Robotic totally endoscopic coronary artery bypass: A word of caution implicated by a five-year follow-up

ObjectiveRobotic totally endoscopic coronary artery bypass of the left anterior descending artery has been introduced in the clinical setting using a wrist-enhanced computer-assisted device to provide a minimally invasive therapeutic approach. Early clinical results were focused on the initial hospital course of patients. This report describes the first 5-year follow-up of patients after totally endoscopic coronary artery bypass in a single center.MethodsFrom May 1999 to June 2001, 41 patients (36 male, 5 female; mean age 60.6 ± 8.9 years) underwent totally endoscopic coronary artery bypass for isolated high-grade lesions of the left anterior descending coronary artery by means of the da Vinci system (Intuitive Surgical, Inc, Mountain View, Calif). Clinical follow-up was performed 5 years after the operation. End points of the follow-up were freedom from major adverse events such as death, myocardial infarction, and repeated revascularization of the left anterior descending artery.ResultsHospital survival was 100%. Overall survival after 5 years was 92.7% (38/41 patients). Three (7.3%) patients died of noncardiac causes. Freedom from reintervention of the left anterior descending artery after a mean of 69 ± 7.4 months was 87.2% (36/41 patients). Freedom from any major adverse events during the whole follow-up was 75.7% (31/41 patients).ConclusionEndoscopic surgery on the beating heart remains the ultimate goal for minimally invasive coronary artery surgery. The clinical outcomes and need for reintervention of the target vessel leave room for improvement and may be considered reflective of early experiences typically associated with dramatic departure from conventional therapy. Moving forward, advances in instrumentation and anastomotic technology seem to be essential for reproducible and reliable coronary anastomosis in a totally endoscopic approach

Redo surgery for noninfective isolated mitral valve disease: Initial outcome and further follow‐up compared to primary surgery

Introduction: Isolated redo‐mitral valve replacement (iMVR) is underreported and often mixed up with endocarditis in the present literature. The present study compares first with redo iMVR in noninfective mitral disease. Patients and Methods: A total of 3821 mitral valve procedures were analyzed. The study was restricted to isolated and noninfective mitral valve replacements done by sternotomy. Finally, 402 patients are included, consisting of 102 redo‐ and 300 first surgeries. The mean patient's age was 65.9 ± 10.4 years; the mean EuroSCORE II was 3.0 ± 2.2%. Median follow‐up was 221 days, ranging up to 9.9 years with a total of 367 patient‐years. Results: Redo's had higher EuroSCORE II (5.1 ± 2.9% vs. 2.3 ± 1.4%; p < .01), more atrial fibrillation (31.1% vs. 46.1%; p = .01), chronic obstructive pulmonary disease (7.3% vs. 17.6%; p = .05), coronary artery disease (7.3% vs. 17.6%; p = .03) and more frequently reduced ejection fraction < 30% (3.0% vs. 11.8%; p = .02). Main outcomes showed comparable 30‐days mortality (first: 4.1%, redo: 6.9%; p = .813). Postoperative morbidity of the redo's was associated with increased postoperative bleeding (p < .01) resulting in increased transfusions of packed red blood cells and fresh frozen plasma (each p < .01), more re‐explorations (p < .01) and longer primary intensive care unit stay (p < .01). Postoperative occurrence of stroke, respiratory or renal failure, and myocardial infarction as well as hospital stay differed not significantly. Estimated 5‐years survival was 65.5 ± 12.3% for all patients with no significant differences between the groups. Multivariate logistic regression respiratory failure as relevant for hospital (odds ratio [OR]: 12.3 [1.1–158]; p = .029) and stroke (OR: 4.8 [1.1–12.3]; p = .021) as relevant for long‐term mortality. Conclusion: iMVR for noninfective reasons is infrequent and rare. Compared to primary surgery, redo's suffer mainly from bleeding‐associated morbidity. This does not translate into prolonged hospital stay or inferior immediate or long‐term outcomes. Redo mitral valve replacement can be performed at no significantly increased surgical risk compared with first surgery and the results are particularly not limited by the surgery itself

Aortic root reinforcement in aortic valve endocarditis with annular abscess: The Calamari procedure

Treatment of infective endocarditis can often prove challenging due to its wide range of anatomical presentations. When complicated by an aortic root abscess, patients may require extensive root surgery, which on its own leads to a worse outcome. We present our experience with a surgical technique for reinforcing the aortic annulus with a ring from a Dacron aortic prosthesis placed in the left ventricular outflow tract to avoid the need for root replacement procedures or patch closures of the defect. The technique described in this paper provides a viable alternative to the standard techniques used for the treatment of annular abscesses in aortic valve endocarditis. Due to the relative simplicity and ease of use, this approach may present a means of reducing operation time and possibly postoperative complications of this severe condition

Pushing the limits—further evolutions of transcatheter valve procedures in the mitral position, including valve-in-valve, valve-in-ring, and valve-in-native-ring

