Kareem Bedeir

Elevated Stroke Risk Associated With Femoral Artery Cannulation During Mitral Valve Surgery

Minimally invasive mitral valve (MV) surgery, often requiring femoral artery (FA) cannulation, is increasingly being adopted. There is concern about increased stroke rates associated with minimally invasive MV surgery. This study aims to examine whether FA cannulation is independently associated with increased stroke rates in minimally invasive MV procedures. MV procedures from January 2004 to June 2012 were reviewed using our institutional Society of Thoracic Surgeons database. We included 384 patients after the exclusion of patients with emergency procedures, with infective endocarditis, who underwent other concomitant procedures, who were older than 60 years, and with nonstandard aortic clamping (endoballoon or no clamp). Patients were divided into 2 groups: those who underwent aortic cannulation (n = 327) and those who underwent femoral cannulation (n = 57). Risk adjustments through multivariable regression were used to identify independent predictors for various outcomes. Adjustments were made for cardiopulmonary bypass and aortic clamp times. Preoperatively, the femoral cannulation group had less baseline cerebrovascular disease (P = 0.032), heart failure (P = 0.028), and atrial fibrillation (P = 0.012). Other baseline characteristics were similar. The aortic cannulation group had shorter cardiopulmonary bypass (P < 0.001) and clamp times (P < 0.001). There were more repairs done in the FA cannulation group as opposed to replacements. Risk-adjusted outcomes showed a higher incidence of permanent stroke in the femoral cannulation group (P = 0.032). Other outcomes were not significantly different. In conclusion, FA cannulation may be associated with increased stroke rates in isolated MV surgery. Antegrade arterial cannulation (direct aortic or axillary cannulation) may be preferable in minimally invasive MV procedures. Randomized trial data are needed.

Infective endocarditis: Perioperative management and surgical principles

Despite advances in microbial prevention and elimination, the frequency of endocardial infection is still increasing and it remains to be a serious condition. The strategies and aggressiveness of medical and surgical algorithms for managing these patients are evolving and having a significant effect on morbidity and mortality. This review addresses the current understanding of the processes by which the most common and most threatening complications occur, and the current management strategies that cardiologists and cardiac surgeons should be aware of when treating these seriously ill patients.

Left atrial appendage exclusion: An alternative to anticoagulation in nonvalvular atrial fibrillation

From the Department of Surgery, Brigham andWomen’s Hospital, Boston,Mass; Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minn; Department of Cardiovascular Surgery, Washington University, St. Louis, Mo; Department of Cardiovascular Surgery, Heart & Vascular Center, Valley Health Systems, Winchester, Va. Received for publication May 26, 2016; revisions received Dec 7, 2016; accepted for publication Dec 28, 2016; available ahead of print March 2, 2017. Address for reprints: Basel Ramlawi, MD,MSc, Department of Cardiovascular Surgery, Heart & Vascular Center, Valley Health Systems, Winchester, VA 22601 (E-mail: Basel.ramlawi@gmail.com). J Thorac Cardiovasc Surg 2017;153:1097-105 0022-5223/

Aortic Valve Surgery: Minimally Invasive Options.

36.00 Copyright 2017 by The American Association for Thoracic Surgery http://dx.doi.org/10.1016/j.jtcvs.2016.12.040 The Watchman endocardial left atrial occlusion device (left) and the AtriClip epicardial left atrial occlusion device (right).

Chronic anticoagulation in non-valvular atrial fibrillation: Where things stand.

Minimally invasive aortic valve surgery has not been adopted by a significant proportion of cardiac surgeons despite proven benefits. This may be related to a high learning curve and technical issues requiring retraining. In this review, we discuss the data for minimally invasive aortic valve surgery and describe our operative technique for both ministernotomy and anterior thoracotomy approaches. We also discuss the advent of novel sutureless valves and how these techniques compare to available transcatheter aortic valve procedures.

Cryptogenic Stroke with a Patent Foramen Ovale:: Medical Therapy, Percutaneous Intervention, or Surgery CRYPTOGENIC STROKE WITH A PATENT FORAMEN OVALE BEDEIR, ET AL

One in every five strokes is due to atrial fibrillation. Anticoagulation is the evidence-based practice for stroke risk reduction in patients with atrial fibrillation. After decades of using warfarin, the recent years have seen an exponential increase in the available oral anticoagulants. An understanding of where things stand regarding indications, relative safety and efficacy as well as the limitations of each available choice is crucial.

Cryptogenic Stroke with a Patent Foramen Ovale:: Medical Therapy, Percutaneous Intervention, or Surgery

More than one third of ischemic strokes have an unidentifiable cause. Patent foramen ovale (PFO) plays a controversial role in this subset of patients. The evidence for and against the hypothesis of paradoxical embolism is reviewed and we discuss the optimal management of a PFO under different circumstances. doi: 10.1111/jocs.12693 (J Card Surg 2016;31:156–160)

Timing of Coronary Bypass Surgery in Patients Receiving Clopidogrel: The Role of VerifyNow

More than one third of ischemic strokes have an unidentifiable cause. Patent foramen ovale (PFO) plays a controversial role in this subset of patients. The evidence for and against the hypothesis of paradoxical embolism is reviewed and we discuss the optimal management of a PFO under different circumstances. doi: 10.1111/jocs.12693 (J Card Surg 2016;31:156–160)

Totally Thorascopic Closure of the Left Atrial Appendage

We briefly report for the first time the association between a point of care platelet recovery test and the timing of coronary artery bypass grafting after clopidogrel withdrawal. We observe an association between suggested wait days and platelet recovery unit values that might potentially allow for safe shorter wait times before coronary artery bypass grafting without increased bleeding. Our results represent an observation and should prompt further validation.

Cardiac tamponade by colon

The left atrial appendage (LAA) is a major site of clot formation in atrial fibrillation. Stand-alone thoracoscopic LAA complete closure can decrease stroke risk and may be an alternative to life-long oral anticoagulation. This report describes a technique for totally thoracoscopic LAA exclusion with an epicardial clip device. This approach provides a safe and likely more effective alternative to LAA management than other endocardial devices.