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Objective The objective of this study was to report midterm clinical outcomes with a self-expandable sutureless aortic valve. Methods Between 2010 and 2013, 658 patients at 25 European institutions received the Perceval sutureless valve (LivaNova Plc, London, United Kingdom). Mean follow-up was 3.8 years; late cumulative follow-up was 2325.2 patient-years. Results The mean age of the population was 78.3 ± 5.6 years and 40.0% (n = 263) were 80 years of age or older; mean Society of Thoracic Surgeons-Predicted Risk of Mortality score was 7.2 ± 7.4. Concomitant procedures were performed in 31.5% (n = 207) of patients. Overall duration of cardiopulmonary bypass time was 64.8 ± 25.2 minutes and aortic cross-clamping time was 40.7 ± 18.1 minutes. Thirty-day all-cause mortality was 3.7% (23 patients), with an observed:expected ratio of 0.51. Overall survival was 91.6% at 1 year, 88.5% at 2 years, and 72.7% at 5 years. Peak and mean gradients remained stable during follow-up, and were 17.8 ± 11.3 mm Hg and 9.0 ± 6.3 mm Hg, respectively, at 5 years. Preoperatively, 33.4% of those who received the Perceval valve (n = 210) were in New York Heart Association functional class I or II versus 93.1% (n = 242) at 5 years. Conclusions This series, representing, to our knowledge, the longest follow-up with sutureless technology in a prospective, multicenter study, shows that aortic replacement using sutureless valves is associated with low mortality and morbidity and good hemodynamic performance.

Minimal access aortic valve replacement is associated with favorable clinical outcomes; however, several meta-analyses have reported significantly longer crossclamp times compared with a full sternotomy. We examined the procedural and early safety outcomes after isolated rapid deployment aortic valve replacement by surgical approach in patients enrolled in the Surgical Treatment of Aortic Stenosis With a Next Generation Surgical Aortic Valve trial.The Surgical Treatment of Aortic Stenosis With a Next Generation Surgical Aortic Valve trial was a prospective, multicenter, single-arm study, with successful implants in 287 patients with aortic valve stenosis who underwent rapid deployment aortic valve replacement using the EDWARDS INTUITY Valve System (Edwards Lifesciences, Irvine, Calif). Patients were evaluated perioperatively for procedural times and technical success rates; at discharge, for hospital length of stay; and, at 30 days, for early adverse events.A total of 158 patients underwent isolated aortic valve replacement through a full sternotomy (n = 71), upper hemisternotomy (n = 77), or right anterior thoracotomy (n = 10). Mean age at baseline was 75.7 ± 7.2 years. Mean aortic crossclamp and cardiopulmonary bypass times (minutes) were similar for full sternotomy and upper hemisternotomy, 43.5 ± 32.5/71.6 ± 41.8 and 43.1 ± 13.1/69.6 ± 19.1, respectively, and significantly longer for right anterior thoracotomy, 88.3 ± 18.6/122.2 ± 22.1 (P .000). Early adverse event rates were similar, and in-hospital mortality rates were low regardless of surgical approach.These data suggest that isolated rapid deployment aortic valve replacement through an upper hemisternotomy can lead to shorter crossclamp times than has been reported historically in the literature. This may facilitate minimal access aortic valve replacement by eliminating the issue of prolonged crossclamp times. Further, low in-hospital mortality and new permanent pacemaker implant rates were observed regardless of surgical approach.

Ischemic spinal cord injury remains the most devastating complication after open and endovascular aortic repair. Collateral network near-infrared spectroscopy has been introduced to noninvasively monitor real-time spinal cord oxygenation. In view of recent advancements in endovascular treatment and minimally invasive staged preconditioning before aortic repair, this study sought to evaluate collateral network near-infrared spectroscopy during and after segmental artery occlusion in a chronic porcine model.Surgery for segmental artery occlusion was performed in 12 juvenile pigs, and bilateral lumbar collateral network near-infrared spectroscopy was recorded. Two intervention groups were designed: Group 1 received subtotal segmental artery occlusion (mimicking reimplantation of crucial segmental arteries with patent T12/T13, N = 5), and group 2 received total occlusion (T4-L5, N = 7). Pigs were monitored over 3 days.All animals were paraplegic during the first 24 hours. The subtotal occlusion group completely recovered, whereas 57% of the total occlusion group remained paraplegic (N = 4/7). After segmental artery occlusion, collateral network near-infrared spectroscopy decreased from 92.3% ± 8% of baseline to 69.3% ± 18% after 10 minutes in the subtotal group (P = .003-.017) and from 90.1% ± 4% to 58.2% ± 9% in the total group (P .001-.008). Throughout the postoperative period, collateral network near-infrared spectroscopy in the total occlusion group remained lower compared with the subtotal group (30% baseline threshold, P .05). Lumbar collateral network near-infrared spectroscopy and neurologic outcome were significantly correlated (R = 0.7, P .001).Lumbar collateral network near-infrared spectroscopy reacts to occlusion of segmental arteries and correlates with neurologic outcome. The preliminary data suggest that collateral network near-infrared spectroscopy may be a valuable noninvasive tool for detecting imminent spinal cord ischemia during and after aortic procedures involving segmental artery occlusion.

