PubMed Posts

Background: Coronary artery bypass grafting (CABG) in the setting of an acute coronary syndrome is a high-risk procedure, and the best strategy for myocardial revascularisation remains debated. This study compares the 30-day mortality benefit of on-pump CABG (ONCAB), off-pump CABG (OPCAB), and on-pump beating heart CABG (OnBHCAB) strategies.

Methods: A systematic search of three electronic databases was conducted for studies comparing ONCAB with OPCAB or OnBHCAB in patients with acute coronary syndrome (ACS). The primary outcome, 30-day mortality, was compared using a Bayesian hierarchical network meta-analysis (NMA). A random effects consistency model was applied, and direct and indirect comparisons were made to determine the relative effectiveness of each strategy on postoperative outcomes.

Results: One randomised controlled trial and eighteen observational studies fulfilling the inclusion criteria were identified. A total of 4320, 5559, and 1962 patients underwent ONCAB, OPCAB, and OnBHCAB respectively. NMA showed that OPCAB had the highest probability of ranking as the most effective treatment in terms of 30-day mortality (odds ratio [OR], 0.50; 95% credible interval [CrI], 0.23-1.00), followed by OnBHCAB (OR, 0.62; 95% CrI, 0.20-1.57), however the 95% CrI crossed or included unity. A subgroup NMA of nine studies assessing only acute myocardial infarction (AMI) patients demonstrated a 72% reduction in likelihood of 30-day mortality after OPCAB (CrI, 0.07-0.83). No significant increase in rate of stroke, renal dysfunction or length of intensive care unit stay was found for either strategy.

Conclusions: Although no single best surgical revascularisation approach in ACS patients was identified, the significant mortality benefit with OPCAB seen with AMI suggests high acuity patients may benefit most from avoiding further myocardial injury associated with cardiopulmonary bypass and cardioplegic arrest.

Background: Partial intraluminal thrombosis of the frozen elephant trunk (FET) stent graft is a poorly described but not infrequent complication after aortic arch surgery. This study aims to describe and analyze the occurrence of early FET stent graft thrombosis.

Methods: Retrospective single-center analysis including patients who underwent aortic arch replacement with FET technique between 2006 and 2020. Stent graft thrombosis was diagnosed through computed tomography scan. Several computed tomography scan parameters and clinical variables were analyzed as predictors of this event.

Results: A total of 125 patients were included for analysis. Among these, 21 (16.8%) patients developed early postoperative FET stent graft thrombosis. Mean volumetric size of the aorta was 12.2 ± 2.0 mL in patients with FET stent graft thrombosis and 10.1 ± 2.8 mL in patients without thrombosis (P < .01). Thrombosis occurred more frequently among patients requiring thoracic endovascular aortic repair completion (15 of 21 [71.4%] patients) than in patients with completely excluded aneurysms (6 of 21 [28.6%] patients) (P = .01). Mean stent-to-aneurysm diameter ratio was 0.8 ± 0.2 among patients with thrombosis and 1.0 ± 0.2 among patients without thrombosis (P < .01). Thrombosis was more frequently observed among patients with conservative management of postoperative bleeding (P = .04). Patients with early FET thrombosis had a nonsignificantly higher in-hospital all-cause mortality than patients without thrombosis (19.0% vs 8.7%; P = .3).

Conclusions: Early postoperative intraluminal thrombosis is a frequent complication post FET surgery. Smaller stent graft sizes, larger or partially covered aneurysms, and major bleeding are associated with early thrombosis. Slight FET oversizing, prompt thoracic endovascular aortic repair completion, and early reintervention for major bleeding may prevent early thrombosis.

Randomized trials of stenting versus surgery for patients with unprotected left main (LM) coronary stenosis have largely shown similar survival between the two interventions. However, patients with LM stenosis represent a heterogeneous group in which subgroups likely to benefit from one therapy more than another are difficult to identify. Increasing coronary disease burden is the most accepted subgrouping for identifying optimal therapy but this can be defined in more detail allowing greater discrimination. Competitive flow reduces bypass graft patency in patients with isolated LM stenosis and complex bifurcation stenoses reduce the effectiveness of coronary stenting. The evidence for LM stenosis subgroupings is presented.

Randomized trials of stenting versus surgery for patients with unprotected left main (LM) coronary stenosis have largely shown similar survival between the two interventions. However, patients with LM stenosis represent a heterogeneous group in which subgroups likely to benefit from one therapy more than another are difficult to identify. Increasing coronary disease burden is the most accepted subgrouping for identifying optimal therapy but this can be defined in more detail allowing greater discrimination. Competitive flow reduces bypass graft patency in patients with isolated LM stenosis and complex bifurcation stenoses reduce the effectiveness of coronary stenting. The evidence for LM stenosis subgroupings is presented.

No abstract available

Background: Over the past two decades surgical approaches for mitral valve (MV) disease have evolved with the advent of minimally invasive techniques. Robotic mitral valve repair (RMVr) safety and efficacy has been well documented, however, mid- to long-term data are limited. The aim of this review was to provide a comprehensive analysis of the available mid- to long-term data for RMVr.

Methods: Electronic searches of five databases were performed to identify all relevant studies reporting minimum five-year data on RMVr. Pre-defined primary outcomes of interest were overall survival, freedom from MV reoperation and from moderate or worse mitral regurgitation (MR) at five years or more post-RMVr. A meta-analysis of proportions or means was performed, utilizing a random effects model, to present the data. Kaplan-Meier curves were aggregated using reconstructed individual patient data.

Results: Nine studies totaling 3,300 patients undergoing RMVr were identified. Rates of overall survival at 1-, 5- and 10-year were 99.2%, 97.4% and 92.3%, respectively. Freedom from MV reoperation at eight-years post RMVr was 95.0%. Freedom from moderate or worse MR at seven years was 86.0%. Rates of early post-operative complications were low with only 0.2% all-cause mortality and 1.0% cerebrovascular accident. Reoperation for bleeding was low at 2.2% and successful RMVr was 99.8%. Mean intensive care unit and hospital stay were 22.4 hours and 5.2 days, respectively.

Conclusions: RMVr is a safe procedure with low rates of early mortality and other complications. It can be performed with low complication rates in high volume, experienced centers. Evaluation of available mid-term data post-RMVr suggests favorable rates of overall survival, freedom from MV reoperation and from moderate or worse MR recurrence.

No abstract available

No abstract available

Robotic mitral valve repair presents its own unique set of challenges. Neochordae implantation is one of the techniques used to achieve adequate repair of the mitral valve. Precise securing of neochordae is vital in achieving a meticulous repair. This article describes how to perform an efficient, reproducible robotic mitral valve repair using a string, a ruler, and a bulldog.

Iatrogenic aortic dissection (IAD) is a rare but devastating complication in cardiac surgery and related procedures. Due to its rarity, published data on emergency surgery following IAD are limited. Herein, we discuss IAD occurring intra- and postoperatively, including those occurring during transcatheter aortic valve replacement and cardiac catheterization, and present benchmark data from our consecutive, single-center experience. We demonstrate changes in patient characteristics, surgical approaches, and outcomes over a 23-year period.