M. Diab

Cardiac surgery 2015 reviewed

For the year 2015, almost 19,000 published references can be found in PubMed when entering the search term “cardiac surgery”. The last year has been again characterized by lively discussions in the fields where classic cardiac surgery and modern interventional techniques overlap. Lacking evidence in the field of coronary revascularization with either percutaneous coronary intervention or bypass surgery has been added. As in the years before, CABG remains the gold standard for the revascularization of complex stable triple-vessel disease. Plenty of new information has been presented comparing the conventional to transcatheter aortic valve implantation (TAVI) demonstrating similar short- and mid-term outcomes at high and low risk, but even a survival advantage with transfemoral TAVI at intermediate risk. In addition, there were many relevant and interesting other contributions from the purely operative arena. This review article will summarize the most pertinent publications in the fields of coronary revascularization, surgical treatment of valve disease, heart failure (i.e., transplantation and ventricular assist devices), and aortic surgery. While the article does not have the expectation of being complete and cannot be free of individual interpretation, it provides a condensed summary that is intended to give the reader “solid ground” for up-to-date decision-making in cardiac surgery.

Cardiac surgery 2016 reviewed

For the year 2016, more than 20,000 published references can be found in Pubmed when entering the search term “cardiac surgery”. Publications last year have helped to more clearly delineate the fields where classic surgery and modern interventional techniques overlap. The field of coronary bypass surgery (partially compared to percutaneous coronary intervention) was enriched by five large prospective randomized trials. The value of CABG for complex coronary disease was reconfirmed and for less complex main stem lesions, PCI was found potentially equal. For aortic valve treatment, more evidence was presented for the superiority of transcatheter aortic valve implantation for patients with intermediate risk. However, the 2016 evidence argued against the liberal expansion to the low-risk field, where conventional aortic valve replacement still appears superior. For the mitral valve, many publications emphasized the significant impact of mitral valve reconstruction on survival in structural mitral regurgitation. In addition, there were many relevant and other interesting contributions from the purely operative arena in the fields of coronary revascularization, surgical treatment of valve disease, terminal heart failure (i.e., transplantation and ventricular assist devices), and aortic surgery. While this article attempts to summarize the most pertinent publications it does not have the expectation of being complete and cannot be free of individual interpretation. As in recent years, it provides a condensed summary that is intended to give the reader “solid ground” for up-to-date decision-making in cardiac surgery.

Cardiac surgery 2014 reviewed.

For the year 2014, more than 17,000 published references can be found in Pubmed when entering the search term “cardiac surgery”. The last year has been characterized by a vivid discussion in the fields where classic cardiac surgery and modern interventional techniques overlap. Specifically, there have been important contributions in the field of coronary revascularization with either percutaneous coronary intervention or bypass surgery as well as in the fields of interventional valve therapy. Here, the US core valve trial with the first demonstration of a survival advantage at 1 year with transcatheter valves compared to surgical aortic valve replacement or the 5-year outcome of the SYNTAX trial with significant advantages for bypass surgery has been the landmark. However, in addition to these most visible publications, there have been several highly relevant and interesting contributions. This review article will summarize the most pertinent publications in the fields of coronary revascularization, surgical treatment of valve disease, heart failure (i.e., transplantation and ventricular assist devices) and aortic surgery. This condensed summary will provide the reader with “solid ground” for up-to-date decision-making in cardiac surgery.

Sizing strategy is a major determinant of postoperative pressure gradients in commonly implanted stented tissue valves

OBJECTIVE We compared the haemodynamic performance of two pericardial aortic prostheses with the stent either on the outside (Perimount), or the inside (Mitroflow) of the valve cusps, with regard to sizing strategies and valve dimensions. METHODS We analysed discharge echoes from all patients who received an isolated Perimount (n = 537) or Mitroflow (n = 164) between January 2007 and November 2010. We obtained outer valve diameters from the manufacturers, and measured sizer dimensions. We compared pressure gradients (ΔP) and maximum velocity across the valve (V(max)). RESULTS The majority of implanted valves had a size label 23 (39.7% of the Perimount; 56.1% of the Mitroflow). The metric outer diameter for size label 23 was 31 mm for Perimount, and 26 mm for Mitroflow. Despite the smaller outer diameter of the Mitroflow compared with the Perimount, peak gradients were lowest in the Mitroflow (ΔP mmHg: 22.3 ± 7.8 for Mitroflow vs 23.9 ± 7.3 for Perimount, n.s.), suggesting a design advantage for the Mitroflow. However, the 23 Mitroflow sizer was 26 mm and the 21 sizer was 23 mm. In contrast, the 23 Perimount sizer was indeed 23 mm. Thus, an intrannular sizing strategy for a patient with a 23 mm annulus most likely results in the selection of 21 Mitroflow and 23 Perimount. Haemodynamic comparison of the 21 Mitroflow with the 23 Perimount reversed the above- described difference (ΔP mmHg: 26.0 ± 10.2 for Mitroflow vs 23.9 ± 7.3 for Perimount, P < 0.05). Multivariate analysis identified a 21 valve as a predictor of high pressure gradients, but found no differences between both valve types. CONCLUSIONS The potential haemodynamic advantage of the Mitroflow is lost due to the different sizing strategy. The results underscore the importance of an optimal sizing strategy, possibly by replica sizing.