ObjectivesSurgical management of tricuspid valve regurgitation mainly consists of tricuspid valve annuloplasty, usually performed with implantation of a rigid ring or a flexible band.MethodsWe performed a retrospective analysis on 820 patients who underwent tricuspid valve repair between March 2002 and July 2009 with either a flexible Cosgrove-Edwards band (n = 415; Edwards Lifesciences LLC, Irvine, Calif) or a rigid Carpentier-Edwards Classic annuloplasty ring (n = 405; Edwards Lifesciences). Mean patient age was 69.2 ± 9.5 years, 54.1% were female, and average logistic EuroSCORE was 13.3% ± 12.5%. Concomitant procedures were performed in 94.6% of patients (mitral valve surgery, 80.6%; aortic valve surgery, 28.2%; coronary artery bypass grafting, 24.5%; atrial fibrillation ablation, 44.5%). One fifth of the operations were reoperative procedures. Follow-up was 94% complete, with mean duration of 21.0 ± 19.0 months.ResultsThirty-day mortality was 10.1% (Cosgrove-Edwards, 11.9%; Carpentier-Edwards, 8.4%), and 5-year survival was 62.4% (Carpentier-Edwards, 64.7%; Cosgrove-Edwards, 60.3%). Postoperative echocardiography showed significant improvement in tricuspid valve function, with reduction in tricuspid regurgitation grade from 2.3 ± 0.7 to 0.7 ± 0.7, and no differences between groups. Use of a Carpentier-Edwards ring, however, was associated with significantly higher risk of dehiscence (Carpentier-Edwards, 8.7%; Cosgrove-Edwards, 0.9%; P

Objective Our objective was to analyze the results of transapical aortic valve implantation in high-risk patients with aortic stenosis at up to 3 years after the procedure. Methods A total of 299 patients underwent transapical aortic valve implantation from February 2006 until January 2010 using the Edwards SAPIEN transcatheter xenograft. Mean patient age was 82 ± 6 years and 70% were female. Logistic EuroSCORE and Society of Thoracic Surgeons score predicted risks for mortality were 31% ± 16% and 12% ± 8%, respectively. All patients were treated in a hybrid operative theater by a team of anesthetists, cardiologists and cardiac surgeons. Results Successful valve implantation was performed in all patients. Transapical aortic valve implantation was uneventful in 267 patients (89.3%), whereas 32 patients (10.7%) required additional interventions. Such interventions included cardiopulmonary bypass support in 18, implantation of a second SAPIEN valve in 15, coronary intervention in 9, conversion to conventional surgery in 6, and annulus perforation in 3 patients (not mutually exclusive). Intraprocedural stroke was not observed in any patient, although 2 (0.7%) patients had a delayed stroke during their hospital stay. Overall survival was 91% at 30 days, 73% at 1 year, 68% at 2 years, and 58% at 3 years. Conclusions Transapical aortic valve implantation can be performed with good outcomes in high-risk patients with aortic stenosis. Perioperative complications occur in approximately 10% of patients, and a variety of interventions are required for these events. We believe a team approach is therefore essential for the success of transapical aortic valve implantation

Objective The study objective was to evaluate the outcomes of surgery for active infective endocarditis with aortic root abscess formation. Methods Between July 1996 and June 2009, 1161 patients underwent operation for aortic valve endocarditis, of whom 172 had aortic root abscess. The infected valve was native in 96 patients and prosthetic in 76 patients. Patients' mean age (± standard deviation) and logistic EuroSCORE-predicted risk of mortality were 62 ± 13 years and 23.1% ± 26%, respectively. Surgery was emergent in 96 patients (58%). The abscess involved the aortic annulus in 90 patients (52%), the intervalvular fibrous body in 81 patients (47%), and the mitral annulus in 21 patients (12%). Surgery consisted of radical resection of the abscess, reconstruction of the annulus with patches, and valve replacement. Estimated mean follow-up was 4.0 ± 0.3 years (range, 0–8.2 years). Results Thirty-day mortality was 25% (n = 43) (prosthetic valve endocarditis vs native valve endocarditis, 35.5% vs 16.7%, P = .005). Independent predictors of mortality were sepsis (odds ratio [OR], 3.6; 95% confidence interval [CI], 1.2–10.7), renal insufficiency (OR, 3.3; 95% CI, 1.1–9.5), concomitant coronary artery bypass grafting (OR, 2.8; 95% CI, 1.1–7.0), and prosthetic valve endocarditis (OR, 2.4; 95% CI, 1.1–5.6). Survival at 1 and 5 years was 55% ± 4% and 50% ± 4%, respectively, and predicted by concomitant mitral endocarditis (OR, 3.2; 95% CI, 1.3–8.2), sepsis (OR, 2.7; 95% CI, 1.6–4.5), renal insufficiency (OR, 1.9; 95% CI, 1.1–3.4), and age (OR, 1.05; 95% CI, 1.02–1.07). Endocarditis recurred in 15 patients (8.7%) at a mean of 1.8 ± 2.4 years postoperatively (39 days to 6 years). Conclusions The surgical treatment of aortic root abscess remains a challenge with relatively high perioperative morbidity and mortality, although long-term survival is satisfactory.

