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Bioprosthetic surgical aortic valve replacement (SAVR) is increasingly adopted in younger patients. We aimed to analyze mid-term follow-up data after SAVR to assess the performance of the prosthesis.Data were collected from a single-center series of 154 patients, who underwent SAVR with a bioprosthetic heart valve with the RESILIA tissue at our Heart Centre in Siegburg. All procedural and midterm patient outcomes were documented.Patients had a mean age of 56.8 ± 9.9 years, 35.7% were female, and the mean logistic European system for cardiac operative risk evaluation (EuroSCORE) was 3.4 ± 3.6%. Diabetes (12.3%), atrial fibrillation (10.4%), and chronic obstructive pulmonary disease (COPD) (5.8%) were common comorbidities. The mean surgery duration was 163.8 ± 73.4 min, with the 23 mm (34.4%) and 25 mm (33.8%) heart valves being most frequently implanted. At 3-year follow-up, mean pressure gradient was 13.9 ± 5.9 mmHg, peak gradient was 23.6 ± 7.7 mmHg, and effective orifice area (EOA) was 1.9 ± 0.4 cm². No patient died during the operation, 3 (2.1%) patients within 30 days, and 4 (2.7%) thereafter with an overall mortality of n = 7. Of the surviving patients, 97.8% were in New York Heart Association (NYHA) class I/II and none had structural valve deterioration (SVD).Results of our single-center study indicate favorable procedural outcomes. The safety outcomes confirm preliminary earlier results of this novel bioprosthesis but include more patients and a longer midterm follow-up.

Propensity score analysis of midterm outcomes after isolated aortic valve replacement through right anterior mini-thoracotomy and partial upper sternotomy could provide information about the most beneficial minimally invasive technique for the patient based on the preoperative risk factors.Between March 2015 and February 2021, 694 minimally invasive isolated aortic valve surgeries were performed at our institution. Among these, 441 right anterior mini-thoracotomies and 253 partial upper sternotomies were performed. A propensity score analysis was performed in 202 matched pairs.Cardiopulmonary bypass time and cross-clamp time were significantly shorter in the right anterior mini-thoracotomy group than in the partial upper sternotomy group (p = 0.001 and p 0.001, respectively). Time to first mobilization and hospital stay were significantly shorter in the right anterior mini-thoracotomy group than in the partial upper sternotomy group (p = 0.005, p = 0.001, respectively). A significantly lower incidence of revision surgery was noted in the right anterior mini-thoracotomy group than in the partial upper sternotomy group (p = 0.046). No significant differences in 30-day mortality (p = 1.000) and 1-year mortality (p = 0.543) were noted. Kaplan-Meier survival estimates were 96.3% in the right anterior mini-thoracotomy group and 92.7% in the partial upper sternotomy group after 4 years (log rank 0.169), respectively.Despite the technical challenges, right anterior mini-thoracotomy can be chosen as first-line strategy for isolated aortic valve replacement. For patients unsuitable for this technique, the partial upper sternotomy remains a safe method that can be performed by a wide range of surgeons.

Introduction Aortic valve replacement (AVR) via right anterior mini-thoracotomy (RAMT) is less traumatic than via other surgical routes; using a novel aortic valve may confer long-term resistance against valve deterioration, and thus be useful in younger, more active patients. Here we aim to validate using the INSPIRIS RESILIA valve with minimally invasive RAMT. Methods Between April 2017 and June 2019, 100 patients underwent video-assisted minimally invasive AVR by RAMT, using the INSPIRIS RESILIA aortic valve. Cannulation for cardiopulmonary bypass (CPB) was through femoral vessels. Clinical data were prospectively entered into our institutional database. Results Cardiopulmonary bypass (CPB) and cross-clamping times were 79 ± 38 and 41 ± 17 min. Surgical access was successful in 100% of cases. There were no cases of intraoperative mortality, 30-day mortality, cerebrovascular events, rethoracotomy for bleeding, valve-related reoperation, right internal mammary artery injury, or conversion to sternotomy. Intensive care and hospital stays were 2 ± 1 and 6 ± 3 days, respectively. One patient had a pacemaker fitted. Postoperative dialysis was necessary in one patient. Trace to mild aortic valve regurgitation occurred in two patients. No structural valve deterioration (SVD) and paravalvular leak were seen. At 1-year follow-up mean effective orifice area (EOA) was 1.8 ± 0.1 cm2, peak gradient was 22.1 ± 3.1 mmHg, and mean gradient was 11.5 ± 2.3 mmHg. Conclusion Our preliminary experience suggests that RAMT for AVR using the INSPIRIS RESILIA aortic valve is safe, effective, and reproducible. Larger studies are needed to evaluate the long-term efficacy and durability of this new valve.

