Journal of Cardiac Surgery最新文献

Background: Patch augmentation of the anterior mitral leaflet (AAML) is being used to treat functional mitral regurgitation (fMR) with the choice of patch material, however, still being a matter of debate. Therefore, the aim of this study was to determine the early- and 1-year results of AAML for fMR.

Methods: Between 2020 and 2022, 30 patients underwent AAML for Carpentier Type IIIb fMR using an untreated autologous pericardial patch in our institution. The mean age of the patients was 61.3 ± 19.3 years, and 16 patients (53.3%) were male. Early- and 1-year results of mitral valve repair were assessed via clinical follow-up including echocardiographic examination.

Results: Twenty patients (66.7%) were operated on through a right mini-thoracotomy and 10 patients (33.3%) via a median sternotomy, with 19 patients (63.3%) receiving a concomitant procedure. Three patients (10%) required postoperative mechanical circulatory support (MCS), with one of those patients (3.3%) deceasing due to multiple organ failure. Postoperative echocardiography showed that all patients (100%) had either no or mild MR. Freedom from moderate to severe MR was 100% (n = 29) at discharge as well as after a 1.1 ± 0.17-year follow-up (n = 26; with an additional three patients (10%) that deceased during the first postoperative year due to non–valve-related causes). No patient required mitral valve-related reoperation or intervention.

Conclusions: AAML using an untreated autologous pericardial patch is a safe and reproducible surgical technique for fMR, with promising early results up to a 1-year follow-up. Further follow-up is warranted to determine long-term results especially with regard to the durability of mitral valve repair.

Background: Calcific aortic valve disease results in severe aortic valve stenosis, the most frequent valvular disorder. Ex vivo animal models provide an essential resource to understand the mechanism of valvular calcification. Therefore, we aimed to develop a new ex vivo porcine aortic root calcification model.

Methods: Porcine aortic roots were subjected to a procalcific treatment with a buffer solution containing a defined calcium concentration (CaCl₂ = 2.2 mmol) in a durability tester (Hi-Cycle tester) with over 53.2 million cycles. The control group consisted of native porcine aortic roots that were not treated. Cusps of porcine aortic valves of both groups (total n = 10) were compared through macroscopic evaluation, analysis of tissue thickness, scanning and transmission electron microscopy, histological examination and calcium determination.

Results: After durability testing, macroscopic examination demonstrated pronounced calcification at regions with high mechanical stress—the commissures and the nadirs of the cusps. Calcific nodules cause tissue thickness after Hi-Cycle testing. Hydroxyapatite crystals were found by scanning electron microscopy, and calcium deposits were noticed by transmission electron microscopy within calcified cusps in the calcified group. The proof of cusp calcification was seen histologically in the calcified group. Calcium content of the aortic cusps differed significantly after treatment with calcification buffer vs control group (7.240 [6.383–9.494] vs. 3.178 [3.140–3.701] μg/cm² cusp area, p = 0.008).

Conclusion: We established a new reproducible and dynamic porcine aortic root calcification model. This ex vivo model may be a helpful alternative for investigating treatment modalities of calcification and functional analysis of heart valves instead of a complex animal model.

Introduction: Minimally invasive direct coronary artery bypass grafting (MIDCAB) offers a less traumatic alternative to conventional median sternotomy. The benefits of avoiding sternotomy align with the goals of enhanced recovery after surgery (ERAS). While early extubation benefits have been demonstrated in conventional CABG, evidence on extubation in the operating room remains scarce. We present a single-center experience with immediate extubation outside of a structured ERAS concept.

Methods: Patients undergoing MIDCAB via a left anterolateral thoracotomy with unilateral ventilation between August 2022 and March 2024 were retrospectively analyzed. Patients who were extubated in the operating room (extubation in tabula, EIT) were compared to those who were extubated in the intensive care unit (ICU) (control, CTRL). The primary outcome was a transfer to general ward within 24 h after admission to ICU. Secondary outcomes aimed to assess safety endpoints, including the rate of reintubation, major adverse cardiac and cerebrovascular events, and length of stays.