Objective Mitral valve surgery for posterior mitral leaflet prolapse consists mostly of leaflet resection, but implantation of premeasured polytetrafluoroethylene neochordae (ie, loops) is another option. The aim of this prospectively randomized trial was to determine how preservation of leaflet structure in combination with premeasured neochordae compares with the widely adopted technique of leaflet resection. Methods A total of 129 patients with severe mitral regurgitation, with a mean mitral regurgitation grade of 3.6 ± 0.6, underwent minimal invasive mitral valve surgery through a right lateral mini-thoracotomy. The mean age was 59.5 ± 12 years, 90 patients were male, the mean preoperative ejection fraction was 65% ± 8%, and the mean New York Heart Association functional class was 2.1 ± 0.7. Posterior mitral leaflet prolapse was diagnosed in all patients. Randomization was performed preoperatively, and crossover was allowed if the surgeon deemed it medically necessary. Crossover from resection to loops occurred in 9 patients, and crossover from loops to resection occurred in 3 patients. Results Mitral valve repair was accomplished in all patients (n = 129, 100%), and all patients received an annuloplasty ring. The mean number of loops implanted on the posterior mitral leaflet was 3.2 ± 0.9, with a mean length of 13.3 ± 2.2 mm. The mean duration of cardiopulmonary bypass was 135 ± 37 minutes and the mean aortic crossclamp time was 82 ± 26 minutes in all patients, with no significant difference between groups. Intraoperative transesophageal echocardiography showed a significantly longer line of mitral valve leaflet coaptation after implantation of loops (7.6 ± 3.6 mm) than after resection (5.9 ± 2.6 mm; P = .03). Thirty-day mortality was 1.6% for the entire group (2/129), with both deaths occurring in the loop group. Cause of death was massive pulmonary embolism in 1 patient and acute right heart failure in 1 patient. Early and mid-term echocardiographic follow-up revealed excellent valve function in the majority of patients, with no significant difference in mitral orifice area (3.6 ± 1.0 cm 2 vs 3.7 ± 1.1 cm 2 , P = .4). Conclusion Both repair techniques for posterior mitral leaflet prolapse are associated with excellent results and appear comparable in the early postoperative course. The loop technique, however, results in a significantly longer line of leaflet coaptation and may therefore be more durable. Longer follow-up is required.

Objective To evaluate the results of open surgical repair for complications after endovascular thoracic aorta stenting. Methods A total of 14 patients (8 male, mean age 59.8 ± 14.8 years) underwent conventional surgical therapy at our institution over a 5-year period after previous thoracic aortic stent implantation. The indications for surgery, intraoperative strategy, and perioperative and follow-up results were analyzed. Results The indication for stent implantation was type B aortic dissection in 10 patients, expanding degenerative thoracic aneurysm in 3 patients, and pseudoaneurysm in 1 patient. The median interval to conventional surgery after stent implantation was 4.5 months (range 0.1–49 months). The indication for surgery was persistent type I endoleak with progressive aneurysm enlargement in 7 patients, aortoesophageal fistula in 2 patients, retrograde type A dissection in 2 patients, infection of the endoprosthesis in 2 patients, and aortic valve insufficiency caused by perforation of noncoronary and right coronary cusps in 1 patient. The endograft had to be removed in 9 (64%) patients, and 5 (36%) patients required replacement of the thoracoabdominal aorta. In-hospital mortality was 7% (1 patient). No patients had a postoperative stroke or paraparesis. Eleven (79%) patients are alive after a mean follow-up of 13.5 ± 10.1 months (range 1–36 months). Conclusions Secondary surgical procedures after stenting of the thoracic aorta can be performed with very good results, despite the challenging clinical scenarios. Identification of successful surgical strategies for this difficult clinical problem is important in the era of increasing endovascular therapy.

Objective Closure of ostium secundum atrial septal defects is generally performed by using an interventional approach. We evaluated the outcome of patients requiring secondary surgical therapy. Methods From September 1996 until December, 2005, 418 patients received interventional and 297 patients underwent surgical closure of an ostium secundum atrial septal defect at our center. Another 15 patients (local, 5; regional, 5; and national, 5 referrals) had complications after occluder placement, and they form the study population. Results Indications for surgical repair in these 15 patients were dislocation of the occluder in 5, neurologic events after occluder placement in 5, residual defects in 4, and sepsis with questionable occluder infection in 1 patient. A total of 7 patients had neurologic events, 5 of embolic origin. The interval between interventional occluder placement and definitive surgical repair was 319 ± 416 days (median 123 days; range 0–1395 days). Patient age at operation was 34.9 ± 18.6 years. Nine patients were operated on via an anterolateral minithoracotomy, and 6 received a conventional sternotomy. One patient with sepsis underwent abdominal surgery on postoperative day 1 and subsequently died of multiorgan failure; there was no proof of occluder endocarditis. At 2.2 ± 1.9 years of follow-up, all other patients had returned to full-time work without residual neurologic impairment. Conclusions Complications may arise after interventional ostium secundum atrial septal defect closure. This must be evaluated against the extremely low risk of a standard surgical closure. The functional outcome after secondary surgical ostium secundum atrial septal defect closure with removal of an occluder system is excellent.