OBJECTIVES Extensive infective endocarditis (IE) stays a serious life-threatening disease with high mortality and morbidity. The aim of this study is to analyse our experience with our modified surgical technique for extensive IE during the last 4 years. METHODS Between March 2017 and February 2021, all patients with extensive IE required our modified technique consisting of a radical surgical resection of all infected cardiac tissues, the replacement of infected valves and a reconstruction of the intervalvular fibrous body, the aortic root and the left ventricular outflow tract with modified elephant trunk were included in this study. RESULTS Our modified technique was performed on 41 patients during the study period. The age median was 74 [interquartile range (IQR): 66.5–76.5] and 61.0% (n = 25) were female. Thirty-three patients (80.5%) were in New York Heart Association Class III–IV and 7 patients (17.1%) in cardiogenic shock. The median logistic European system for cardiac operative risk evaluation II as predicted risk of mortality was 35% (IQR: 28–78%). The median cardiopulmonary bypass time and cross-clamping time were 126 (IQR: 86.5–191) and 78 (IQR: 55.5–108) min, respectively. Intraoperative mortality and 30-day mortality were 4.8% (2 patients) and 19.5% (8 patients), respectively. Low cardiac output with necessity for mechanical support, stroke and new renal dialysis developed in 9.8% (4 patients), 17.1% (7 patients) and 22.0% (9 patients), respectively. New pacemaker implantation was noted in 39.0% (16 patients). Intensive care stay and hospital stay had medians of 6 (IQR: 5–12) and 14 (IQR: 12.5–20.5) days, respectively. One-year mortality and 4-year mortality were 34.1% (14 patients) and 39.0% (16 patients), respectively. Kaplan–Meier survival estimates were 60.3% (95% confidence interval: 46.2–78.6%) at 3 years. CONCLUSIONS Our modified technique can be performed in patients with extensive IE with acceptable early and mid-term morbidity and mortality. We believe that this technique is an available option for this ill-fated group of patients.

Objective Right anterior minithoracotomy is a promising technique for aortic valve replacement and has shown excellent results in terms of mortality and morbidity. Against this background, we analyzed our institutional experience in this technique during the last 3 years. Methods Between April 2017 and March 2019, 513 consecutive all comers with aortic valve disease underwent video-assisted minimally invasive aortic valve replacement through a 3-cm skin incision as right anterior minithoracotomy at our institution. A camera and automatic fastener technology were used for the valve implantation in all patients. Clinical data were prospectively entered into our institutional database. Results Cardiopulmonary bypass time accounted for 68 ± 24 min and the myocardial ischemic time 38 ± 12 minutes. Thirty-day mortality and overall mortality was 0.4% (2 patients) and 1.4% (7 patients), respectively. Postoperative cerebrovascular events were noted in 8 patients (1.5%). Intensive care stay and hospital stay were 2 ± 2 and 9 ± 7 days, respectively. Pacemaker implantation, injury of the right internal mammary artery, and conversion to full sternotomy were noted in 7 patients (1.4%), 3 patients (0.6%), and 1 patient (0.2%), respectively. Paravalvular leak need to intervention was noted in 2 patients (0.4%). Rethoracotomy rate was 2% (11 patients). Transient postoperative dialysis was necessary for 14 patients (3%). Conclusions Video-assisted minimally invasive aortic valve replacement through the right anterior minithoracotomy is a safe approach and yields excellent outcomes in high-volume centers. The use of a camera and automatic fastener technology facilitates this procedure.