Results: A total of n = 79 patients were included. After propensity score matching, the cohorts consisted of n = 20 (CTRL) and n = 35 (EIT) patients, who had a median age of 68 years (IQR: 63–75), were 83.6% male, and showed comparable baseline characteristics. The majority of patients (92.7%) underwent single arterial bypass grafting. Fifteen patients (27.3%) met the primary endpoint with no significant difference between the two cohorts (CTRL 20.0%, EIT 31.4%, p = 0.531). Three patients in the EIT cohort required reintubation due to revision surgery (n = 2) and cardiopulmonary resuscitation (n = 1) due to thrombotic ischemia. The median stay in ICU was 23 h (IQR: 18–28), the total length of hospital stay 6d (IQR: 5–8) respectively.

Conclusion: EIT after MIDCAB is safe and feasible. However, on its own, it does not affect subsequent transfers and should therefore be only considered as the first step toward a comprehensive ERAS approach.

Background: Severe calcific disease of the ascending aorta may prohibit cross-clamping during coronary artery bypass grafting (CABG) due to unacceptable morbidity and mortality associated with atheroembolic complications. Clampless hypothermic noncardioplegic low flow fibrillation (HLFF) may minimize neurologic complications while allowing for complete revascularization.

Methods: From 2002 to 2019, 142 patients with unclampable aorta (UCA) underwent isolated CABG using clampless HLFF. Short-term and long-term outcomes were compared with an isolated conventional on-pump CABG cohort (n = 268) risk-matched (RM) for type of CABG, STS score, age, and sex.

Results: UCA and RM cohort patients were comparable in terms of age (73.7 ± 7.8 vs. 72.7 ± 8.7, p = 0.281), sex (34.4% vs. 32.5% female, p = 1.000), STS score (4.01 ± 3.43 vs. 3.80 ± 3.33, p = 0.539), and number of diseased vessels (p = 0.323). 90% of patients underwent central cannulation; UCA group patients received a comparable number of arterial (p = 0.432) or venous grafts (p = 0.493). Incidence of stroke was 6.3% in the UCA cohort and 2.6% in the RM cohort (p = 0.059). Need for reoperation, postoperative transfusions, incidence of atrial fibrillation, and renal impairment was similar (all p > 0.050). UCA patients spent a longer time on the ventilator, in the ICU, and in the hospital (all p = 0.001). Operative mortality was not different between UCA and RM groups (3.5% vs. 4.5%, p = 0.797) as was all-cause mortality over long-term follow-up (p = 0.093).

Conclusions: While a higher incidence of stroke was observed, without reaching statistical significance, hypothermic fibrillatory arrest remains a valuable and safe tool for coronary revascularization in UCA patients, offering comparable short-term and long-term survival outcomes allowing for complete revascularization.

Background: A cost–benefit analysis of open vein harvesting (OVH) versus endoscopic vein harvesting (EVH) for leg wound complications in intermediate- and high-risk cardiac surgical patients was performed based on the German Diagnosis-Related Groups (G-DRG) in a retrospective cohort.

Methods: The highest Fowler score and EuroSCORE II were utilized as risk variables for leg wound infection. Risk adjustment (1:1) was performed to compare two groups of patients undergoing surgery with OVH or EVH techniques. Total costs, including costs of facilities, additional hospital stays, and personnel expenses based on Institute for the Hospital Remuneration System calculations, were compared with G-DRG reimbursements.

Results: The baseline characteristics of the two groups did not differ significantly. Thirty-four (41.8%) patients developed a wound healing disorder, 28 in the OVH group and 6 in the EVH group (p = 0.037). During the hospital stay, five (7.4%) patients in the OVH group had major leg wound healing disorders. Patients in the OVH group had a marginally longer hospital stay, though without statistical significance (14.3 vs. 11.7 days; p = 0.424). The total cost was 23,223€ for the OVH group compared with 18,627€ for the EVH group (p < 0.001); thus, the cost of the OVH group exceeded that of the EVH group by 4596€ based on G-DRG calculations.

Conclusion: EVH was associated with significant cost savings and fewer leg wound complications in intermediate- or high-risk patients. The G-DRG reimbursement system ended with the statement that case-based flat rates are not viable for hospitals treating vulnerable groups of patients.

