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Competing Interests: Declaration of competing interest The authors declare the following financial interests and/or personal relationships that may be considered potential competing interests: All authors report financial support and employment by University Medical Centre Groningen.

The purpose of this study is to evaluate the diagnostic and therapeutic yield of a specialized clinic for children with suspicion of a hereditary thoracic aortic disease (HTAD), including Marfan Syndrome (MFS), and to investigate the diagnostic value of presenting symptoms and findings during evaluation. This retrospective observational study included all patients younger than 18 years old at initial referral between 1998 and 2018. Clinical data, medical treatment, surgical interventions, and clinical events during surveillance were collected until December 2023. A case-control comparison between patients with and without an eventual diagnosis of HTAD was performed using logistic regression analysis to investigate the diagnostic value of collected variables. A total of 355 children were referred and evaluated at the clinic, resulting in 89 new diagnoses, with a diagnostic yield of 21% HTAD, including 59 cases of MFS. Younger age at referral, ectopia lentis, aortic dilatation, and facial features were among the strongest predictors of MFS and other HTAD, while pectus excavatum and arm span-height ratio had no predictive value at childhood age. Of patients with MFS, 65% received antihypertensive medication, and 8% of patients with HTAD underwent prophylactic aortic surgery, in some cases even during childhood. Conclusion: Evaluation of children for HTAD in our specialized Marfan clinic resulted in a high diagnostic yield and subsequent therapeutic implications. Indeed, early recognition of symptoms and signs and referral to such a specialized clinic may lead to early diagnosis, surveillance, and timely treatment, thereby possibly limiting acute aortic events and even mortality., Competing Interests: Declarations Ethical approval The study was approved by the Ethical Review Board of the UMCG. The need for patient consent was waived due to the retrospective nature of the study. Competing interest The authors declare no competing interests., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objectives: Anomalous aortic origin of a coronary artery (AAOCA) is a group of rare congenital heart defects with various clinical presentations. The lifetime-risk of an individual living with AAOCA is unknown, and data from multicentre registries are urgently needed to adapt current recommendations and guide optimal patient management. The European AAOCA Registry (EURO-AAOCA) aims to assess differences with regard to AAOCA management between centres., Methods: EURO-AAOCA is a prospective, multicentre registry including 13 European centres. Herein, we evaluated differences in clinical presentations and management, treatment decisions and surgical outcomes across centres from January 2019 to June 2023., Results: A total of 262 AAOCA patients were included, with a median age of 33 years (12-53) with a bimodal distribution. One hundred thirty-nine (53.1%) were symptomatic, whereas chest pain (n = 74, 53.2%) was the most common complaint, followed by syncope (n = 21, 15.1%). Seven (5%) patients presented with a myocardial infarction, 2 (1.4%) with aborted sudden cardiac death. Right-AAOCA was most frequent (150, 57.5%), followed by left-AAOCA in 51 (19.5%), and circumflex AAOCA in 20 (7.7%). There were significant differences regarding diagnostics between age groups and across centres. Seventy-four (28.2%) patients underwent surgery with no operative deaths; minor postoperative complications occurred in 10 (3.8%) cases., Conclusions: Currently, no uniform agreement exists among European centres with regard to diagnostic protocols and clinical management for AAOCA variants. Although surgery is a safe procedure in AAOCA, future longitudinal outcome data will hopefully shed light on how to best decide towards optimal selection of patients undergoing revascularization versus conservative treatment., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