Objective Despite various evidence supporting the advantages of multiple arterial grafting, inconsistencies in use of the procedure have resulted in high variability in the acceptance and practice of arterial grafting. The purpose of this study was to assess the effects of an arterial versus venous second grafts on outcomes at 5-year follow-up in the coronary artery bypass grafting population from the Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery (SYNTAX) trial. Methods Patients (n = 1419) with an arterial graft to the left anterior descending artery and ≥1 other graft were included and divided according to the second graft's type: 2nd-graft-arterial group (n = 456) and 2nd-graft-venous group (n = 963). Five-year outcomes were compared between subgroups. Event rates were estimated with Kaplan-Meier analyses. Propensity-score matching was used, to control for selection bias due to nonrandom group assignment in a 1:1 manner, resulting in 432 pairs with balanced baseline characteristics. Results In unmatched groups, the 2nd-graft-arterial group had significantly lower rates of death (8.9% vs 13.1%; P = .02), and composite safety endpoint of death/stroke/myocardial infarction (13.3% vs 18.7%; P = .02), compared with the 2nd-graft-venous group. The rate of major adverse cardiac or cerebrovascular events was similar between groups (22.9% vs 25.5%; P = .30), because it includes the rate of repeat revascularization (12.6% in the 2nd-graft-arterial group vs 9.6% in the 2nd-graft-venous group; P = .10). After propensity-score matching, no statistically significant differences were found between groups. Conclusions This study reveals comparable 5-year outcomes with arterial and venous conduits as second grafts after an arterial graft anastomosed to the left anterior descending artery. This study demonstrates the multi-institutional variation in patient selection and operator technique with regard to arterial revascularization, although extended follow-up beyond 5 years is required to estimate its impact on long-term outcomes. Clinical Trial Number NCT00114972

Objective The aim of this study was the evaluation of histologic changes induced on the esophagus by surgical ablation therapy for atrial fibrillation. Methods Experiments were performed on 39 sheep. Circular lesions were created endocardially or epicardially in the left atrium and at the pulmonary veins by using different energy sources: cryoablation, microwave, laser, and unipolar or bipolar radiofrequency. Temperatures inside the esophagus were measured, and esophageal tissue was investigated macroscopically and histopathologically. Results Esophageal damage was seen histologically in 24 of 39 cases. The epithelium was intact in all cases. Unipolar radiofrequency induced the most intensive esophageal lesions in 4 of 6 cases. The affected areas were small (1.56-3.01 mm) but reached deep into the tissue. Endocardial cryoablation resulted in wider lesions (2.01-8.54 mm), which were intensive in only 2 of 6 cases. Epicardial cryoablation and bipolar radiofrequency induced wide (1.11-6.8 mm) but mainly mild alterations. Endocardial and epicardial microwave energy affected the esophagus in single cases, and lesions were small (0.97-2.81 mm). Only in 1 case did laser energy induce a moderate alteration (5.30 mm) of the esophageal wall. Conclusions Esophageal alterations were found in numerous cases. However, marked lesions were especially induced by endocardial unipolar radiofrequency and cryoablation.

Objective With recent advances in diagnostic imaging, the value of autopsy has been called into question. The aim of our study was to assess the current impact of autopsy for early postoperative quality management in cardiac surgery. Methods Between 2000 and 2003, a total of 14,313 patients underwent cardiac surgery at our center. Of these, 898 patients (6.3%) died, and autopsy was performed in 468 cases (52.1%). Data from clinical and postmortem examination were prospectively analyzed regarding causes of death, postoperative complications, concomitant diseases, and surgery-associated pathologic findings. Results Mean age was 68.7 years. Mean survival was 13.9 postoperative days. On autopsy, causes of death were cardiac in 49.8% of cases (n = 233), respiratory in 8.3% (n = 39), cerebral in 6.4% (n = 30), abdominal in 4.7% (n = 22), multiorgan failure or sepsis in 14.9% (n = 70), pulmonary embolism in 6.6% (n = 31), procedure associated in 8.3% (n = 39), and others in 0.9% (n = 4). Discrepancies between clinical and postmortem determinations of cause of death were found in 108 cases (23.1%). These were acute myocardial infarction (n = 38), low cardiac output (n = 9), respiratory (n = 8), cerebral (n = 5), abdominal (n = 7), multiorgan failure or sepsis (n = 12), pulmonary embolism (n = 18), and procedure associated (11). Clinically unrecognized postoperative complications were found in 364 cases (77.8%). Unknown concomitant diseases were found in 464 cases (99.1%), with potential therapeutic relevance in 90 cases (19.2%). In 85 cases (18.2%), autopsy examination revealed 96 premortem unrecognized surgery-associated pathologic findings. Conclusion A high overall discrepancy rate between premortem and autopsy diagnoses was recognized. Autopsy revealed clinically relevant information in a significant number of cases. Therefore autopsy remains essential for quality assessment in perioperative treatment.

Background Despite improved outcomes after cardiac operations, postoperative delirium remains a common complication that is associated with increased morbidity and prolonged hospital stay. Methods Univariate and multivariate predictors of postoperative delirium were determined from prospectively gathered data on 16,184 patients undergoing cardiac operations with cardiopulmonary bypass (conventional, n=14,342) and without cardiopulmonary bypass (beating-heart surgery, n=1847) between April 1996 and August 2001. Delirium was defined as a transient mental syndrome of acute onset characterized by global impairment of cognitive functions, a reduced level of consciousness, attentional abnormalities, increased or decreased psychomotor activity, and a disordered sleep-wake cycle. Results The overall prevalence of postoperative delirium was 8.4%. Of 49 selected patient-related risk factors and treatment variables, 35 were highly associated with postoperative delirium by univariate analysis. Stepwise logistic regression revealed the following variables as independent predictors of delirium: history of cerebrovascular disease, peripheral vascular disease, atrial fibrillation, diabetes mellitus, left ventricular ejection fraction of 30% or less, preoperative cardiogenic shock, urgent operation, intraoperative hemofiltration, operation time of 3 hours or more, and a high perioperative transfusion requirement. Two variables were identified as having a significant protective effect against postoperative delirium: beating-heart surgery and younger patient age. Conclusions Postoperative delirium is a common complication in cardiac operations. The increased use of beating-heart surgery without cardiopulmonary bypass may lead to a lower prevalence of this complication and thus improve patient outcomes.