Background: Reducing operative times and standardizing surgical techniques are important in robot-assisted cardiac surgery. We have implemented V-Loc barbed sutures as a technical refinement to left atrial closure and report our outcomes.

Methods: We retrospectively analyzed 45 consecutive patients who underwent robot-assisted mitral valve repair between January 2023 and September 2024 at Nagoya University Hospital. Patients were divided into two groups: a V-Loc group (n = 29) and a conventional suture group (n = 16). The primary endpoint was left atrial closure time. Secondary endpoints included perioperative complication and reoperation rates.

Results: The V-Loc group demonstrated a shorter left atrial closure time (11 [7.8–13] minutes vs. 16 [14.5–19] minutes in the conventional group, p < 0.01), representing a 31.3% reduction. One patient in the V-Loc group required reoperation due to intercostal vessel bleeding, unrelated to the closure technique. No operative mortality or major complications were encountered in either group. During a median follow-up period of 16 months (up to 27 months), no complications associated with the atrial closure technique were observed.

Conclusions: The use of V-Loc barbed sutures for left atrial closure in robot-assisted mitral valve surgery significantly reduced operative times while maintaining procedural safety. This technique represents a promising approach for standardizing and streamlining robotic cardiac procedures.

Background: Bleeding after cardiac surgery is common. Intraoperative assessment of whole blood coagulation may allow early targeted treatment of coagulopathy associated with cardiopulmonary bypass. The performance of an ultrasound-mediated method of whole blood coagulation testing is assessed and compared with guidance by routine laboratory testing.

Methods: A retrospective single-center experience of 1077 patients is reported comparing transfusion practices with and without viscoelastic testing in two consecutive years with no other changes in clinical practice. The primary end point was the incidence and volume of transfusion of packed red cells, platelets, fresh frozen plasma (FFP), and cryoprecipitate. Secondary endpoints included hospital mortality, re-exploration for bleeding, stroke, new onset renal failure, and prolonged ventilation.

Results: There was no difference in the incidence of patients needing transfusion, but there was a significant drop in the volume of products given with the adoption of whole-blood testing. The decline in FFP and cryoprecipitate reached statistical significance. Although there was not a statistically significant decline in red cell administration, patients tolerated targeted nonred cell administration with less postoperative anemia. There were no other changes in clinical outcomes.

Conclusion: Intraoperative ultrasound-mediated whole blood coagulation testing resulted in a substantial decline in nonred cell blood product administration in cardiac surgery patients.

Objective: To investigate the effect of modified remote ischemic preconditioning (MRIC) on perioperative outcomes in patients undergoing coronary artery bypass grafting (CABG) on cardiopulmonary bypass (CPB).

Methods: This study included 118 patients who planned to undergo CABG surgery at the Affiliated Hospital of Xuzhou Medical University. These patients were randomly divided into the MRIC group (n = 40), remote ischemic preconditioning (RIPC) group (n = 39), or control group (n = 39). The MRIC group received 3 cycles of 5 min ischemia/5 min reperfusion on the left upper limb at 2 days, 1 day, and 2 h preoperatively. The RIPC group received RIPC 2 h preoperatively, while the control group did not receive ischemic preconditioning. The STS score of patients was calculated according to the coronary angiography results and clinical data for risk stratification. The serum concentrations of N-terminal pro-B-type natriuretic peptide (NT-proBNP), creatine kinase MB (CK-MB), high-sensitivity cardiac troponin-T (hs-cTnT), and creatinine (Cr) of patients were recorded at postoperative 0, 12th, 24th, 48th, 72th h , and seventh days for each patient. Major adverse cardiac events (MACEs) in the hospital were recorded.

Results: A total of 118 participants were included. The overall MACE incidence was 83.4%. A total of 36 MACE cases (92.3%) occurred in the control group, 28 cases (70.0%) in the MRIC group (RR: 0.75; 95% CI: 0.61–0.95), and 35 cases (89.7%) in the RIPC group (RR: 0.97; 95% CI: 0.84–1.12). Compared to the control group, MRIC and RIPC groups had lower concentrations of CK-MB at postoperative 0 and 12th h (p < 0.05); MRIC group had lower concentrations of hs-cTnT at postoperative 12th h (p < 0.05). The MRIC group had a higher concentration of NT-proBNP at postoperative 24th, 48th, and 72th h (p < 0.05). The differences in the concentration of Cr among the three groups were not statistically significant (p > 0.05); There was no statistically significant difference in the effects of MRIC on the indexes of the low-risk patients and the medium-high-risk patients (p > 0.05).