Objective: Compared with fresh frozen plasma (FFP), Omniplasma has been attributed to an increased coagulation potential and an increased fibrinolytic potential. This study aimed to compare Omniplasma and FFP used for cardiopulmonary bypass (CPB) priming regarding the incidence of postoperative thrombotic or hemorrhagic complications and outcomes in pediatric patients undergoing cardiac surgery., Design: A retrospective observational cohort study SETTING: This single-center study was performed at the University Medical Center Groningen., Participant: All pediatric patients up to 10 kg undergoing cardiac surgery with CPB., Interventions: Procedures in which FFP was used for CPB priming were compared with those in which Omniplasma was used., Measurements and Main Results: The primary outcome parameter was a composite endpoint consisting of the following: (1) pediatric intensive care unit (PICU) mortality, (2) thromboembolic complications, and (3) hemorrhagic complications during PICU stay. The authors included 143 procedures in the analyses, 90 (63%) in the FFP group and 53 (37%) in the Omniplasma group. The occurrence of the combined primary endpoint (FFP 20% v Omniplasma 11%, p = 0.18) and its components did not differ between the used CPB priming agent). Omniplasma for CPB priming was associated with decreased unfractionated heparin administration per kg bodyweight (585 IU v 510 IU, p = 0.03), higher preoperative and postoperative activated clotting times (ACT) discrepancy (90% v 94%, p = 0.03), a lower postoperative ACT value (125 v 118 seconds, p = 0.01), and less red blood cell transfusion per kilogram bodyweight (78 v 55 mL, p = 0.02). However, none of the variables differed statistically significantly in the multivariate logistic regression analyses., Conclusions: The authors did not find an association between the plasma used for CPB priming and thromboembolic and hemorrhagic complications and death in neonates and infants undergoing cardiac surgery. Omniplasma seems to be safe to use in this population., Competing Interests: Declaration of competing interest None., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: The number of patients with an arterial switch operation (ASO) for transposition of the great arteries (TGA) is steadily growing; limited information is available regarding the clinical course in the current era., Objectives: The purpose was to describe clinical outcome late after ASO in a national cohort, including survival, rates of (re-)interventions, and clinical events., Methods: A total of 1,061 TGA-ASO patients (median age 10.7 years [IQR: 2.0-18.2 years]) from a nationwide prospective registry with a median follow-up of 8.0 years (IQR: 5.4-8.8 years) were included. Using an analysis with age as the primary time scale, cumulative incidence of survival, (re)interventions, and clinical events were determined., Results: At the age of 35 years, late survival was 93% (95% CI: 88%-98%). The cumulative re-intervention rate at the right ventricular outflow tract and pulmonary branches was 36% (95% CI: 31%-41%). Other cumulative re-intervention rates at 35 years were on the left ventricular outflow tract (neo-aortic root and valve) 16% (95% CI: 10%-22%), aortic arch 9% (95% CI: 5%-13%), and coronary arteries 3% (95% CI: 1%-6%). Furthermore, 11% (95% CI: 6%-16%) of the patients required electrophysiological interventions. Clinical events, including heart failure, endocarditis, and myocardial infarction occurred in 8% (95% CI: 5%-11%). Independent risk factors for any (re-)intervention were TGA morphological subtype (Taussig-Bing double outlet right ventricle [HR: 4.9, 95% CI: 2.9-8.1]) and previous pulmonary artery banding (HR: 1.6, 95% CI: 1.0-2.2)., Conclusions: TGA-ASO patients have an excellent survival. However, their clinical course is characterized by an ongoing need for (re-)interventions, especially on the right ventricular outflow tract and the left ventricular outflow tract indicating a strict lifelong surveillance, also in adulthood., Competing Interests: Support was received from the Netherlands Cardiovascular Research lnitiative: An initiative with support of the Dutch Heart Foundation and Hartekind, CVON2019-002 OUTREACH. The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (© 2024 The Authors.)

Objectives: The most recent valve-sparing root replacement technique combines the advantages of the reimplantation (David) and remodelling (Yacoub) techniques. The aortic root is reconstructed according to the remodelling technique, the aortic valve is repaired according to the principle of effective height, and an external ring provides annular support. The purpose of this study was to evaluate operative and mid-term outcomes using this technique in patients with Marfan syndrome., Methods: Adult patients with Marfan syndrome who had an indication for aortic root surgery according to European Society of Cardiology guidelines and were operated on using this new root replacement technique were retrospectively evaluated. Follow-up was obtained from standard outpatient visits and included echocardiography., Results: The study group comprised 22 patients (mean age 36 years, 68% males). Mean follow-up was 7.5 years. There were no mortalities. Two patients required aortic valve replacement because of aortic regurgitation. In both patients, the aortic root was severely dilated (≥65 mm) preoperatively, with grade III aortic valve regurgitation and aortic valve cusps that were very fragile. Aortic regurgitation was grade ≤I on follow-up in 18 of the remaining 20 patients., Conclusions: Valve-sparing root replacement using remodelling combined with aortic-ring annuloplasty is safe in patients with Marfan syndrome. The mid-term outcome is promising in patients undergoing elective valve-sparing root replacement at recommended root diameters. However, in patients with extremely dilated aortic roots and already severe aortic regurgitation, the technique should be used cautiously as aortic cusps are fragile and might not be suitable for durable repair., Clinical Registration Number: UMCG Research registry #11208., (© Crown copyright 2023.)