OBJECTIVES Both surgical and percutaneous femoral accesses for the establishment of extracorporeal circulation are used in minimally invasive cardiac surgeries. The goal of this study was to compare the outcomes with the MANTA vascular closure device after percutaneous arterial decannulation via the surgical approach. METHODS Between November 2018 and January 2021, a total of 490 consecutive patients underwent minimally invasive cardiac operations at our institution. Cannulation and decannulation of femoral vessels were under direct vision surgically or percutaneously. The MANTA system was used to close the femoral artery in all patients with percutaneous cannulation. Demographic, clinical and procedural data were collected retrospectively. RESULTS Surgical cut-down and suture closure of the femoral artery was performed in 222 patients (45.3%); percutaneous access and closure with the MANTA system was used in 268 patients (54.7%). The surgical group presented a significantly higher incidence of any access site complication compared to the percutaneous group [18 patients (8.1%) vs 6 patients (2.2%); P = 0.003]. Lymph fistula and wound healing disorders occurred more frequently in the surgical group (3.2% vs 0% [P = 0.004] and 3.6% vs 0% [P = 0.002], respectively). Median procedural duration and stays in the intensive care unit were significantly lower in the percutaneous group {127 [interquartile range (IQR) 97–158] min vs 150 (IQR 117–185) min (P CONCLUSIONS Percutaneous access and closure with the MANTA system are feasible, safe and associated with lower incidences of all-cause access site complications and shorter stays in the intensive care unit compared to surgical access and closure in minimally invasive cardiac surgeries.

OBJECTIVES The number of cardiac implantable electronic devices is growing worldwide because they play a relevant role in improving the survival rate in patients with specific heart diseases. Cardiac implantable electronic devices complications including infection, dysfunction or venous stenosis increase the need for the least traumatic way to explant leads. Our goal was to report the successes and procedural complication rates of transvenous lead extraction (TLE) in a consecutive series of patients. METHODS From 2010 to 2016, 108 patients underwent TLE of 227 leads due to endocarditis (n = 21; 19%), pocket infection (n = 58; 54%) or lead dysfunction (n = 29; 27%). In 98% (n = 106) of the patients, laser-assisted lead extraction was performed. In 2% (n = 2) of the patients, the application of a solitary locking stylet was sufficient. The patient mean age was 68 ± 14 years; 25% of the patients had previous cardiac surgery. TLE was performed a mean of 9 ± 6 years after the implantation of the existing device. RESULTS Complete procedural success (removal of all lead material from the vascular space) was achieved in 98.7% (n = 224), and clinical success (achievement of all clinical goals associated with the indication for lead removal and absence of major complications) was achieved in 98% (n = 106). In 2 patients the procedure failed due to a vascular tear requiring a thoracotomy. In 1 patient, complete lead extraction was not possible due to heavy calcification (coronary-sinus lead). The 30-day mortality rate was 3.7% (n = 4); the patients died of multiorgan failure (n = 1), cardiac failure (n = 1) and septicaemia (n = 2). The procedure-related major complication rate was 2% (n = 2). CONCLUSIONS Laser-assisted TLE seems to be a safe and effective procedure with an acceptable complication rate.

The wearable cardioverter-defibrillator (WCD) is used for temporary protection of patients deemed to be at high risk for sudden death (SCD) not yet meeting indications for the implantable defibrillator (ICD). To evaluate the efficacy, safety, and compliance of/to WCD use and subsequent medium-term outcome of patients in a single-center observational study. A total of 102 consecutive patients were fitted with the WCD from 2012 to 2015 and followed for a mean of 11 months (±8 months). The most common clinical indication for WCD-prescription (63%) was a new diagnosis of severely impaired LV function (LVEF ≤35%). The median wear time of the WCD was 54 days with a daily use of 23 h. Appropriate WCD therapy occurred in four patients (seven shocks for VF, one shock for VT). An ICD was finally implanted in 56 patients (55%). Improvement in LV function was the most common reason not to implant an ICD (HR 0.37; 95% CI 0.19–0.73; p = 0.004). Two patients had inappropriate shocks from their WCD due to atrial fibrillation/flutter. Five patients fitted with an ICD after the end of WCD therapy suffered VT/VF episodes. After wearing the WCD, six patients died (five ICD recipients and one non-ICD recipient). WCD therapy was well accepted by patients and provided temporary protection against ventricular tachyarrhythmias in patients at risk for SCD. The WCD may help to avoid unnecessary ICD implantations in a significant proportion of patients.

