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Abstract: Objective: Isolated lung perfusion (ILuP) is an experimental technique currently tested to increase the 5-year survival of 40% after surgical resection of pulmonary metastases from certain solid tumors. The standard technique of anterograde perfusion was compared with retrograde isolated lung perfusion in which the drug is introduced through the pulmonary veins while the effluent is collected from the pulmonary artery. Since the lung has a dual arterial circulation through the pulmonary artery and bronchial circulation, perfusion through the pulmonary veins can result in a more homogeneous distribution throughout the lung with subsequent higher melphalan concentration. Methods: We randomized 20 rats into two groups. Group one underwent anterograde isolated left lung perfusion while group two underwent retrograde isolated left lung perfusion. A dose of 2mg/kg melphalan (MN) was administered to the lung at a flow of 0.5mL/min during 30min, followed by a 5-min washout with buffered hetastarch (BHE). The final melphalan lung concentration (FMLC) was determined in the hilum, at the apex, the mid-periphery and the base of the lung. Statistical analysis was done with an unpaired student''s t-test. Results: Retrograde left ILuP resulted in a higher FMLC in the hilum (P<0.0001) and in the base of the lung (P=0.03), while anterograde ILuP induced a higher concentration at the apex of the lung (P=0.04). No difference was seen in the mid-peripheral area of the lung (P=0.92). Conclusions: In this experimental study, retrograde perfusion seems to increase final melphalan lung concentration in hilar and basal regions of the lung compared to anterograde perfusion. [Copyright &y& Elsevier]

Background: Primary cardiac diffuse large B-cell lymphoma (CDLBCL) is an exceptionally rare entity, estimated to represent less than 1% of all primary cardiac tumours. In this case report, we emphasize the diagnostic importance of multimodality imaging and the need for additional procedures, such as tissue biopsy, in a case with a primary cardiac lymphoma presenting with cardiac tamponade., Case Summary: An 80-year-old male was admitted to the emergency department with a life-threatening tamponade demanding immediate sternotomy. Pre-operative echocardiography unveiled pericardial effusion and a thickened apex. While computed tomography ruled out an aortic dissection, surgery revealed an unexpected vascular-rich mass at the right ventricle and apex, too perilous for biopsy. Post-operative imaging misinterpreted this mass as a benign haematoma. Subsequently, the patient was admitted to the intensive care unit, but after a conservative treatment strategy, the patient died. An autopsy revealed a primary CDLBCL., Discussion: This case demonstrates the deceptive nature of primary CDLBCL, often complicated by cardiac tamponade. It underscores the pivotal role of pathologic assessment, even amidst the perils of sternotomy, to determine the origin of abnormal cardiac masses. A heightened awareness among physicians is imperative, for such elusive diagnoses may slip by, with potentially fatal outcomes., Competing Interests: Conflict of interest: None declared., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Objectives: The ELANA® Heart Bypass creates a standardized sutureless anastomosis. Hereby, we investigate the influence of arteriotomy and graft size on coronary hemodynamics., Methods: A computational fluid dynamics (CFD) model was developed. Arteriotomy size (standard 1.43 mm 2 ; varied 0.94 - 3.6 mm 2 ) and graft diameter (standard 2.5 mm; varied 1.5 - 5.0 mm) were independent parameters. Outcome parameters were coronary pressure and flow, and fractional flow reserve (FFR)., Results: The current size ELANA (arteriotomy 1.43 mm 2 ) presented an estimated FFR 0.65 (39 mL/min). Enlarging arteriotomy increased FFR, coronary pressure, and flow. All reached a maximum once the arteriotomy (2.80 mm 2 ) surpassed the coronary cross-sectional area (2.69 mm 2 , i.e. 1.85 mm diameter), presenting an estimated FFR 0.75 (46 mL/min). Increasing graft diameter was positively related to FFR, coronary pressure, and flow., Conclusion: The ratio between the required minimal coronary diameter for application and the ELANA arteriotomy size effectuates a pressure drop that could be clinically relevant. Additional research and eventual lengthening of the anastomosis is advised., (© 2023. The Author(s).)