Replica sizing strategy for aortic valve replacement improves haemodynamic outcome of the epic supra valve

OBJECTIVES Current sizing strategies suggest valve selection based on annulus diameter despite supra-annular placement of biological prostheses potentially allowing placement of a larger size. We assessed the frequency of selecting a larger prosthesis if prosthesis size was selected using a replica (upsizing) and evaluated its impact on haemodynamics. METHODS We analysed all discharge echocardiograms between June 2012 and June 2014, where a replica sizer was used for isolated aortic valve replacement (Epic Supra: 266 patients, Trifecta: 49 patients). RESULTS Upsizing was possible in 71% of the Epic Supra valves (by 1 size: 168, by 2 sizes: 20) and in 59% of the Trifectas (by 1 size: 26, by 2 sizes: 3). Patients for whom upsizing was possible had the lowest pressure gradients within their annulus size groups. The difference was significant in annulus diameters of 21-22 or 25-26 mm (Epic Supra) and 23-24 mm (Trifecta). Trifecta gradients were the lowest. However, the ability to upsize the Epic Supra by 2 sizes eliminated the differences between Epic Supra and Trifecta. Upsizing did not cause intraoperative complications. CONCLUSIONS Using replica sizers for aortic prosthesis size selection allows the implantation of bigger prostheses than recommended in most cases and reduces postoperative gradients, specifically for Epic Supra.

Cardiac surgery 2017 reviewed

For the year 2017, more than 21,000 published references can be found in PubMed when entering the search term “cardiac surgery”. This review focusses on conventional cardiac surgery, considering the new interventional techniques only if they were directly compared to classic techniques but also entails aspects of perioperative intensive care management. The publications last year provided a plethora of new and interesting information that helped to quantify classic surgical treatment effects and provided new guidelines for the management of structural heart disease, which made comparisons to interventional techniques easier. The field of coronary bypass surgery was primarily filled with confirmatory evidence for the beneficial role of coronary artery bypass grafting for complex coronary disease and equal outcomes for percutaneous coronary intervention for less complex disease including main stem lesions. For aortic valve treatment, the new guidelines provide an equal recommendation for surgical and transcatheter aortic valve replacement for high and intermediate risk giving specific check lists to individualize decision-making by the heart team. For low-risk aortic stenosis, surgical valve replacement remains the primary indication. For the mitral valve, the importance of surgical experience of the individual surgeon on short- and long-term outcome was presented and the prognostic impact of mitral repair for primary mitral regurgitation was emphasized. In addition, there were many relevant and interesting other contributions from the purely operative arena in the fields of tricuspid disease as well as terminal heart failure (i.e., transplantation and ventricular assist devices). While this article attempts to summarize the most pertinent publications, it does not have the expectation of being complete and cannot be free of individual interpretation. As in recent years, it provides a condensed summary that is intended to give the reader “solid ground” for up-to-date decision-making in cardiac surgery.

Percutaneous cannulation for cardiopulmonary bypass in minimally invasive surgery is associated with reduced groin complications

OBJECTIVES Femoral cutdown is standard in most centres if groin cannulation is used for cardiopulmonary bypass in minimally invasive cardiac surgery (MICS). Arterial closure devices (ACDs) allow placement of larger cannulas percutaneously, but its benefit in MICS is unclear. We assessed our results with percutaneous groin cannulation using ACDs in comparison with conventional surgical access in patients undergoing MICS. METHODS We reviewed 445 consecutive patients having undergone MICS between October 2010 and March 2015. Of those, 92 (21%) were performed with conventional surgical access to the groin vessels and 353 (79%) with the use of ACDs. RESULTS Operative risk was higher in the ACD group [logistic EuroSCORE 7.9% (SD: 8.1) vs 10.6% (SD: 12.3); P = 0.010]. The use of ACDs significantly reduced operation time [193 min (SD: 43.8) vs 173 min (SD: 47.1); P < 0.001] and hospital stay [Cutdown: median 9 days (8, 14); ACD: median 9 days (7, 12), P = 0.040] without affecting the time to full mobilization. The incidence of any complication was significantly lower in the ACD group (2.3% vs 8.7%; P = 0.007). Complications with conventional cannulation consisted of lymphatic fistulae (n = 4), wound infections (n = 2), stenosis (n = 1) and haematoma (n = 1). In the ACD group, there were local dissections (n = 2) and stenoses (n = 3). There was 1 haematoma in both groups. There were 2 vascular injuries in the ACD group (n = 2), leading to conversion to surgical access. CONCLUSIONS Percutaneous groin cannulation using ACDs for establishing cardiopulmonary bypass in minimally invasive valve surgery significantly reduces groin complications, operation time and hospital stay. However, the remaining complications are mainly of vascular nature versus wound infection and lymph fistulae with cutdown.