Background: Neonates with critical congenital heart disease (CCHD) undergoing cardiac surgery with cardiopulmonary bypass (CPB) are at risk of brain injury that may result in adverse neurodevelopment. To date, no therapy is available to improve long-term neurodevelopmental outcomes of CCHD neonates. Allopurinol, a xanthine oxidase inhibitor, prevents the formation of reactive oxygen and nitrogen species, thereby limiting cell damage during reperfusion and reoxygenation to the brain and heart. Animal and neonatal studies suggest that allopurinol reduces hypoxic-ischemic brain injury and is cardioprotective and safe. This trial aims to test the hypothesis that allopurinol administration in CCHD neonates will result in a 20% reduction in moderate to severe ischemic and hemorrhagic brain injury., Methods: This is a phase III, randomized, quadruple-blinded, placebo-controlled, multicenter trial. Neonates with a prenatal or postnatal CCHD diagnosis requiring cardiac surgery with CPB in the first 4 weeks after birth are eligible to participate. Allopurinol or mannitol-placebo will be administered intravenously in 2 doses early postnatally in neonates diagnosed antenatally and 3 doses perioperatively of 20 mg/kg each in all neonates. The primary outcome is a composite endpoint of moderate/severe ischemic or hemorrhagic brain injury on early postoperative MRI, being too unstable for postoperative MRI, or mortality within 1 month following CPB. A total of 236 patients (n = 188 with prenatal diagnosis) is required to demonstrate a reduction of the primary outcome incidence by 20% in the prenatal group and by 9% in the postnatal group (power 80%; overall type 1 error controlled at 5%, two-sided), including 1 interim analysis at n = 118 (n = 94 with prenatal diagnosis) with the option to stop early for efficacy. Secondary outcomes include preoperative and postoperative brain injury severity, white matter injury volume (MRI), and cardiac function (echocardiography); postnatal and postoperative seizure activity (aEEG) and regional cerebral oxygen saturation (NIRS); neurodevelopment at 3 months (general movements); motor, cognitive, and language development and quality of life at 24 months; and safety and cost-effectiveness of allopurinol., Discussion: This trial will investigate whether allopurinol administered directly after birth and around cardiac surgery reduces moderate/severe ischemic and hemorrhagic brain injury and improves cardiac function and neurodevelopmental outcome in CCHD neonates., Trial Registration: EudraCT 2017-004596-31. Registered on November 14, 2017. ClinicalTrials.gov NCT04217421. Registered on January 3, 2020., (© 2022. The Author(s).)