Persistent left superior vena cava is known to be a challenging anatomic abnormality for transvenous cardiac device implantation. In the a case of a young man presenting with dilative cardiomyopathy with severely impaired left ventricular ejection fraction (LVEF) and second-degree atrioventricular block (AV block), cardiac resynchronization therapy (CRT) with defibrillator (CRT-D) implantation was indicated. A transvenous approach was attempted, but placement of the right ventricular lead was not successful due to anatomic abnormalities. Therefore, epicardial CRT leads were implanted via a left mini-thoracotomy. For primary prevention of sudden death, the patient was also fitted with an additional subcutaneous implantable cardioverter defibrillator (S-ICD). Any cross-talk between the devices was ruled out both intraoperatively and by ergometry prior to discharge. The combination of epicardial CRT-P with S‑ICD implantation might be a safe and effective alternative in patients with cardiac anatomic abnormalities.

Objective: Left-ventricular assist device (LVAD) implantation complicated by early right ventricle (RV) failure has a poor prognosis. This study details our center’s experience with veno-arterial extracorporeal membrane oxygenation (ECMO) as perioperative RV support in patients with preoperative biventricular failure undergoing LVAD implantation. Methods: Ten patients, who underwent LVAD implantation, were retrospectively analyzed. Six patients were already supported with ECMO before LVAD implantation. In four patients, the ECMO was implanted before weaning from cardiopulmonary bypass. Results: All patients showed reduced RV function with elevated right-ventricular end-diastolic diameter (RVEDD) (38 4 mm) and RV systolic pressure (48 14 mmHg). The mean pulmonary artery pressure (PAP) was 36 9 mmHg. Nine patients showed dilatation of the tricuspid annulus (35 mm) with moderate tricuspid valve insufficiency and received tricuspid valve annuloplasty. After removal of the ECMO, none of the patients developed RV failure. ECMO was removed 4 1 days after LVAD implantation. Four patients expired while on LVAD support due to not-device-related sepsis (two patients), mesenteric ischemia (one patient), and gastrointestinal bleeding (one patient), respectively. Overall survival was 60%. Conclusion: ECMO provided a satisfactory perioperative right-heart support in patients with preoperative biventricular failure undergoing LVAD implantations, who otherwise were better candidates for biventricular assist device. ECMO allowed time for the already compromised right ventricle to get attuned to the increasing preload, and avoids distension and RV failure. # 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Objectives: The unreinforced aortic root, in bicuspid aortic valve disease, has been shown to dilate and cause recurrent regurgitation. The objective of this study was to determine whether reduction aortoplasty can reliably prevent aortic root dilatation after aortic valve repair in bicuspid disease. Methods: A total of 66 patients, with a mean age of 41.2 12 years and with incompetent bicuspid aortic valves and concomitant dilatation of the aortic root, were included in this study. As many as 49 patients had patch augmentation of the free edge of the bicuspid aortic leaflets and reduction aortoplasty, and a further 17 patients had patch augmentation and a modified David type repair. Patients were followed up by echocardiography and clinically in yearly intervals. Results: At midterm (mean follow-up was 5.1 2.1 years), only one patient in the reduction aortoplasty group showed aortic root dilatation, leading to significant aortic valve regurgitation. Other than that, there was no progression of regurgitation in the whole group of patients. In the David type repair group, no re-operations, progression of aortic root dilatation or recurrent regurgitation occurred. In general, there was only one death in the reduction aortoplasty group. This patient developed endocarditis after 1 year and diedof acute heartfailure prior to readmissionto our hospital.Conclusion:Both reduction aortoplastyand modified David type repair, paired with patch augmentation of the incompetent bicuspid valve, provide excellent midterm results. The reduction of the diameter of the ascending aorta by reduction aortoplasty seems to provide reliable stability that is comparable to the David type repair. # 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Purpose Important comorbid conditions in elderly patients referred for aortic valve replacement require alternative treatment options with possible reduction of the extracorporeal circuit time and reliable hemodynamic features. We report on clinical experiences with the sutureless, nitinol-stented 3f Enable (ATS Medical, Minneapolis, MN) aortic valve prosthesis in 32 patients. Description The procedure was performed using cardiopulmonary bypass with cardioplegic arrest. After resection of the stenotic aortic valve and debridement of the annulus, the valve was inserted and released. Mean age was 78 ± 3; mean logistic Euroscore was 13.7. Concomitant procedures were mitral valve and tricuspid valve repair (n = 1), coronary artery bypass graft (n = 9), and subvalvular myectomy (n = 3). Evaluation Implantation of the valve required 9 ± 5 minutes. Cardiopulmonary bypass and aortic cross-clamp time were 87 ± 16 and 55 ± 11 minutes for stand-alone procedures. Combined procedures required 126 ± 42 and 84 ± 28 minutes, respectively. Two patients were abandoned intraoperatively and converted to standard procedures due to misalignment of the valve. In the other 30 patients, no paravalvular leakage was detected. The transvalvular gradient at discharge was 9 ± 6 mm Hg (mean) and 18 ± 9 mm Hg (peak). Six months after surgery, gradients were 10 ± 4 mm Hg (mean) and 18 ± 6 mm Hg (peak). Conclusions Sutureless valve implantation is feasible and safe with the 3f Enable (ATS Medical) bioprosthesis. Reduction of cardiopulmonary bypass and aortic cross-clamp time seems to be possible with increasing experience. Hemodynamic data are promising with low gradients at discharge and after 6 months.