The disadvantages of mitral valve replacement with a bioprosthesis in the long-term may not play an important role if the shorter life expectancy of older patients is taken into account. This study aims to evaluate whether mitral valve replacement in the elderly is associated with similar outcome compared to repair in the short- and long-term. All patients aged 70 years and older undergoing minimally invasive mitral valve surgery were studied retrospectively. Primary outcome was 30-day complication rate, secondary outcome was long-term survival and freedom from re-operation. 223 Patients underwent surgery (124 replacement and 99 repair) with a mean age of 76.4 ± 4.2 years. 30-Day complication rate (replacement 73.4% versus repair 67.7%; p=.433), 30-day mortality (replacement 4.0% versus repair 1.0%; p=.332) and 30-day stroke rate (replacement 0.0% versus repair 1.0%; p=.910) were similar in both groups. Multivariable cox regression revealed higher age, diabetes and left ventricular dysfunction as predictors for reduced long-term survival, while a valve replacement was no predictor for reduced survival. Sub analysis of patients with degenerative disease showed no difference in long-term survival after propensity weighting (HR 1.4; 95%CI 0.84 - 2.50; p=.282). The current study reveals that mitral valve repair and replacement in the elderly can be achieved with good short- and long-term results. Long-term survival was dependent on patient related risk factors and not on the type of operation (replacement versus repair)., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objectives: In patients with deep sternal wound infection (DSWI), primary closure of the sternal bone over high negative pressure Redon drains has shown to be a safe and feasible treatment method. Addition of local gentamicin could accelerate healing and improve clinical outcomes., Methods: We conducted a randomized controlled trial to evaluate the effectiveness of local gentamicin in the treatment of DSWI. In the treatment group, collagenous carriers containing gentamicin were left between the sternal halves during sternal refixation. In the control group, no local antibiotics were used. Primary outcome was hospital stay. Secondary outcomes were mortality, reoperation, wound sterilization time, time till removal of all drains and duration of intravenous antibiotic treatment., Results: Forty-one patients were included in the trial of which 20 were allocated to the treatment group. Baseline characteristics were similar in both groups. Drains could be removed after a median of 8.5 days in the treatment group and 14.5 days in the control group (P-value: 0.343). Intravenous antibiotics were administered for a median of 23.5 days in the treatment group and 38.5 days in the control group (P-value: 0.343). The median hospital stay was 27 days in the treatment group and 28 days in the control group (P-value: 0.873). Mortality rate was 10% in the treatment group and 9.5% in the control group (P-value: 0,959). No side effects were observed., Conclusions: This randomized controlled trial showed that addition of local gentamicin in the treatment of DSWI did not result in shorter length of stay., Clinical Trial Registration Number: 2014-001170-33., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objective: The ELANA Heart Bypass System is a new sutureless technique for coronary anastomoses. A titanium clip connects the graft with the coronary artery, whereafter the arteriotomy is performed by excimer laser. Since this anastomotic construction evidently differs from the standard hand-sewn anastomosis, we aim to evaluate the process of anastomotic healing and remodeling. Methods: Preclinical evaluation of anastomotic remodeling in 42 pigs who underwent off-pump left internal mammary artery to left anterior descending artery anastomosis by either the ELANA Heart Bypass ( n  = 24) or the hand-sewn ( n  = 18) technique. Anastomotic remodeling was evaluated by scanning electron microscopy and histology in short-term follow-up intervals up to 3 months. Anastomotic patency is determined by coronary angiography at latest follow-up before termination. Results: The nonendothelial surface of both the ELANA and the hand-sewn anastomoses were covered with neointima from 14 days onwards. Only half the amount of intima hyperplasia was present in the anastomotic surface of the patent ELANA anastomosis, compared with the hand-sewn anastomosis (98 [48-1358] vs 218 [108-296] µm, P  = 0.001). Yet patency of the ELANA was inferior to the hand-sewn anastomoses (79% vs 100%, P  = 0.06). Conclusions: This study shows the technical perioperative feasibility of the ELANA Heart Bypass System. Although limited intima hyperplasia was observed, hand-sewn anastomoses had superior patency during follow-up. The results of this trial suggest that an additional study with a new prototype is required before clinical implementation.