Conclusion: (1) MRIC has cardioprotective effects and reduces the occurrence of postoperative MACE. (2) MRIC could not reduce the concentrations of NT-proBNP and Cr postoperatively. (3) MRIC showed no significant difference in myocardial protection in patients with different STS score risk stratifications.

Objectives: We evaluated real world use of angiotensin II (AT II) in patients with vasoplegic syndrome (VS) following cardiac surgery.

Design: A retrospective chart review was performed to describe and evaluate VS following cardiac surgery under cardiopulmonary bypass (CPB) for AT II use and associated outcomes. Among these outcomes examined were death, stroke, myocardial infarction, acute kidney injury (AKI), tracheostomy need, ventilator hours, and hospital and cardiovascular intensive care unit (CVICU) lengths of stay (LOS). These outcomes were compared across patients with VS who received AT II vs. patients who did not receive AT II using Wilcoxon rank sum and Chi-square testing, as appropriate.

Setting: Academic medical center.

Participants: Adult postcardiac surgery VS patients.

Interventions: AT II vs. non-AT II receiving VS patients.

Measurements and Main Results: Of 2013 included patients undergoing cardiac surgery under CPB during the study period, 52 met criteria for VS, 11 (21.2%) received AT II, and 41 (71.8%) did not. The incidence of AKI, tracheostomy, CVICU LOS, and hospital LOS was higher in the AT II group (Tables 1 and 2). The median maximum postoperative NEE dose within 24 h following surgery was higher in the AT II group: 0.44 mcg/kg/min (IQR 0.39, 0.57) versus 0.23 mcg/kg/min (IQR 0.21, 0.26, p < 0.001).

Conclusions: AT II use was rare among cardiac surgical patients. AT II use was associated with increased resource use. AT II patients were on higher pressure dosing and may have had worse outcomes without AT II. Larger, prospective studies are needed to understand the impact of AT II on outcomes in this population.

Background: Venous thromboembolism (VTE) is a rare complication after coronary artery bypass surgery (CABG), leading to increased morbidity and mortality. There are no current societal guidelines directing prophylaxis. Utilizing a regional database, we sought to determine the prevalence of VTE and characterize regional center practices.

Methods: We identified all patients undergoing on-pump, isolated CABG (2010–2020). Patients on oral therapeutic anticoagulation or requiring mechanical circulatory support were excluded. Participating centers were surveyed to determine center level practices. Multivariable regression and hierarchical logistic regression were utilized for risk-adjusted outcomes and influence of center practices on VTE rates, respectively.

Results: Of 20,719 CABG patients, the overall prevalence of postoperative VTE was 1.3% (266/20,719). Patients developing VTE were more often female (30.1% vs. 23.4%, p = 0.01), had higher STS predicted risk of mortality (1.2% [0.7%, 2.2%] vs. 0.9% [0.5%, 1.7%], p < 0.001) and higher unadjusted operative mortality (4.1% vs. 1.0%, p < 0.001). Risk-adjusted analysis demonstrated pulmonary embolism as an independent predictor of mortality (OR = 3.4 [1.06, 11.0], p = 0.04). Increasing time from admission to surgery (OR = 1.05 [1.01, 1.09], p = 0.001), preoperative heparin use (OR = 1.47 [1.13, 1.90], p = 0.004), and intraoperative prothrombin complex concentrate (PCC) (OR = 4.85 [1.47, 15.96], p = 0.009) were predictors of VTE. Regional practices were mainly homogenous with no specific center-level protocol associated with decreases in VTE.

Conclusion: VTE following CABG is an infrequent postoperative complication with pulmonary embolism as an independent predictor of mortality. Increasing time from admission to surgery and intraoperative PCC may increase the risk of VTE.