Objective: During ligation of the ductus arteriosus, cerebrovascular autoregulation (CAR) may deteriorate. It is unknown whether different surgical approaches affect changes in CAR differently. The objective of this study was to compare the potential change in CAR in preterm infants during and after ligation comparing two surgical approaches: sternotomy and posterolateral thoracotomy. Design: This was an observational cohort pilot study. Setting: Level III NICU. Patients: Preterm infants (GA < 32 weeks) requiring ductal ligation were eligible for inclusion. Interventions: Halfway the study period, our standard surgical approach changed from a posterolateral thoracotomy to sternotomy. We analyzed dynamic CAR, using an index of autoregulation (COx) correlating cerebral tissue oxygen saturation and invasive arterial blood pressure measurements, before, during, and after ligation, in relation to the two approaches. Measurements and Main Results: Of nine infants, four were approached by thoracotomy and five by sternotomy. Median GA was 26 (range: 24.9-27.9) weeks, median birth weight (BW) was 800 (640-960) grams, and median post-natal age (PNA) was 18 (15-30) days, without differences between groups. COx worsened significantly more during and after thoracotomy from baseline (Δρ from baseline: during surgery: Δ + 0.32, at 4 h: Δ + 0.36, at 8 h: Δ + 0.32, at 12 h: Δ + 0.31) as compared with sternotomy patients (Δρ from baseline: during surgery: Δ + 0.20, at 4 h: Δ + 0.05, at 8 h: Δ + 0.15, at 12 h: Δ + 0.11) ( F = 6.50; p = 0.038). Conclusions: In preterm infants, CAR reduced significantly during and up to 12 h after ductal ligation in all infants, but more evident during and after posterolateral thoracotomy as compared with sternotomy. These results need to be confirmed in a larger population., (Copyright © 2020 Kooi, van der Laan, Accord, Roofthooft, Aries and Elting.)

Background: Pulmonary valve replacement is very common among patients with congenital heart disease. The Carpentier Edwards Perimount valve (Edwards Lifesciences, Irvine, Calif), which was originally designed for the aortic position is among the most implanted valves. We aim to describe the follow-up of this valve in the pulmonary position., Methods: Patients with a Perimount valve implanted between 2003 and 2013 in the University Medical Center Groningen were followed for the primary end point reintervention, defined as surgical or transcatheter valve replacement. Secondary end point was the occurrence of valve failure, defined as significant valvular regurgitation or stenosis. Explanted valves were histologically examined., Results: Forty-five patients (median age at operation 27.8 years, 55.6% women) had a mean follow-up duration of 5.8 ± 3.3 years. There were 7 reinterventions (5 surgical and 2 transcatheter). Freedom from reintervention was respectively 95% ± 4% and 83% ± 8% at 5- and 10- years of follow-up. Freedom from valve failure was 75% ± 4% at 2 years, 65% ± 8% at 5 years of follow-up and 57% ± 10% at 10 years of follow-up. Morphology evaluation (n = 4) showed stiffened valves in the open position, with extensive fibrous tissue overgrowth on the leaflets and a variable proliferation of myofibroblasts., Conclusions: The Perimount valve has adequate function in the pulmonary valve position at 5 years of follow-up, although after 10 years of follow-up valve failure and reinterventions are common. Explanted valves show retraction and stiffening of the leaflets due to a fibrotic layer on both sides of the leaflet., (Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: We sought to determine the indications, type, and outcomes of reoperations on the aortic root after repair of tetralogy of Fallot (TOF)., Methods: Eleven centers belonging to the European Congenital Heart Surgeons Association contributed to the data collection process. We included 36 patients who underwent surgical procedures on the aortic root, including surgery on the aortic valve and ascending aorta, between January 1975 and December 2017. Original diagnoses included TOF-pulmonary stenosis (n = 18) and TOF-pulmonary atresia (n = 18). The main indications for reoperation were aortic insufficiency (n = 19, 53%), aortic insufficiency and dilatation of the ascending aorta (n = 10, 28%), aortic root dilatation (n = 4, 11%), and ascending aorta dilatation (n = 3, 8%)., Results: The median age at reoperation was 30.4 years (interquartile range 20.3-45.3 years), and mechanical aortic valve replacement was the most common procedure performed. Five patients died early after reoperation (14%), and larger ascending aorta diameters were associated with early mortality (P = .04). The median age at the last follow-up was 41.4 years (interquartile range 24.5-51.6 years). Late death occurred in five patients (5/31, 16%). Most survivors (15/26, 58%) were asymptomatic at the last clinical examination (New York Heart Association, NYHA class I). The remaining patients were NYHA class II (n = 7) and III (n = 3). The most common symptoms were fatigue (n = 5), dyspnea (n = 4), and exercise intolerance (n = 3)., Conclusions: Reoperations on the aortic root are infrequent but may become necessary late after TOF repair. The main indications for reoperation are aortic insufficiency, either isolated or associated with a dilatation of the ascending aorta. The surgical risk at reoperation was high and the presence of ascending aorta dilation is related to higher mortality., (© 2019 Wiley Periodicals, Inc.)