Background: To which extent atrial remodeling occurs before atrial fibrillation (AF) is unknown., Objective: The PREventive left atrial appenDage resection for the predICtion of fuTure Atrial Fibrillation (PREDICT-AF) study investigated such subclinical remodeling, which may be used for risk stratification and AF prevention., Methods: Patients (N = 150) without a history of AF with a CHA 2 DS 2 -VASc score of ≥2 at an increased risk of developing AF were included. The left atrial appendage was excised and blood samples were collected during elective cardiothoracic surgery for biomarker discovery. Participants were followed for 2 years with Holter monitoring to determine any atrial tachyarrhythmia after a 50-day blanking period., Results: Eighteen patients (12%) developed incident AF, which was associated with increased tissue gene expression of collagen I (COL1A1), collagen III (COL3A1), and collagen VIII (COL8A2), tenascin-C (TNC), thrombospondin-2 (THBS2), and biglycan (BGN). Furthermore, the fibroblast activating endothelin-1 (EDN1) and sodium voltage-gated channel β subunit 2 (SCN2B) were associated with incident AF whereas the Kir2.1 channel (KCNJ2) tended to downregulate. The plasma levels of COL8A2 and TNC correlated with tissue expression and predicted incident AF. A gene panel including tissue KCNJ2, COL1A1, COL8A2, and EDN1 outperformed clinical prediction models in discriminating incident AF., Conclusion: The PREDICT-AF study demonstrates that atrial remodeling occurs long before incident AF and implies future potential for early patient identification and therapies to prevent AF (ClinicalTrials.gov identifier NCT03130985)., (Copyright © 2021 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Objective: This preclinical study determines the feasibility and 6-month patency rates of a new distal coronary connector, the Excimer Laser Assisted Nonocclusive Anastomosis (ELANA) Heart Bypass., Methods: Twenty Dutch Landrace pigs received either a hand-sewn ( n = 8) or an ELANA ( n = 12) left internal thoracic artery to left anterior descending artery anastomosis, using off-pump coronary artery bypass grafting. Six-month patency rates were demonstrated by coronary angiography and histological evaluation. Throughout, procedural details and complication rates were collected., Results: The ELANA Heart Bypass demonstrated 0% mortality and complication rates during follow-up. It was demonstrated feasible, with comparable perioperative flow measurements (ELANA vs hand-sewn, median [min to max], 24 [14 to 28] vs 17 [12 to 31] mL/min; P = 0.601) and fast construction times (3 [3 to 7] vs 31 [26 to 37] min; P < 0.001). Yet, an extra hemostatic stitch was needed in 25% of the ELANA versus 12.5% of the hand-sewn anastomoses. The 6-month patency rate of the ELANA Heart Bypass was 83.3% versus 100% in hand-sewn anastomoses. The 2 occluded ELANA-anastomoses were defined model-based errors., Conclusions: The ELANA Heart Bypass facilitates a sutureless distal coronary anastomosis. A design change is suggested to improve hemostasis and will be evaluated in future translational studies. This new technique is a potential alternative to hand-sewn anastomoses in (minimally invasive) coronary surgery.

Introduction: Totally thoracoscopic ablation for symptomatic atrial fibrillation (AF) refractory to drug or catheter based therapy is indicated as a Class 2A recommendation according to latest guidelines. Evidence for long-term rhythm control and stroke reduction is limited. The aim of this study was to report on long-term outcome after totally thoracoscopic ablation., Methods and Results: In total 82 consecutive patients were included that underwent totally thoracoscopic ablation including left appendage closure (2012-2013). The primary outcome was freedom from atrial arrhythmia recurrence. Secondary outcomes were survival, freedom from cerebrovascular events, freedom from reablation and definite pacemaker implantation. The mean age was 59.9 ± 8.6 years and 71% were male. The mean CHA 2 DS 2 -VASc score was 1.2 ± 1.0. The overall freedom from atrial arrhythmia was 60% after a mean follow up of 4.0 ± 0.6 years. Freedom from cerebrovascular events was 98.8% after mean follow-up of 4.4 ± 0.3 years and overall survival was 98.8%, with one noncardiac related death. The observed rate of ischemic stroke, hemorrhagic stroke or transient ischemic attack was 0.3 per 100 patient-years., Conclusions: Totally thoracoscopic ablation is an effective sustainable rhythm control therapy for AF with a reasonable recurrence rate and low stroke rate when performed in dedicated AF centers., (© 2019 Wiley Periodicals, Inc.)

Aims: To perform a systematic outcome analysis in order to provide cardiologists and general pactitioners with more adequate information to guide their decision making regarding rhythm control. Totally thoracoscopic maze (TTmaze) for the treatment of atrial fibrillation (AF) is recommended as a Class 2a indication mainly based on single centre studies including small patient cohorts and inconsistent lesion sets., Methods and Results: We studied consecutive patients undergoing TTmaze in three European referral centres (2012-15). Primary outcome was freedom from atrial tachyarrhythmia (ATA). Secondary outcomes were 30-day complications, the composite endpoint of ischaemic stroke, haemorrhagic stroke or transient ischaemic attack (TIA), all-cause mortality, and predictors of ATA recurrence. Four hundred and seventy-five patients were included, with a mean age of 61 ± 9 years and 69.5% male. The mean CHA2DS2-VASc score was 1.7 ± 1.3. The overall freedom from ATA was 68.8% after a mean follow-up period of 20 ± 9 months. Freedom from ATA was 72.7% for paroxysmal AF, 68.9% for persistent AF, and 54.2% for longstanding persistent AF. Multivariate analysis revealed female gender [hazard ratio (HR): 1.87, P = 0.005], in-hospital AF (HR: 1.95, P = 0.040), longer duration of preoperative AF (HR: 1.06, P = 0.003) and mitral regurgitation (HR: 1.84, P = 0.025) as independent predictors of ATA recurrence. Overall 30-day freedom from any complication was 92.4%. Freedom from cerebrovascular events after mean follow-up of 30 ± 16 months was 98.7% and overall survival was 98.3%. The observed rate of ischaemic stroke, haemorrhagic stroke, or TIA was low (0.5 per 100 patient-years)., Conclusion: Totally thoracoscopic maze is a safe and effective rhythm control therapy., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: journals.permissions@oup.com.)

