump coronary artery bypass grafting allows preventing global myocardial ischemia (due to the constant native coronary blood-flow) and avoiding possible negative consequences of cardiopulmonary bypass use. The main limitations of this technique are associated with high risk of hemodynamic instability due to low cardiac output and systolic output caused by target arteries exposition. On-pump beating heart technique is a reasonable compromise between conventional on-pump coronary artery bypass grafting, cardioplegia and off-pump procedure. It is a safe and effective technique with outcomes that are equivalent or superior to the outcomes reported for conventional coronary artery bypass grafting in patients with unstable hemodynamics, low left ventricular ejection fraction and in high-risk patients. The literature review presents the results of on-pump beating heart coronary artery bypass grafting.

The relentlessly beating heart has the greatest oxygen consumption of any organ in the body at rest reflecting its huge metabolic turnover and energetic demands. The vast majority of its energy is produced and cycled in form of ATP which stems mainly from oxidative phosphorylation occurring at the respiratory chain in the mitochondria. A part from energy production, the respiratory chain is also the main source of reactive oxygen species and plays a pivotal role in the regulation of oxidative stress. Dysfunction of the respiratory chain is therefore found in most common heart conditions. The pathophysiology of mitochondrial respiratory chain dysfunction in hereditary cardiac mitochondrial disease, the aging heart, in LV hypertrophy and heart failure, and in ischaemia-reperfusion injury is reviewed. We introduce the practicing clinician to the complex physiology of the respiratory chain, highlight its impact on common cardiac disorders and review translational pharmacological and non-pharmacological treatment strategies.

Primary spontaneous coronary artery rupture (SCAR) without any underlying condition is a rare disorder. The acute and often dramatic nature of hemopericardium with cardiac tamponade advocates immediate pericardial drainage or surgical intervention with timely recognition of coronary artery rupture. This is the first case report of primary SCAR successfully treated on a beating heart without cardiopulmonary bypass.

To the best of our knowledge, this is the first report describing robotic beating-heart quadruple all-arterial totally endoscopic coronary artery bypass combined with percutaneous coronary intervention attempting complete revascularization (residual SYNTAX score 0). A 66-year-old male with severe triple-vessel coronary artery disease underwent percutaneous coronary intervention for a sub-total occlusion of the right coronary artery as the initial component of a hybrid revascularization strategy. Subsequently, the left coronary system was revascularized via robotic beating-heart totally endoscopic coronary artery bypass with bilateral internal mammary artery grafts.

Goal of the study: to evaluate the accuracy of invasive measurement of cardiac output (CO) by pulse wave transit time (PWTT) (esCCO, Japan) compared to transpulmonary thermodilution (TPTD) (PiCCO2 , Germany) after aortocoronary bypass (ACB) without cardiopulmonary bypass (ACB without CPB). Methods. 21 patients with ACB without CPB were enrolled into the study. During early post-operative period CO was simultaneously registered at eight stages basing on PWTT (COPWTT) and TPTD (COTPTD). Statistic analysis included evaluation of congruence of CO absolute values and capability to follow-up changes in CO. Results. In accordance with Bland-Altman analysis the average difference between two methods made 0.3 l/min. with consistency limits of ± 2.1 l/min. and percent error of 40%. Polar chart analysis showed the angular difference of 2.6°, radial consistency limits ± 53.3° and polar concordance of 69%. Conclusion: Lower repeatability of CO measurement by PWTT and insufficient capability to follow the changes in CO after ACB without CPB don not allow recommending this method in its invasive variant for routine practice as an alternative to thermodilution methods.

Background: Conventional mitral valve (MV) operations allow direct anatomic assessment and repair on an arrested heart, but require cardiopulmonary bypass, aortic cross-clamping, sternotomy...

Background The currently proposed criteria for identifying patients who would benefit from cardiac resynchronization therapy (CRT) still need to be optimized. A multi-scale heart simulation capable of reproducing the electrophysiology and mechanics of a beating heart may help resolve this problem. The objective of this retrospective study was to test the capability of patient-specific simulation models to reproduce the response to CRT by applying the latest multi-scale heart simulation technology. Methods and results We created patient-specific heart models with realistic three-dimensional morphology based on the clinical data recorded before treatment in nine patients with heart failure and conduction block treated by biventricular pacing. Each model was tailored to reproduce the surface electrocardiogram and hemodynamics of each patient in formats similar to those used in clinical practice, including electrocardiography (ECG), echocardiography, and hemodynamic measurements. We then performed CRT simulation on each heart model according to the actual pacing protocol and compared the results with the clinical data. CRT simulation improved the ECG index and diminished wall motion dyssynchrony in each patient. These results, however, did not correlate with the actual response. The best correlation was obtained between the maximum value of the time derivative of ventricular pressure (dP/dtmax) and the clinically observed improvement in the ejection fraction (EF) (r = 0.94, p Conclusions By integrating the complex pathophysiology of the heart, patient-specific, multi-scale heart simulation could successfully reproduce the response to CRT. With further verification, this technique could be a useful tool in clinical decision making.

Background For revascularization of myocardium, the on-pump beating heart technique has been successfully used in patients with either low or high risk. However, the use of this technique in patients with low ejection fraction is not well thoroughly evaluated. The aim of the work was to evaluate the on-pump beating heart technique in subjects with severe left ventricular dysfunction and to compare results with on-pump non-beating (conventional) technique. Methods The present study was held at Al-Azhar University Hospitals, Cairo, Egypt during the period from January 2014 till June 2016. The study included 200 patients who achieved the inclusion criteria. They were allocated either to on-pump beating heart (n = 84) or conventional group (n = 116). Patients were evaluated for in hospital mortality or major postoperative complications. Results On-pump beating heart was found to be associated with low in hospital mortality, postoperative CK-MB, new myocardial infarction, renal dysfunction and need for hemodialysis. Conclusions On-pump beating heart technique was better than conventional technique for cardiac revascularization in patients with severe left ventricular dysfunction.

Cardiac rhabdomyoma, a type of benign myocardial tumor, is regarded as the most common fetal cardiac tumor. Rhabdomyomas are usually found before birth or during the first year of life. It is widely accepted that rhabdomyomas are strongly associated with tuberous sclerosis, and tend to regress spontaneously without surgical excision. However, if the tumor has caused significant obstruction or refractory arrhythmias, the surgery should be advocated. Most of the surgeries for pediatric cardiac tumors are performed under cardiopulmonary bypass (CPB) with cardioplegia. Here, we present a case of successful resection of a right ventricular rhabdomyoma obstructing the right ventricular outflow tract (RVOT) and involving pulmonary valve annulus in an infant, performed under the guidance of transesophageal echocardiography (TEE) on a beating heart.