Novel thoughts on patient-prosthesis mismatch in aortic valve replacement: the rationale for the PAR I trial.

The hemodynamic performance of prosthetic tissue valves is influenced by valve design and valve-specific sizing strategies. Design determines the actual geometric opening area (GOA) of the prosthetic valve and sizing strategy its actual chosen size. Currently, hemodynamic performance is assessed by determining the effective orifice area (EOA; derived from the continuity equation by relating flow velocities with the area of the left ventricular outflow tract [LVOTA]). The question whether a valve is too small (patient-prosthesis mismatch [PPM]) is currently addressed by relating EOA to body surface area (EOA index [EOAi]). However, this relation may not be appropriate because the EOAi relates flow velocity to patient-specific anatomic parameters twice (i.e., LVOTA and body surface area). This potential confounder may explain the controversies regarding PPM. However, intuitively, leaving a gradient behind after aortic valve replacement cannot be irrelevant. PPM becomes even more relevant with transcatheter valve-in-valve implantation, where a second prosthesis is taking up inner space of a valve that may have already been too small initially. Thus, a reliable method to determine the presence of PPM is needed. The Prosthesis-to-Annulus Relation I (PAR I) trial is a German multicenter study assessing the relation between the prosthetic GOA and the LVOTA as a potentially new parameter for the prediction of hemodynamic outcome. The results may possibly guide future valve size selection and may allow prediction of functionally relevant PPM. Here, we will demonstrate the shortcomings of the currently applied EOAi for the assessment of hemodynamic relevance and present the rationale for the PARI trial, which recently started recruiting patients.

Coronary Artery Bypass Grafting using Bilateral Internal Thoracic Arteries through a Left-Sided Minithoracotomy: A Single-Center Starting Experience

OBJECTIVE  Coronary artery bypass grafting (CABG) using bilateral internal thoracic artery (BITA) is associated with the best long-term survival. However, using BITA increases the risk of sternal wound infections with conventional sternotomy. We describe here our initial results of minimally invasive CABG (MICS-CABG) using BITA. METHODS  Patients were operated through an incision similar to that of standard minimally invasive direct CABG. All operations were performed off-pump. We evaluated patients quality of life (QoL) using the Medical Outcomes trust, 36-Item Short Form Health Survey (SF-36). RESULTS  Between February 2016 and August 2017, we performed 21 cases of MICS-CABG using BITA. There was no intraoperative complication and no conversion to sternotomy or to on-pump. Two patients required reexploration through the same minithoracotomy for postoperative bleeding. Two cases of early postoperative graft failure were identified. There was no stroke or in-hospital mortality. The median duration of follow-up was 13 months, with a maximum of 19 months. Relief of angina was achieved in all patients. There was one readmission for superficial wound infection, which was conservatively treated. An 84-year-old man died 4 months after the operation. The remaining 20 patients attested good QoL with the SF-36 questionnaire. CONCLUSIONS  Myocardial revascularization using BITA can be safely achieved off-pump through a left-sided minithoracotomy with good postoperative and short-term outcomes.

Minimally Invasive, Isolated Tricuspid Valve Redo Surgery: A Safety and Outcome Analysis

Background Isolated tricuspid valve (TV) surgery is considered a high risk‐procedure. The optimal surgical approach is controversial. We analyzed our experience with isolated TV redo surgery performed either minimally invasively (redo‐MITS) or through sternotomy. Methods We retrospectively analyzed all patients with previous cardiac surgery who underwent redo‐MITS (n = 26) and compared them to redo‐Sternotomy (n = 17). A group of primary‐MITS (n = 61) served as control. Results The redo‐MITS approach consisted of a right anterolateral mini‐thoracotomy, transpericardial right atrial access, and beating heart TV surgery without caval occlusion. Redo‐MITS patients were oldest and had the most comorbidities (EuroScore II: 9.83 ± 6.05% versus redo‐Sternotomy: 8.42 ± 7.33% versus primary‐MITS: 4.15 ± 4.84%). There were no intraoperative complications or conversions to sternotomy in both MITS groups. Redo‐Sternotomy had the highest 30‐day mortality (24%), the poorest long‐term survival, and the highest perioperative complication rate. Redo‐MITS did not differ in perioperative outcome from primary‐MITS. Multivariable logistic regression analysis identified redo‐Sternotomy (odds ratio [OR] = 9.76; 95% confidence interval [CI] 1.88‐63.26), liver cirrhosis (OR = 9.88; 95% CI 2.20‐54.20), and body mass index (BMI) (OR = 1.16; 95% CI 1.02‐1.35) as independent predictors of 30‐day mortality. The Cox model revealed redo‐Sternotomy (hazard ratio [HR] = 2.67; 95% CI 1.18‐6.03), liver cirrhosis (HR = 3.31; 95% CI 1.45‐7.58), and pulmonary hypertension (HR = 2.26; 95% CI 1.04‐4.92) as risk factors for poor long‐term survival. TV surgery significantly reduces NYHA class. Conclusion Minimally invasive, isolated TV surgery as reoperation without caval occlusion and on the beating heart can be safe and may improve clinical outcome.