Die Entwicklung eines Pseudoaneurysmas zahlt zu den potentiellen Komplikationen nach Aortenklappenkonduitimplantation. Wir berichten uber den Fall einer Sternumpenetration mit einer Hautperforation als Komplikation eines grosen thrombosierte Pseudoaneurysmas acht Jahren nach Versorgung mit einem Aortenklappenkonduit. Die Inzidenz solcher Komplikationen liegt bei etwa 7% und ist auf eine Nahtinsuffizienz im Anastomosenbereich zuruckzufuhren.

The BioPhysio bioprosthesis (Edwards Lifesciences LLC, Irvine, CA, USA) was designed to further improve the hemodynamic performance currently achieved by stented valves. A flexible Nitinol stent that preserves aortic root dynamics, thus maximizing the effective orifice area (EOA), is a key innovation of this prosthesis. The study aim was to provide a clinical evaluation of this new device.Between December 2004 and August 2005, a total of 50 patients (27 males, 23 females; mean age 75.8 +/- 5.1 years; range: 55-84 years) received a BioPhysio aortic bioprosthesis. Clinical outcomes, EOAs, mean gradients and regression of left ventricular hypertrophy were evaluated echocardiographically at discharge, and at six, 12, 24, 36, 48, and 60 months after surgery.The 60-month follow up was complete for all patients. No patients died within 30 days of surgery, but the late mortality was 14% (n = 6). There was one sudden unexplained death. One patient developed endocarditis at two years after surgery and underwent reoperation. There were no cases of stroke or renal failure. The BioPhysio prosthesis showed a good hemodynamic performance, with a significant fall in mean gradient to 15.1 +/- 8.3 mmHg, a mean EOA of 1.5 +/- 0.7 cm2, and a mean ejection fraction of 61 +/- 7.2%. There were no cases of aortic regurgitation. The NYHA functional class was improved in all patients, and there was a significant reduction in the left ventricular mass index to 185.7 +/- 49.6 g/m2 at 24 months.The clinical performance of the BioPhysio aortic bioprosthesis is comparable to that of regular stentless aortic valves. However, clinical approval for the widespread use of this bioprosthesis was not obtained.