Background: To date, a posterolateral thoracotomy approach is considered the gold standard for surgical closure of patent ductus arteriosus (PDA), also in preterm neonates. However, a posterolateral thoracotomy approach can induce post-thoracotomy lung injury of the immature and vulnerable lungs of preterm neonates. Therefore, this study aims to compare a posterolateral thoracotomy and median sternotomy for surgical closure of PDA in preterm neonates., Methods: Between September 2010 and November 2014, both surgical approaches were used to treat a symptomatic PDA in very and extremely preterm neonates. The hospital records of all these neonates were retrospectively reviewed to assess all-cause mortality and postoperative morbidity in both groups., Results: Despite comparable preoperative patient profiles, the postoperative pulmonary complication rate was significantly lower in the median sternotomy group (52.9% vs 94.7%; P = .006). Moreover, significantly lower mean airway pressures (MAPs) were seen in the median sternotomy group directly after surgery (ΔMAP median [interquartile range], 0.00 [2.13] vs 0.80 [1.67] cmH 2 O; P = .025). Postoperative blood transfusion (median [interquartile range], 20 [14] vs 17 [16] mL; P = .661) rates did not differ between both approaches. In addition, Kaplan-Meier survival analysis demonstrated no statistically significant differences between both groups., Conclusions: In our experience, a median sternotomy approach for surgical PDA closure is at least noninferior to a posterolateral thoracotomy approach. Given the lower postoperative pulmonary complication rate and lower postoperative MAPs directly after surgery, the median sternotomy approach may be considered superior for preterm neonates with immature and vulnerable lungs., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

An acute aortic dissection of the pulmonary autograft with a free rupture of the neoaortic wall is a rare complication after a Ross procedure. In this case, the intimal tear was localized in the noncoronary sinus of the pulmonary autograft and the neoaortic wall was ruptured in the involved sinus area. The dissection was contained in the pulmonary autograft. This report describes a successful aortic root replacement of a patient with the clinical symptoms of an acute aortic type A dissection with a free rupture of the neoaortic wall., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

In neonates with interrupted aortic arch and severe left ventricular outflow tract obstruction full relief of left ventricular outflow tract obstruction and adequate aortic arch repair is required. It has been shown that neonatal Ross-Konno provides adequate and durable relieve of left ventricular outflow tract gradient. Additional aortic arch repair using the swing-back technique provides a simplified reconstruction of the arch with a tension-free, direct anastomosis. We describe the technique and results of our experience in 3 neonates., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: We investigated the impact and the predictive value of sinus rhythm at 12 months (SR12) on subscales of three different HrQoL questionnaires: SF-36., EuroQoL and MFI 20., Methods: Data of 125 cardiac surgery patients with pre-operative AF from our previous randomized trial were used. Based on their rhythm outcome patients were divided in two groups: SR12 or AF at 12 months follow up (non-SR12). All questionnaires were self-administered pre-operatively and at 3 months, 6 months and 12 months after surgery., Results: Synus rhytm at 12 months was predictive of improvement of SF36- mental score (MS, p = 0.021), Euro-QoL-MS (p = 0.009), VAS (p = 0.006), and MFI 20-MS (p = 0.009). We failed to find any significant interactions between SR12 and any of the other significant risk factors: age <65 years, paroxysmal type of AF and preoperative AF duration <12 months. In contrast, SR12 was not significant in predicting physical score (PS) subscales of any of the questionnaires (all, p > 0.05) which were predicted by age <65 years (SF36-PS, p = 0.029) by paroxysmal type of AF and age <65 years (Euro-QoL-PS, p = 0.017 and p = 0.04, respectively) and by AF duration <12 months, paroxysmal type of AF and age < 65 years (MFI 20-PS, p = 0.019, p = 0.020 and p = 0.015, respectively)., Conclusions: Specific mental-related HrQoL scales are much more sensitive to sinus rhythm conversion. Sinus rithm mantainance shows significant effects on mental scores independently of other cofactors. Successful conversion to sinus rhythm after surgical ablation during cardiac surgery does not significantly affect phisical health related quality of life during 1 year follow up.