Background Suturing of a coronary anastomosis in totally endoscopic coronary artery bypass grafting on the beating heart is technically demanding. The potential benefits of the endoscopic Magnetic Vascular Positioner device (Ventrica, Inc, Fremont, Calif) to facilitate construction of a coronary anastomosis in a closed chest environment were evaluated. Methods Totally endoscopic coronary artery bypass grafting on the beating heart was performed in 8 foxhound-beagle inbred dogs with the da Vinci telemanipulation system (Intuitive Surgical, Mountain View, Calif). A prototype of the endoscopic Magnetic Vascular Positioner device was used to facilitate construction of the coronary anastomosis. One pair of magnets was inserted in the internal thoracic artery and left anterior descending artery using robotic instruments to guide and place the endoscopic delivery platform. All animals underwent angiography; gross inspection of the anastomotic site was performed after excision of the hearts. Results The procedure was accomplished in all animals in 169 minutes (155-190 minutes). Dissection of the left anterior descending coronary artery (6.5 minutes; 1-20 minutes), positioning of the stabilizer (8.5 minutes; 7-16 minutes), placement of occlusion tapes (6 minutes, 3-10 minutes), and arteriotomy 5.5 minutes (3-30 minutes) was achieved without problems. By use of the Magnetic Vascular Positioner device, the anastomosis at the graft site was performed with the graft still in situ. Except for 1 premature deployment, all other deployments were easily accomplished in 3 minutes (1-28 minutes). The following adverse events were encountered: bleeding from the right ventricle caused by occlusion tape (1), anastomotic leakage on reperfusion requiring repair stitches (2), and anastomotic occlusion as a result of thrombus (1). All except 1 animal with a patent graft and anastomosis survived the procedure. The overall patency was 7 of 8. Discussion The combination of robotic technology allowing for dexterous manipulation in a closed chest environment and a simple yet effective and timesaving technique for anastomotic coupling may facilitate beating heart totally endoscopic coronary artery bypass grafting.

Objective Surgical intervention is an option for treating the remodeled and dilated left ventricles of patients with heart failure. Providing end-diastolic support with an innovative mesh-like cardiac support device reduces mechanical stress, improves function, and reverses cardiac remodeling in animal models without safety issues. The objective of this study was to review the global clinical safety and feasibility experience of this device. Methods The Acorn CorCap cardiac support device (Acorn Cardiovascular, Inc, St Paul, Minn) has been implanted worldwide in more than 130 patients with dilated cardiomyopathy with or without concomitant cardiac surgery. The device is positioned around the ventricles and given a custom fit. A series of 48 patients were implanted with the device in initial safety and feasibility studies, of whom 33 also received concomitant cardiac surgery. Results At implantation, 11 patients were in New York Heart Association class II, 33 were in class III, and 4 were in class IV. The average CorCap implantation time was 27 minutes. The mean intraoperative reduction in left ventricular end-diastolic dimension was 4.6% ± 1%. There were no device-related intraoperative complications. Eight early and 9 late deaths occurred during follow-up extending to 24 months. Actuarial survival was 73% at 12 months and 68% at 24 months. There were no device-related adverse events or evidence of constrictive disease, and coronary artery flow reserve was maintained. Ventricular chamber dimensions decreased, whereas ejection fraction and New York Heart Association class were improved in patients overall and in those patients implanted with the CorCap device without concomitant operations. Conclusions The CorCap device appears safe for patients with dilated cardiomyopathy. Randomized clinical trials are underway in Europe, Australia, and North America.

Objective: This report describes the early and midterm results after intraoperative radiofrequency ablation of atrial fibrillation for patients with isolated chronic atrial fibrillation or atrial fibrillation in combination with additional valvular and nonvalvular cardiac diseases. Methods: From August 1998 to March 2001, a total of 234 patients with chronic atrial fibrillation underwent isolated intraoperative radiofrequency ablation alone (n = 74, 31.6%) or in combination with other cardiac procedures, such as mitral valve reconstruction (n = 57, 24.4%), mitral valve replacement (n = 38, 16.2%), aortic valve replacement (n = 11, 5.1%), coronary artery bypass grafting (n = 8, 5.0%), or a combination of the last with other cardiac procedures (n = 46, 19.7%). In all cases anatomic reentrant circuits confined within the left atrium were eliminated by placing contiguous lesion lines involving the mitral anulus and the orifices of the pulmonary veins through the use of radiofrequency energy application (exposure time, 20 seconds). A median sternotomy was used in 101 cases (43.2%), and video assistance through a right lateral minithoracotomy was used in 133 cases (56.8%). Results: A total of 188 patients (83.9%) were discharged in sinus rhythm, 17 patients (7.6%) had atrial fibrillation, and 19 patients (8.5%) had atypical flutter. Pacemakers were implanted in 23 patients (9.8%). There were 10 in-hospital deaths (4.2%), and 30-day mortality was 5 patients (2.1%). In 3 cases (1.3%) an atrioesophageal fistula developed, necessitating surgical repair. Six months' follow-up was complete for 122 (61.0%) of 200 patients, with 99 patients still in stable sinus rhythm (81.1%, 95% confidence interval 73.1%-89.9%). Twelve months' follow-up was complete for 80 (90.9%) of 88 patients, with 58 patients still in sinus rhythm (72.5%, 95% confidence interval 61.3%-83.2%). Conclusions: Intraoperative radiofrequency ablation is a curative procedure for chronic atrial fibrillation. It is technically less challenging than the maze procedure and can be applied through a minimally invasive approach. Protection of the esophagus seems mandatory to avoid the deleterious complication of a left atrioesophageal fistula, such as was observed in 3 cases. J Thorac Cardiovasc Surg 2002;123:919-27