Objective For elderly patients with symptomatic aortic valve stenosis, aortic valve replacement with tissue valves is still the treatment of choice. Stentless valves were introduced to clinical practice for better hemodynamic features as compared with stented tissue valves. However, the implantation is more complex and time demanding, especially in minimal invasive aortic valve replacement. We present our clinical data on 22 patients having received a sutureless ATS 3f Enable aortic bioprosthesis via partial upper sternotomy. Methods The procedure was performed using CPB with cardioplegic arrest. After resection of the stenotic aortic valve and debridement of the annulus, the valve was inserted and released. Mean age was 79 years, and mean logistic Euroscore was 13. Subvalvular myectomy was performed in two patients. Prosthetic valve sizes were 19 mm (n = 1), 21 mm (n = 7), 23 mm (n = 6), 25 mm (n = 6), and 27 mm (n = 2). Results Implantation of the valve required 10 ± 6 minutes. Cardiopulmonary bypass and aortic crossclamp time were 87 ± 16 and 55 ± 11 minutes, respectively. Early mortality (Conclusions Sutureless valve implantation via partial sternotomy is feasible and safe with the ATS 3f Enable bioprosthesis. Reduction of cardiopulmonary bypass and aortic crossclamp time seems possible with increasing experience. Hemodynamic data are very promising with low gradients at discharge and after 12 month. Sutureless valve implantation via minimal invasive access may be an alternative treatment option for elderly patients with high comorbidity.

Background The 3f aortic bioprosthesis is a stentless valve resembling the native aortic valve. It has been postulated that improved hemodynamic performance with this prosthesis may translate into superior durability. We hereby report the midterm results using this valve substitute. Methods Fifty patients with severe aortic stenosis received the 3f aortic bioprosthesis between 2002 and 2004 in our unit. Clinical outcomes, effective orifice area, mean gradients, and ejection fraction were evaluated at discharge, at 6 and 12 months, and yearly thereafter. Results Mean follow-up was 52 ± 10 months and was complete in 96% of surviving patients. Hemodynamic performance of the 3f valve was satisfactory for substitutes in the range of 25 mm and 27 mm; smaller valve substitutes showed unfavorable hemodynamic performance with mean gradients of 18 ± 7 mm Hg for 21-mm prosthesis, and 14 ± 5 mm Hg for 23-mm prosthesis. Consequently, the regression of left ventricular hypertrophy was incomplete. Late mortality included 10 patients (valve-related in 1, cardiac-related in 3) for a survival of 77% ± 3% at 4 years. Four patients required reoperation owing to endocarditis in 2 and paravalvular leak in other 2. Freedom from reoperation was 93% at 4 years. Six patients experienced 9 neurologic events, accounting for 82% freedom from neurologic events. Conclusions Its unique design makes the 3f aortic bioprosthesis less complex to implant than conventional stentless valves, as only a single suture line is necessary. The hemodynamic profile and clinical performance of the prosthesis are inconsistent with the established stentless valves, especially with regard to higher incidence of neurologic complications seen during the follow-up.

Objective: Reoperation rates after repair of bicuspid aortic valves are higher than for mitral valve reconstruction. Satisfactory results have been reported for patch augmentation for tricuspid aortic valves. We have applied this technique for the repair of bicuspid aortic valves. Methods: Autologous pericardium is sutured to the free edge of the prolapsing bicuspid leaflet. A large coaptation surface is created and competence of the bicuspid valve is achieved. Forty patients underwent reconstruction of their bicuspid aortic valves by pericardial patch augmentation. Patients were followed up at regular intervals by echocardiography in yearly intervals. Results: There were no perioperative deaths. One year postoperatively, one patient died due to endocarditis. Seven patients (17.5%) had aortic regurgitation grade I, and the other 33 patients had non or trivial aortic regurgitation at discharge. At 4.2 3.1 years postoperatively, only four patients (10%) had aortic regurgitation grade I. There were no cases of progression of regurgitation. Planimetric effective orifice areas ranged above 2 cm 2 . Mean aortic gradients dropped from 8.2 4.8 mmHg at discharge to 3.8 3 at four years and the mean height of coaptation surface from 14.7 2 mm to 12.3 4, respectively. Conclusions: The pericardial patch augmentation technique increases coaptation surface, and thus provides reliable early and midterm competence of reconstructed bicuspid aortic valves. # 2008 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