Background: This study reports the outcomes of patients who underwent electrical cardioversion for atrial fibrillation recurrence following mitral valve surgery and associated radiofrequency ablation compared to those who did not undergo concomitant atrial fibrillation ablation., Methods: The population consisted of 116 patients with persistent/long-standing persistent AF who underwent mitral valve surgery with (Group A, n=54) or without (Group B, n=62) associated radiofrequency ablation between January 2007 and January 2011 at three institutions and who subsequently underwent cardioversion for persistent atrial fibrillation within 12 months of their initial procedure., Results: The mean follow-up duration was 30.7±9.4 months. Of the 104 patients with acute restoration of SR 42 (40.3%) had AF recurrence. The average time to recurrence after cardioversion was 7.3±4.2 days. Recurrence was significantly lower in patients undergoing ablation surgery (21.4%) than in those undergoing no ablation surgery (78.6%, p<0.001). Non-performed ablation procedure (p<0.001), time from surgery≥88 days and left atrial dimensions≥45.5 mm before cardioversion (both, p=0.005) were multivariable predictors of atrial fibrillation recurrence. In Group B the use of amiodarone was inversely correlated with recurrence of AF (p<0.001). This correlation was not significant (r=-0.02, p=0.85) in Group A., Conclusions: Electrical cardioversion for recurrent AF showed better results and stable recovery of sinus rhythm in patients undergoing concomitant surgical ablation during mitral valve surgery. This might be attributable to substrate modification caused by surgical lesions. Amiodarone improved the ECV-success rate only in patients with no associate ablation. Further larger randomized studies are necessary to confirm our findings., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Objectives: We investigated real-life oral anticoagulation (OAC) treatment after surgical ablation and examined its adherence to current recommendations. We also explored factors related to OAC use preoperatively and at follow-up., Methods: One hundred and fifteen patients with atrial fibrillation (AF) were evaluated during 12-month follow-up after surgery. Patients were divided into two categories according to the congestive heart failure, hypertension, age ≥75 years, diabetes and prior stroke [or transient ischaemic attack or thromboembolism] (CHADS2) score: 60 patients were assigned to the high-risk group (CHADS2 score ≥2) and 55 to the low-risk group (CHADS2 score ≤1). OAC use was defined as guideline adherent, undertreatment or overtreatment., Results: Baseline overall guideline adherence was 62%. OAC was underprescribed in high-risk patients and overprescribed in low-risk patients (both, P < 0.001). The only factor associated with OAC use after logistic regression analysis were age >75 years (P = 0.01) and preoperative AF > paroxysmal (P = 0.013). Overall guideline adherence at 12-month follow-up showed a trend towards a better adherence in the sinus rhythm (SR) subgroup (74% vs 55%, P = 0.02). OAC was underprescribed in high-risk patients and overprescribed in low-risk patients (both P < 0.001). After logistic regression analysis, preoperative OAC use (P = 0.007) and other indications for OAC (P = 0.01) were predictors of anticoagulation treatment., Conclusions: Real-life OAC prescription in AF patients showed a moderate guideline adherence, with high-risk patients being undertreated and low-risk patients being overtreated. These findings stress the importance that antithrombotic treatment in patients undergoing AF surgery needs to be critically re-evaluated.

The "hybrid" approach to multivessel coronary artery disease combines surgical left internal thoracic artery (LITA) to left anterior descending coronary artery (LAD) bypass grafting and percutaneous coronary intervention of the remaining lesions. Ideally, the LITA to LAD bypass graft is performed in a minimally invasive fashion. This review aims to clarify the place of hybrid coronary revascularization (HCR) in the current therapeutic armamentarium against multivessel coronary artery disease. Eighteen studies including 970 patients were included for analysis. The postoperative LITA patency varied between 93.0% and 100.0%. The mean overall survival rate in hybrid treated patients was 98.1%. Hybrid treated patients showed statistically significant shorter hospital length of stay (LOS), intensive care unit (ICU) LOS, and intubation time, less packed red blood cell (PRBC) transfusion requirements, and lower in-hospital major adverse cardiac and cerebrovascular event (MACCE) rates compared with patients treated by on-pump and off-pump coronary artery bypass grafting (CABG). This resulted in a significant reduction in costs for hybrid treated patients in the postoperative period. In studies completed to date, HCR appears to be a promising and cost-effective alternative for CABG in the treatment of multivessel coronary artery disease in a selected patient population.