ObjectiveSuperior aortic valve hemodynamic performance can accelerate left ventricular mass regression and enhance survival and functional status after surgical aortic valve replacement. This can be achieved by rapid deployment aortic valve replacement using a subannular balloon-expandable stent frame, which functionally widens and reshapes the left ventricular outflow tract, to ensure a larger effective orifice area compared with conventional surgical valves. We report the intermediate-term follow-up data from a large series of patients enrolled in the Surgical Treatment of Aortic Stenosis With a Next Generation Surgical Aortic Valve (TRITON) trial.MethodsIn a prospective, multicenter (6 European hospitals), single-arm study, 287 patients with aortic stenosis underwent rapid deployment aortic valve replacement using a stented trileaflet bovine pericardial bioprosthesis. Core laboratory echocardiography was performed at baseline, discharge, and 3 months, 1 year, and 3 years after rapid deployment aortic valve replacement.ResultsThe mean patient age was 75.7 ± 6.7 years (range, 45-93; 49.1% women). The mean aortic valve gradient significantly decreased from discharge to 3 years of follow-up. The mean effective orifice area remained stable from discharge to 3 years. At 1 year, the left ventricular mass index had decreased by 14% (P

Objective: A computer-enhanced instrumentation system was used in 148 patients to minimize access in cardiac surgical procedures. Methods: The da Vinci telemanipulation system (Intuitive Surgical, Mountain View, Calif) provides a high-resolution 3-dimensional videoscopic image and allows remote, tremor-free, and scaled control of endoscopic surgical instruments with 6 degrees of freedom. By April 2000, the system had been used in 131 patients for coronary artery bypass grafting and 17 patients for mitral valve repair. In the coronary bypass group, the system was used in one of three ways: (1) to take down the internal thoracic artery followed by a minimally invasive direct coronary bypass procedure (n = 81); (2) to perform the anastomosis between the internal thoracic artery and the left anterior descending coronary artery in standard-sternotomy coronary bypass (n = 15); or (3) for total endoscopic coronary artery bypass grafting to anastomose the left internal thoracic artery to the left anterior descending on the arrested heart (n = 27) or the beating heart (n = 8). In 17 patients with nonischemic mitral valve insufficiency the mitral valve was repaired. Closed-chest cardiopulmonary bypass with cardioplegic arrest (Port-Access technique; Heartport, Inc, Redwood City, Calif) was used for arrested-heart total endoscopic coronary bypass and mitral valve repair. Results: The da Vinci system allows for precise tissue handling and enables the endoscopic performance of cardiac surgical tasks that require a high degree of dexterity (coronary anastomosis, mitral valve repair). No technical mishaps have occurred. The internal thoracic artery was successfully taken down in 79 of 81 patients in the group undergoing minimally invasive coronary bypass and, after a steep learning curve, is currently performed in less than 40 minutes. The postoperative patency rate is 96.3%. Total endoscopic coronary bypass was completed in 22 of 27 cases with 95.4% patency as demonstrated by angiography at 3 months' follow-up. Closed-chest endoscopic beating-heart bypass grafting was successfully performed in 2 out of 8 patients with the use of a new endoscopic stabilizer. In the group having mitral valve repair, primary endoscopic computer-enhanced repair was successfully completed in 14 of 17 patients; three others had to be changed to a standard endoscopic technique, including 1 who required valve replacement. At 3 months' follow-up, 1 additional patient underwent early reoperation for recurrent mitral insufficiency. Overall early and late mortality in this cohort of 148 patients was 2.0% and was not related to the use of the system. Conclusion: In conclusion, computer-enhanced endoscopic cardiac surgery can be performed safely in selected patients. Internal thoracic artery takedown is now routinely performed with good results. Total endoscopic coronary bypass is feasible on the arrested heart but does not offer a major benefit over the minimally invasive direct approach because cardiopulmonary bypass is still required. The early clinical experience with closed-chest beating-heart bypass grafting outlines the limitations of this approach despite some procedural success. (J Thorac Cardiovasc Surg 2001;121:842-53)

a graft-assisted anastomosis between the ascending aorta and the supraceliac abdominal aorta. In our patient, a graft was implanted between the ascending and descending aortas. To avoid uncontrolled bleeding, there are 3 aspects that must be focused on perioperatively. First, all ductal tissue must be aggressively removed. Otherwise the anastomosis between the graft and the aorta will be susceptible to bleeding. Second, the anastomosis should be free of tension. Careful study of CT scans and better preoperative preparation are helpful to achieve complete dissociation of the descending aorta. More important, implanting a conduit will assist in reducing the tension. Third, pressuring hemostasis is effective when uncontrolled bleeding occurs. A bandage was placed with a little pressure on the stoma and thoracic cavity. One of the tips was placed out of the thoracic cavity. The bleeding volume was 900 mL on postoperative day 1 and 350 mL on postoperative day 2. The hemostasis