The occurrence rate of atrial fibrillation (AF) after coronary artery bypass grafting, quoted in the literature, is wide ranging from 5% to over 40%. It is speculated that, off-pump coronary artery bypass grafting (OPCAB) and also minimally invasive cardiac surgery reduces the incidence of postoperative AF due to reduced trauma, ischemia, and inflammation. Current data, however, do not clearly answer the question, whether the incidence of postoperative AF is reduced in using minimally invasive techniques, ideally resulting in the combination of both small access and off-pump surgery. The aim of this study was to evaluate the incidence of postoperative AF in patients undergoing totally endoscopic off-pump coronary artery bypass grafting (TECAB). A retrospective analysis of 72 patients undergoing myocardial revascularization was performed. Early postoperative incidence of AF was compared between three groups of patients: 24 after conventional coronary artery bypass grafting (CABG), 24 after OPCAB, and 24 after totally endoscopic off-pump CABG. Clinical profile of the patients, including factors having potential influence on postoperative AF was matched for groups. Postoperative AF occurred in 25% of the patients in the CABG group, in 16% of the patients in the OPCAB group, and in 16% of the patients in the TECAB group. This difference has no statistical significance. Risk factors and incidence of postoperative complications were comparable in all groups excepting the number of distal anastomoses. There was a statistical significance between CABG group and TECAB group. Avoiding cardiopulmonary bypass and minimizing surgical trauma did not reduce the incidence of postoperative AF in this patient collective. It remains an attractive hypothesis that postoperative AF is reduced by off-pump myocardial revascularisation and minimizing surgical trauma but more robust data are required.

Background Recent findings indicate that molecular chaperones actively participate in myocardial cytoprotection. Moreover, ischemic tolerance can be induced in humans by brief ischemic events. Therefore, we investigated patients with severe angina attacks before coronary artery bypass grafting. We focused on appearance of anti-hsp70 antibodies as an immunologic response to heat shock protein induction by ischemia followed up by hemodynamic measurements perioperatively. We correlated these clinical findings with the presence of antibodies against hsp70 and the antioxidative capacity of patients' sera. Methods Thirty-five consecutive patients with coronary artery disease scheduled for coronary artery bypass grafting were included. Seventeen patients had severe angina, and 18 patients suffered from chronic stable angina preoperatively. In the patients' sera, antibodies against hsp70 were detected by enzyme-linked immunosorbent assay, and antioxidative capacity was detected using the chromogen assay. Cardiac output and pulmonary capillary wedge pressure were measured using a thermodilution catheter. We also evaluated C-reactive protein and creatine kinase MB isoenzyme, and performed a conventional leukocyte count. Results The sera of the 17 patients with severe angina attacks before surgery contained antibodies against hsp70 and a low antioxidative capacity. The interval between a severe angina attack and anti-hsp70 antibody titer are inversely correlated. These patients had better cardiac output and lower pulmonary capillary wedge pressure values after surgery. Conclusions Severe angina before cardiac surgery coincided with an improved outcome as measured by hemodynamic variables as compared with chronic stable angina. This finding correlated significantly with a low antioxidative capacity and the presence of antibodies against hsp70. These pathophysiologic mechanisms might therefore play a role in myocardial protection.

BACKGROUND At least 20 - 30 % of patients undergoing coronary artery bypass graft surgery (CABG) or beating-heart surgery develop postoperative atrial fibrillation (AF). We evaluated the effect of thoracic epidural anesthesia (TEA) on the occurrence of postoperative AF in patients submitted to CABG without cardiopulmonary bypass (OPCABG). METHODS We performed a retrospective analysis of 125 patients undergoing myocardial revascularization. Early postoperative incidence of AF was compared between three groups of patients - 50 after conventional CABG, 45 after OPCABG, and 30 after OPCABG combined with TEA intraoperatively and postoperatively. Clinical profile of the patients, including factors with a potential influence on postoperative AF was matched for groups. RESULTS Postoperative AF occurred in 13.3 % of the TEA-treated patients, in 17.7 % of the patients in the OPCABG group, and in 26 % of the patients in the CABG group. This difference did not carry any statistical significance. Risk factors and incidence of postoperative complications were comparable in all groups. CONCLUSION TEA has no effect on the incidence of postoperative AF in patients undergoing beating-heart surgery.