This study was performed to assess the cost-effectiveness of concomitant ablation surgery (AS) compared to regular cardiac surgery in atrial fibrillation (AF) patients over a one-year follow-up. Cost analysis was performed from a societal perspective alongside a prospective, randomised, double-blinded, multicentre trial. One hundred and fifty patients with documented AF were randomly assigned to undergo cardiac surgery with or without AS. One hundred and thirty-two patients were included in the cost-effectiveness study. All costs (medical and non-medical) were measured during follow-up. Costs data were combined with quality adjusted life years (QALYs) to obtain the incremental costs per QALY. Total costs of the AS group were significantly higher compared to the regular cardiac surgery group [cost difference bootstrap: €4,724; 95% uncertainty interval (UI), €2,770-€6,678]. The bootstrapped difference in QALYs was not statistically significant (0.06; 95% UI: -0.024 to 0.14). The incremental cost-effectiveness ratio is €73,359 per QALY. The acceptability curve showed that, even in the case of a maximum threshold value of €80,000 per QALY gained, the probability of AS being more cost-effective than regular cardiac surgery did not reach beyond 50%. Concluding that concomitant AS in AF is not cost-effective after a one-year follow-up compared to regular cardiac surgery.

The surgical approach of the carotid artery for carotid endarterectomy demands knowledge of normal anatomy and anatomic variation. During carotid endarterectomy, a rare anatomic variant of the origin of the upper root of the ansa cervicalis was found. Contrary to commonly found anatomy, no upper root of the ansa cervicalis originating from the hypoglossal nerve was found. Instead, what seemed to be the ansa cervicalis originated from the vagus nerve and passed over the carotid bifurcation, branching to the infrahyoid muscles. Transection of this ansa cervicalis, for the purpose of good exposure, had no functional or cosmetic consequences., (Copyright (c) 2010 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.)

Introduction: This is a multicenter, prospective, randomized controlled trial to determine the effect of add-on arrhythmia surgery on health-related quality of life during 1-year follow-up of cardiac surgery patients with atrial fibrillation., Methods: 150 patients with documented atrial fibrillation were randomly assigned to undergo cardiac surgery with or without add-on surgery. Patients completed quality of life questionnaires, comprising the RAND 36-item Health Survey 1.0 (SF-36), Multidimensional Fatigue Inventory-20 (MFI-20) and EuroQoL (EQ-5D and VAS) at baseline and 3, 6, and 12 months following operation., Results: 132 patients completed the questionnaires at a minimum of one time-point during follow-up. At baseline patient characteristics, operative data and health-related quality of life were comparable. At 12-month follow-up 62 patients were free of atrial fibrillation without significant differences between groups (P = 0.28). Conversion to SR occurred in 69.8% (37/53) of patients with paroxysmal AF, in 28.2% (11/39) of patients with permanent AF and in 44.4% (12/27) of patients in persistent AF. Cardiac surgery in general resulted in an overall improvement of the RAND SF-36 and the MFI-20. However, the EQ-5D showed a significant deterioration in the subscale Pain/Discomfort for both groups (P < 0.001), with a significant worse outcome for the control group (P = 0.006)., Conclusions: Health-related quality of life in patients with paroxysmal, permanent and persistent atrial fibrillation improves after cardiac surgery regardless of giving add-on surgery or not, but this improvement is presumably more affected by treating the underlying heart disease than by restoring sinus rhythm.