Background: We assessed the results of a modified technique for aortic root reconstruction including preservation of the native aortic valve and sinuses. Methods: A modified technique for reconstruction of the aortic root was devised in which the native aortic sinuses are preserved and remodeled, the diameter of the sinotubular junction is reduced, the ventriculoaortic junction is reinforced with a Dacron prosthesis, and the coronary ostia are reimplanted. Since January 1995, this modified operative technique was performed in 13 patients with a mean age of 54 ± 21 years. The median grade of aortic regurgitation was 3; in 10 patients it was caused by dilatation of the sinotubular junction, and 3 had additional annuloaortic ectasia. Results: The aortic crossclamping time was 61 ± 18 minutes. In-hospital mortality was 2 of 13 (15.3%) patients, both deaths being related to complications of aortic dissection. In 1 patient aortic regurgitation increased to grade 3, necessitating aortic valve replacement. At a mean follow-up of 2.1 years, the remaining 10 patients had stable aortic valve function with a median grade of regurgitation of 1. The mean New York Heart Association functional class was 1.2. Conclusions: Aortic root reconstruction with preservation of the native aortic valve and sinuses allows symmetric reconstruction of the aortic sinuses and adaptation of the diameters of the sinotubular and ventriculoaortic junctions, thus optimizing aortic valve function. Moreover, it prevents contact of the aortic valve leaflets with the Dacron graft, which may enhance the durability of the repair. (J Thorac Cardiovasc Surg 1999;117:1151-6)

Objective Barlow's disease remains a challenging surgical pathology in patients presenting with mitral regurgitation. We reviewed our early and long-term results for patients with Barlow's disease who underwent minimally invasive mitral valve surgery. Methods Between 1999 and 2010, 145 patients with Barlow's disease underwent minimally invasive mitral valve repair at Leipzig Heart Center. Preoperative echocardiography and intraoperative valve analysis confirmed annular dilatation, bileaflet prolapse, and excessive leaflet tissue in all cases. We retrospectively reviewed mitral valve repair techniques, early and late postoperative clinical outcomes, and follow-up echocardiographic data. Results Successful mitral valve repair was performed in 94.5% of patients (n = 137), initial mitral valve replacement was performed in 2.8% of patients (n = 4), and mitral valve replacement after unsuccessful mitral valve repair was performed in 2.8% of patients (n = 4). Mean aortic crossclamp time was 99 ± 33 minutes, cardiopulmonary bypass time was 153 ± 47 minutes, and total duration of surgery was 200 ± 44 minutes. Mitral valve repair techniques consisted of ring annuloplasty and a variety of other methods (not mutually exclusive): "loop" neochordae (72% of patients), posterior mitral leaflet resection (28%), Alfieri stitch (17%), commissural plication (9%), chordal transfer (9%), and anterior mitral leaflet resection (7%). Concomitant procedures consisted of cryoablation for atrial fibrillation (28%), tricuspid valve repair (6%), and closure of an atrial septal defect/patent foramen ovale (12%). Thirty-day mortality was 1.4% (n = 2), rethoracotomy for bleeding was required in 4.1% of patients (n = 6), and conversion to sternotomy was required in 1 patient (0.7%). Long-term clinical follow-up was obtained in 100% of patients, and long-term echocardiographic data were obtained in 93.3% of surviving patients. Long-term survival was 94.7% ± 2.2% at 5 years and 88.3% ± 4.9% at 10 years. Freedom from mitral valve reoperation was 96.8% ± 1.6% at 5 years and 93.8% ± 2.6% at 10 years. Freedom from greater than 2+ grade mitral regurgitation was 90.2% ± 3.4% at 5 years and 88.4% ± 3.9% at 10 years. Conclusions A wide variety of repair techniques can be used to perform successful minimally invasive mitral valve repair in the majority of patients with Barlow's disease, with good early and long-term results.

Sutureless aortic valve replacement (AVR) offers an alternative to standard AVR in aortic stenosis. This prospective, single-arm study aimed to demonstrate safety and effectiveness of a bovine pericardial sutureless aortic valve at 1 year.From February 2010 to September 2013, 658 patients (mean age 78.3 ± 5.6 years; 40.0% octogenarian; 64.4% female; mean Society of Thoracic Surgeons score 7.2 ± 7.4) underwent sutureless AVR in 25 European centers. Concomitant cardiac procedures were performed in 29.5% and minimally invasive cardiac surgery in 33.3%.One-year site-reported event rates were 8.1% for all-cause mortality, 4.5% for cardiac mortality, 3.0% for stroke, 1.9% for valve-related reoperation, 1.4% for endocarditis, and 0.6% for major paravalvular leak. No valve thrombosis, migration, or structural valve deterioration occurred. New York Heart Association class improved at least 1 level in 77.5% and remained stable (70.4% New York Heart Association class I or II at 1 year). Mean effective orifice area was 1.5 ± 0.4 cm(2); pressure gradient was 9.2 ± 5.0 mm Hg. Left ventricular mass decreased from 138.5 g/m(2) before surgery to 115.3 g/m(2) at 1 year (P .001). Echocardiographic core laboratory findings confirmed that paravalvular leak was rare and remained stable during follow-up.The Perceval sutureless valve resulted in low 1-year event rates in intermediate-risk patients undergoing AVR. New York Heart Association class improved in more than three-quarters of patients and remained stable. These data support the safety and efficacy to 1 year of the Perceval sutureless valve in this intermediate-risk population.