Aims: Our objectives were to compare effectiveness and long-term prognosis after epicardial thoracoscopic atrial fibrillation (AF) ablation vs. endocardial catheter ablation, in patients with prior failed catheter ablation or high risk of failure., Methods and Results: Patients were randomized to thoracoscopic or catheter ablation, consisting of pulmonary vein isolation with optional additional lines (2007-2010). Patients were reassessed in 2016/2017, and those without documented AF recurrence underwent 7-day ambulatory electrocardiography. The primary rhythm outcome was recurrence of any atrial arrhythmia lasting >30 s. The primary clinical endpoint was a composite of death, myocardial infarction, or cerebrovascular event, analysed with adjusted Cox proportional hazard ratios (HRs). One hundred and 24 patients were randomized with 34% persistent AF and mean age 56 years. Arrhythmia recurrence was common at mean follow-up of 7.0 years, but substantially lower with thoracoscopic ablation: 34/61 (56%) compared with 55/63 (87%) with catheter ablation [adjusted HR 0.40, 95% confidence interval (CI) 0.25-0.64; P < 0.001]. Additional ablation procedures were performed in 8 patients (13%) compared with 31 (49%), respectively (P < 0.001). Eleven patients (19%) were on anti-arrhythmic drugs at end of follow-up with thoracoscopy vs. 24 (39%) with catheter ablation (P = 0.012). There was no difference in the composite clinical outcome: 9 patients (15%) in the thoracoscopy arm vs. 10 patients (16%) with catheter ablation (HR 1.11, 95% CI 0.40-3.10; P = 0.84). Pacemaker implantation was required in 6 patients (10%) undergoing thoracoscopy and 3 (5%) in the catheter group (P = 0.27)., Conclusion: Thoracoscopic AF ablation demonstrated more consistent maintenance of sinus rhythm than catheter ablation, with similar long-term clinical event rates., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Aims: Thoracoscopic surgical ablation has evolved into a successful strategy for symptomatic atrial fibrillation (AF) refractory to other therapy. More widespread referral is limited by the lack of information on potential complications. Our aim was to systematically evaluate 30-day complications of totally thoracoscopic surgical ablation., Methods and Results: We retrospectively studied consecutive patients undergoing totally thoracoscopic surgical ablation at a referral centre in the Netherlands (2007-2016). Patients received pulmonary vein isolation, with additional lesion lines as needed, and left atrial appendage exclusion. The primary outcomes were freedom from any complications and freedom from irreversible complications at 30-days. Secondary outcomes included intra- and post-operative complications according to severity. Included were 558 patients with median age 62 years (interquartile range 56-68 years), 70% male and 53% with a previous failed catheter ablation. The cohort consisted of 43% paroxysmal AF, 47% persistent AF, and 10% long-standing persistent AF. Freedom from any 30-day complication was 88.2%, and from complications with life-long affecting consequences 97.5%. The intra-operative complication rate was 2.3% with no strokes or death observed. The median hospital length of stay was 4 days. The percentage of patients with major and minor complications at 30-days was 3.2% and 8.1%, respectively, with one patient dying of an ischaemic stroke. The only patient groups with excess complications were women aged ≥70 years and patients with a history of congestive heart failure., Conclusions: Totally thoracoscopic ablation is associated with a low complication rate in a referral centre and may be a useful alternative to other rhythm control strategies.

Since the introduction of thoracoscopic ablation for atrial fibrillation (AF), the field of minimally invasive AF treatment has evolved toward an established treatment option for AF, with an overall 2-year antiarrhythmic drug free success rate of 77%. Complications are usually minor, and the incidence of bleeding needing conversion to sternotomy or (mini-)thoracotomy varies between 0% and 1.6%. Bleeding is often related to encircling the pulmonary veins, which is a blind maneuver that has to be done without direct camera vision. We propose here a modified surgical technique to simplify the procedure, shorten the operating time, and lower the risk of complications.