ObjectiveTranscatheter heart valve (THV) procedures are constantly evolving. We report our experience with valve-in-valve, valve-in-ring, and direct-view valve-in-native-ring implantation in the mitral position.MethodsFourteen patients undergoing THV implantation in the mitral position were included. Clinical and postoperative data, including echocardiography and further follow-up, were analyzed.ResultsTen valve-in-valve and 2 valve-in-ring procedures were successfully performed using the transapical access route. For the third valve-in-ring procedure we used an antegrade left-atrial access via right anterolateral minithoracotomy. In 1 patient surgical mitral valve replacement was planned. Intraoperatively, the annulus appeared severely calcified and regular implantation of a bioprosthesis was not possible. As a last resort, a 29-mm Sapien XT valve (Edwards Lifesciences Inc, Irvine, Calif) was implanted under direct view. The initial result was satisfactory, but on the first postoperative day relevant paravalvular regurgitation occurred. Subsequently, the valve was fixed to an atrial cuff by 1 running suture. In this series 27-, 29-, and 31-mm bioprostheses and 28- and 30-mm annuloplasty rings were treated with 26- or 29-mm Sapien XT valves. Postoperative echocardiography on day 10 and after 6 weeks revealed good prosthesis function in all cases. In 2 valve-in-valve patients who solely received anticoagulation therapy with acetylsalicylic acid, signs of beginning valve thrombosis occurred after 8 weeks and 3 months, respectively. During further course, valve function was normalized using warfarin therapy.ConclusionsOur results demonstrate feasibility of valve-in-valve and valve-in-ring THV procedures in the mitral position. Permanent anticoagulation therapy with warfarin seems to be necessary to prevent valve dysfunction. THV implantation in a calcified native mitral ring for bailout seems not to be reproducible and thus cannot be recommended

Cardiac Surgery for Treatment of COVID-19-Associated Infectious Endocarditis

BACKGROUND: Significant uncertainty exists about the optimal timing of surgery for infectious endocarditis (IE) surgery in patients with active SARS-CoV-2 infection. This case series and a systematic review of the literature were carried out to evaluate the timing of surgery and postsurgical outcomes for patients with COVID-19-associated IE. METHODS: The PubMed database was searched for reports published from June 20, 2020, to June 24, 2021, that contained the terms infective endocarditis and COVID-19. A case series of 8 patients from the authors\u27 facility was also added. RESULTS: A total of 12 cases were included, including 4 case reports that met inclusion criteria in addition to a case series of 8 patients from the authors\u27 facility. Mean (SD) patient age was 61.9 (17.1) years, and patients were predominantly male (91.7%). Being overweight was the main comorbidity among patients studied (7/8 [87.5%]). Among all patients evaluated in this study, dyspnea (n = 8 [66.7%]) was the leading symptom, followed by fever (n = 7 [58.3%]). Enterococcus faecalis and Staphylococcus aureus caused 75.0% of COVID-19-associated IE. The mean (SD) time to surgery was 14.5 (15.6) days (median, 13 days). In-hospital and 30-day mortality for all evaluated patients was 16.7% (n = 2). CONCLUSION: Clinicians must carefully assess patients diagnosed with COVID-19 to prevent missing underlying diseases such as IE. If IE is suspected, clinicians should avoid postponement of crucial diagnostic and treatment steps

Hemocompatibility tuning of an innovative glutaraldehyde-free preparation strategy using riboflavin/UV crosslinking and electron irradiation of bovine pericardium for cardiac substitutes

Hemocompatibility tuning was adopted to explore and refine an innovative, GA-free preparation strategy combining decellularization, riboflavin/UV crosslinking, and low-energy electron irradiation (SULEEI) procedure. A SULEEI-protocol was established to avoid GA-dependent deterioration that results in insufficient long-term aortic valve bioprosthesis durability. Final SULEEI-pericardium, intermediate steps and GA-fixed reference pericardium were exposed in vitro to fresh human whole blood to elucidate effects of preparation parameters on coagulation and inflammation activation and tissue histology. The riboflavin/UV crosslinking step showed to be less efficient in inactivating extracellular matrix (ECM) protein activity than the GA fixation, leading to tissue-factor mediated blood clotting. Intensifying the riboflavin/UV crosslinking with elevated riboflavin concentration and dextran caused an enhanced activation of the complement system. Yet activation processes induced by the previous protocol steps were quenched with the final electron beam treatment step. An optimized SULEEI protocol was developed using an intense and extended, trypsin-containing decellularization step to inactivate tissue factor and a dextran-free, low riboflavin, high UV crosslinking step. The innovative and improved GA-free SULEEI-preparation protocol results in low coagulant and low inflammatory bovine pericardium for surgical application

Austrian syndrome in the context of a fulminant pneumococcal native valve endocarditis

This is the case of a young male suffering from Austrian syndrome, which is the triad of endocarditis, meningitis, and pneumonia due to invasive S. pneumoniae infection. He reported recurrent fever for six months without any antibiotic treatment, which may have determined the further course of the syndrome. Echocardiography revealed massive native valve endocarditis, and the patient was considered for ultima-ratio cardiac surgery. Intraoperative aspect presented extensive affection of the aortic root with full destruction of aortic valve, mitral valve, and aortomitral continuity. The myocardium showed a phlegmonlike infiltration. Microbiologic testing of intraoperatively collected specimens identified penicillin-sensitive Streptococcus pneumoniae. S. pneumoniae is a very uncommon cause for infective infiltrative endocarditis and is associated with severe clinical courses. Austrian syndrome is even more rare, with only a few reported cases worldwide. In those patients, only early diagnosis, immediate antibiotic treatment, and emergent cardiac surgery can save lives