Evaluation of the PAS-Port Proximal Anastomosis System in coronary artery bypass surgery (the EPIC trial)

ObjectiveDuring coronary surgery, proximal vein graft anastomoses have been performed by using an aortic partial occlusion clamp to allow for a hand-sewn anastomosis. The purpose of this multicenter, prospective, randomized trial was to evaluate the efficacy of the PAS-Port device (Cardica, Inc, Redwood City, Calif), which allows an automated proximal anastomosis to be performed without aortic clamping.MethodsBetween June 22, 2006, and March 22, 2007, 220 patients requiring coronary artery bypass grafting with at least 2 vein grafts were enrolled. Within each patient, 1 graft was randomly assigned to receive a PAS-Port device, and the other was assigned to receive a hand-sewn anastomosis to the ascending aorta. The primary end point was angiographic patency (<50% stenosis) 9 months after surgical intervention. Secondary end points included average time to complete each anastomosis and 9-month freedom from major adverse cardiac events.ResultsOne hundred eighty-three patients received matched grafts that were angiographically assessed at 9 months. The 9-month graft patency was 82.0% (150/183) for hand-sewn and 80.3% (147/183) for PAS-Port grafts. The patency rate of PAS-Port anastomoses was statistically noninferior to that of hand-sewn anastomoses (95% lower confidence limit for difference, −7.95%). The freedom from major adverse cardiac events at 9 months was 97.7% for PAS-Port (95% confidence interval, 94.5%–99.0%) and 98.2% for hand-sewn (95% confidence interval, 95.1%–99.3%) grafts. The PAS-port device was associated with a 4.6 ± 3.9–minute reduction in anastomotic time compared with that seen with a hand-sewn anastomosis (P < .001).ConclusionsThe PAS-Port proximal anastomotic device produces an effective anastomosis with a 9-month patency rate that is comparable with that of a hand-sewn anastomosis. It allows for construction of a proximal anastomosis without aortic clamping and requires less time than a hand-sewn anastomosis

Trends in surgical aortic valve replacement in pre- and post-transcatheter aortic valve replacement eras at a structural heart center

BackgroundThe advent of transcatheter aortic valve replacement (TAVR) has directly impacted the lifelong management of patients with aortic valve disease. The U.S. Food and Drug Administration has approved TAVR for all surgical risk: prohibitive (2011), high (2012), intermediate (2016), and low (2019). Since then, TAVR volumes are increasing and surgical aortic valve replacements (SAVR) are decreasing. This study sought to evaluate trends in isolated SAVR in the pre- and post-TAVR eras.MethodsFrom January 2000 to June 2020, 3,861 isolated SAVRs were performed at a single academic quaternary care institution which participated in the early trials of TAVR beginning in 2007. A formal structural heart center was established in 2012 when TAVR became commercially available. Patients were divided into the pre-TAVR era (2000–2011, n = 2,426) and post-TAVR era (2012–2020, n = 1,435). Data from the institutional Society of Thoracic Surgeons National Database was analyzed.ResultsThe median age was 66 years, similar between groups. The post-TAVR group had a statistically higher rate of diabetes, hypertension, dyslipidemia, heart failure, more reoperative SAVR, and lower STS Predicted Risk of Mortality (PROM) (2.0% vs. 2.5%, p &lt; 0.0001). There were more urgent/emergent/salvage SAVRs (38% vs. 24%) and fewer elective SAVRs (63% vs. 76%), (p &lt; 0.0001) in the post-TAVR group. More bioprosthetic valves were implanted in the post-TAVR group (85% vs. 74%, p &lt; 0.0001). Larger aortic valves were implanted (25 vs. 23 mm, p &lt; 0.0001) and more annular enlargements were performed (5.9% vs. 1.6%, p &lt; 0.0001) in the post-TAVR era. Postoperatively, the post-TAVR group had less blood product transfusion (49% vs. 58%, p &lt; 0.0001), renal failure (1.4% vs. 4.3%, p &lt; 0.0001), pneumonia (2.3% vs. 3.8%, p = 0.01), shorter lengths of stay, and lower in-hospital mortality (1.5% vs. 3.3%, p = 0.0007).ConclusionThe approval of TAVR changed the landscape of aortic valve disease management. At a quaternary academic cardiac surgery center with a well-established structural heart program, patients undergoing isolated SAVR in the post-TAVR era had lower STS PROM, more implantation of bioprosthetic valves, utilization of larger valves, annular enlargement, and lower in-hospital mortality. Isolated SAVR continues to be performed in the TAVR era with excellent outcomes. SAVR remains an essential tool in the lifetime management of aortic valve disease

Ischaemic conditioning and targeting reperfusion injury: a 30 year voyage of discovery

To commemorate the auspicious occasion of the 30th anniversary of IPC, leading pioneers in the field of cardioprotection gathered in Barcelona in May 2016 to review and discuss the history of IPC, its evolution to IPost and RIC, myocardial reperfusion injury as a therapeutic target, and future targets and strategies for cardioprotection. This article provides an overview of the major topics discussed at this special meeting and underscores the huge importance and impact, the discovery of IPC has made in the field of cardiovascular research

Hybrid coronary revascularization: the Emory experience

This article reviews the Emory University Experience with hybrid coronary revascularization and identifies key factors essential for the success of this relatively new and evolving strategy for the treatment of coronary artery disease. Key decisional and technical factors were identified. In addition, careful patient selection, stepwise progression in learning the different aspects of the procedure, and close collaboration between cardiac surgery-interventional cardiology are key factors for success

Review paper <br>Postconditioning: a brief review

Preconditioning represents the most effective form of cardioprotection that can be induced to attenuate the injury accompanying a longer lasting ischemia (=index ischemia) of sufficient duration and severity to cause myocardial necrosis. Preconditioning can be induced by short bouts of ischemia, several pharmaceuticals (e.g. adenosine), and volatile anesthetics all imposed before the index ischemia. A brief ischemia of an organ other than the heart can likewise initiate protection of the heart, which has been called “preconditioning at a distance” or “remote preconditioning”. According to the more recent literature, short bouts of ischemia after an index ischemia can also initiate cardioprotection, e.g. improved post-ischemic endothelial function, reduced infarct size and less apoptosis; this protective maneuver has been called “postconditioning”. Postconditioning can also be elicited at a distant organ, termed “remote postconditioning”. It is the aim of this short review to (1) characterize preconditioning and in particular postconditioning, (2) describe possible mechanisms, and (3) call attention to the clinical relevance of this cardioprotective strategy