Aim: To evaluate changes in pulmonary function tests (PFTs) at different follow-up durations after stereotactic body radiotherapy (SBRT) and surgery in stage I and II non-small-cell lung cancer (NSCLC)., Patients and Methods: Differences between pre-treatment- and follow-up PFTs were analyzed in 93 patients treated with surgery and 30 patients treated with SBRT for NSCLC. Follow-up durations were categorized into: early (0-9 months), middle (10-21 months) and late (≥22 months). Wilcoxon signed-rank test was used to analyze differences between pre-treatment and follow-up PFTs., Results: Forced expiratory volume in one second, forced vital capacity and diffusion capacity for carbon monoxide corrected for the actual hemoglobin level significantly diminished after surgery for all follow-up durations: 11-17% of predicted values. After SBRT, PFTs remained stable, but a declining trend of 6% (p=0.1) was observed after 22 months., Conclusion: SBRT might lead to less treatment-related toxicity measured by PFTs than surgery in both the short and long term., (Copyright© 2015 International Institute of Anticancer Research (Dr. John G. Delinassios), All rights reserved.)

Background: Surgical resection is the treatment of first choice for patients with stage I-II non-small cell lung cancer (NSCLC). However, stereotactic body radiotherapy (SBRT) has been shown to be a good alternative treatment., Patients and Methods: Overall survival (OS), progression-free survival (PFS) and recurrence rates were compared between patients with stage I-II NSCLC treated with SBRT (n=53) and those treated with surgical resection (n=175). The propensity score method was used to correct for confounding by indication., Results: Before correction, the OS and PFS rates at 1 and 3 years were significantly different between SBRT and surgery, in favor of surgery. After correction, the OS and PFS after SBRT were not significantly different compared to surgery. The recurrence rates for the two treatments were also similar both before and after correction., Conclusion: This retrospective study showed that clinical outcomes after SBRT are equal to those after surgery in patients with stage I-II NSCLC., (Copyright© 2015 International Institute of Anticancer Research (Dr. John G. Delinassios), All rights reserved.)

Introduction: Isolated lung perfusion (ILuP) is an experimental surgical technique for the treatment of pulmonary metastases. Phase I trials showed a wide range in drug lung levels. This may be due to the variance of lung size and pulmonary intravascular volume (PIV). Therefore, we developed a method to assess PIV and investigated the relation of PIV and dry lung weight (DLW)., Material and Methods: Thirty-two rats of 555+/-8 and 199+/-5g underwent left ILuP two, four and eight minutes. Venous effluent was analyzed for haemoglobin, red blood cells (RBC), leucocytes, platelets, albumin and creatinine. PIV was calculated by dividing the product of perfusate volume and post-ILuP parameter by the difference between post-ILuP and pre-ILuP parameter., Results: No significant differences in PIV for all perfusion times were noted between the different variables (P=0.14). Based on haemoglobin (P<0.0009), RBC (P=0.006), leucocytes (P=0.0003), platelets (P=0.017) and creatinine (P=0.003) analysis, PIV was significantly smaller in rats of 199g while PIV/DLW ratio was not significantly different., Conclusion: Because PIV/DLW ratio is independent of body weight, we advocate PIV calculation using haemoglobin and RBC as an excellent parameter for drug dose calculation during ILuP intraoperatively in order to achieve more reproducible local drug levels and higher efficacy.

Objective: Increased restenosis rates have been reported after stenting long lesions with multiple standard length stents. Long slotted tube stents have become available for the treatment of long lesions or dissections. To compare clinical outcome after the use of long Multi-Link stents in long coronary lesions versus standard length Multi-Link stents in Benestent type lesions., Methods and Results: We evaluated clinical outcome (six months) of 147 consecutive patients in whom one or more > or = 25 mm long Multi-Link stents were successfully deployed. The results were compared with the West-2 registry in which a 15 mm Multi-Link stent was used. The patients with long stents had more complex lesions and unstable symptoms. Target lesion revascularization after six months follow-up was comparable with that observed after implantation of a standard length stent (6.9% vs. 6.1%, p = 0.81). Overall cardiac event-free survival was similar for both groups (89.7% vs. 91.5%, p = 0.73)., Conclusions: Patients treated with one or more long (> or = 25 mm) Multi-Link stents have a similar event-free survival and an equivalent target lesion repeat revascularization risk after six months than patients treated with a standard length stent.