Introduction: Intrapericardial (IPC) delivery of antiarrhythmic agents is an appealing idea to increase the therapeutic width and reduce side effects of drugs, particularly in the thin atria. The aim of this study was to determine the effects of IPC versus intravenous (IV) d,l-sotalol and flecainide infusion on transmural atrial electrophysiology and sustained atrial fibrillation (AF) in the goat., Methods and Results: Effects of IPC and IV sotalol and flecainide infusion on epi- and endocardial atrial electrophysiology, ECG, and tissue drug concentrations were studied in goats without and with persistent AF (>24 hours). Epicardial atrial refractory period (AERP, bcl 400 ms) increased after 120 minutes of 1 mg/kg/hour IPC sotalol with 61 +/- 8 ms (P = 0.02), whereas the endocardial AERP was not affected. One mg/kg/hour IPC flecainide increased the epicardial pacing threshold and the epicardial AERP with 4 +/- 0.5 mA (P = 0.003) and 33 +/- 11 ms (P = 0.05), respectively. Endocardial values were unchanged. Marked ST-elevations in the precordial ECG leads were observed after IPC flecainide. In the AF group, IPC drugs did not prolong AF cycle length to a greater extent than IV delivery. The number of cardioversions was not different between the two delivery routes. A steep transmural drug concentration gradient after IPC sotalol and flecainide was observed in all heart chambers., Conclusion: IPC sotalol and flecainide infusion in goats markedly affects epicardial atrial electrophysiology. IPC delivery, however, does not prolong AFCL or terminate AF to a greater extent than IV infusion. This suggests that the perpetuation of AF is not dominated by the epicardial and sub epicardial atrial layers.

Some patients in need of hemodynamic support do not respond to intra-aortic balloon pump (IABP) therapy. Hemodynamic stability can then be obtained by a more potent cardiac assist device, like the Impella catheter pump. Whether additional IABP support additional to Impella support can provide more optimal hemodynamic myocardial conditions is examined in this study. Seven sheep were implemented with IABP and Impella. An acute myocardial infarction was induced. Hemodynamic performance was assessed during baseline, during Impella support and IABP support individually, and during the combined Impella plus IABP support. The Impella support provided a reduction of afterload with 30% and an increase of coronary artery flow with 47%. The IABP increased coronary artery flow (13%), carotid artery flow (16%), and aortic ascending blood pressure (6%); a similar (but stronger) effect was provided when using the IABP support additional to Impella support and, respectively, increases of 33, 21, and 19% were established. The oxygen demand-supply ratio decreased by 25% due to the extra use of the IABP. A combination of IABP and Impella provides the most optimal hemodynamic myocardial conditions compared to either stand-alone support.

Background: Surgical pulmonary vein isolation has gained widespread use as a treatment modality for patients with concomitant atrial fibrillation. However, several uncertainties persist concerning the appropriate energy source, approach, and the need for lesion transmurality. In this study, we present an in-depth histologic investigation of epicardial ablation lesions in 3 patients., Methods: Within a large clinical series of adjuvant epicardial beating-heart microwave isolation of the pulmonary veins, with intraoperative measurement of electrical block, 3 nonablation-related deaths allowed detailed histologic investigation of the lesions. All three patients were in sinus rhythm prior to death. Transmural histologic sections from the box lesion encircling the pulmonary veins were microscopically examined for tissue damage, lesion depth, width, and transmurality, as well as for signs of ongoing repair., Results: Three out of 13 tissue samples showed transmural lesions. In three sections no histologic damage was observed and in the remaining samples transmural extent of myocardial damage ranged from 48% to 82% (mean, 64 +/- 13%). Lesion depths varied between 1.2 mm and 5.7 mm (mean 2.6 +/- 1.3 mm). The lesion depth did not differ significantly among patients and was not related to the thickness of the epicardial or myocardial layers. Interestingly, several sections showed clear necrosis of nerve bundles located in the epicardial tissue., Conclusions: This post-mortem histologic study showed that in the majority of samples the lesions were not transmural and that the extent of myocardial damage was highly variable. Even in this validated approach of epicardial beating heart ablation with satisfactory clinical results, transmurality of lesions cannot be assumed.