Objectives A new class of rapid-deployment aortic valves has emerged with the potential to simplify minimally invasive aortic surgery and reduce crossclamp and cardiopulmonary bypass times. We report the 1-year clinical outcomes of aortic valve replacement with the EDWARDS INTUITY Valve System (Edwards Lifesciences LLC, Irvine, Calif) in the Surgical Treatment of Aortic Stenosis With a Next Generation Surgical Aortic Valve (TRITON) trial. Methods Seventeen surgeons from 6 European centers treated 152 consecutive patients with aortic stenosis requiring valve replacement in a prospective, single-arm trial. A stented trileaflet bovine pericardial bioprosthesis with a balloon-expandable, cloth-covered stent frame at the inflow aspect was implanted in 146 patients (mean age, 75.5 ± 6.7 years; 52.7% were female). Five valve sizes were evaluated (19-27 mm); 58.9% of cases had isolated aortic valve replacement, and 41.1% of cases involved concomitant procedures. Minimally invasive surgical approaches occurred in 48.8% of the isolated aortic valve replacements. Patients were followed at discharge, 3 months, and 1 year postoperatively. Results Implantation success was 96.1% (146/152), early valve-related mortality was 1.4% (2/146), and cumulative survival was 92.5% at a mean follow-up of 9.8 ± 5.1 months. Crossclamp time for isolated aortic valve replacement was 41.1 ± 10.6 minutes. Independent core laboratory–adjudicated mean effective orifice area and aortic valve pressure gradient were 1.7 ± 0.2 cm 2 and 8.8 ± 3.0 mm Hg at 3 months, and 1.7 ± 0.2 cm 2 and 8.4 ± 3.4 mm Hg at 1 year, respectively. Conclusions Implantation of the EDWARDS INTUITY Valve System is feasible, safe, and efficacious for aortic valve replacement. Aortic crossclamp and cardiopulmonary bypass times were reduced compared with those for conventional aortic valve replacement. Early hemodynamic performance was excellent and remained so up to 1 year.

ObjectiveMyocardial infarction leads to contractile dysfunction. In patients with diabetes, impaired contractility has been associated with the loss of insulin effects and mitochondrial dysfunction. We assessed cardiac insulin sensitivity and mitochondrial and contractile function in rats after ligation of the left coronary artery.MethodsAt 2 weeks after left coronary artery ligation, we performed echocardiography in vivo and assessed the substrate use and insulin response in the isolated working heart and the regulation of insulin (Akt, glucose transporter type 4) and mitochondrial signaling (p38 mitogen-activated protein kinase, peroxisome proliferator-activated receptor-γ coactivator 1α, mitochondrial transcription factor A) using polymerase chain reaction and Western blotting.ResultsThe infarcted hearts were dilated and had a reduced ejection fraction (ejection fraction

ObjectiveCompared with reoperative aortic valve replacement for nonendocarditic causes, the contemporary risk and long-term outcomes of reoperation for aortic prosthetic valve endocarditis are ill-defined.MethodsBetween December 1994 and April 2008, 313 patients underwent reoperative aortic valve replacement, of whom 152 (48.6%) had prosthetic valve endocarditis. Mean follow-up was 6.5 ± 0.4 years and 97.4% complete.ResultsPatients with prosthetic valve endocarditis were older with a higher risk profile. The overall hospital mortality was 15.3% (n = 48) (prosthetic valve endocarditis vs nonendocarditis: 24.3%, n = 37, vs 6.8%, n = 11; P

ObjectiveAnalysis of average and individual surgical performance for minimally invasive direct coronary artery bypass was used to enhance quality control for that operation.MethodsA total of 1441 standard minimally invasive direct coronary artery bypass procedures performed from August 1996 to January 2006 were analyzed for mortality and 10 other major perioperative complications. Learning curves and assessment of perioperative outcome were calculated using descriptive statistics and cumulative sum observed minus expected failure analysis for 8 involved surgeons with a personal experience ranging from 27 to 443 procedures.ResultsThe incidence of in-hospital mortality was 0.9% and compared favorably with the predicted mortality calculated by the logistic EuroSCORE (3.6%, P < .01). Cumulative sum analysis revealed that 2 surgeons crossed the 95% reassurance boundary after 50 operations and that 2 surgeons crossed the 95% reassurance boundary after 100 operations. There were significant differences between surgeons with regard to the learning curves and perioperative complications (3.6%–29.6%, P < .01). Two surgeons crossed the 95% alarm-line indicating unacceptably high failure rates.ConclusionsMinimally invasive direct coronary artery bypass has become a procedure with low mortality and low complication rates, but results are case-load and surgeon dependent. Cumulative sum analysis is a valuable method allowing for a breakdown of complication rates over time displaying individual surgeons’ strengths.

Objective Some patients with significant arteriosclerosis of the heart are not amenable to revascularization of a coronary artery because they have a combination of microangiopathy and significant macroangiopathy. We investigated the benefit of arterialization of a cardiac vein under these circumstances in an acute animal model. Methods In the hearts of 8 sheep, microspheres were injected into the left coronary artery; 60 minutes later, a stenosis of the left anterior descending artery was performed. After 45 minutes, retrograde venous revascularization was performed by sewing the left internal thoracic artery to the concomitant vein of the left anterior descending artery in a beating-heart technique. For flow reversal, the vein was ligated proximally to the anastomosis. The efficiency of the bypass graft was evaluated by coronary angiography and flow measurement. Cardiac output, electrocardiography, and mean arterial blood pressure were assessed in each phase of the experiment. Results The ischemic state of the myocardium was confirmed by a significant decrease of cardiac output, stroke volume, and mean arterial blood pressure, and a significant elevation of the ST segment in the electrocardiography. After retrograde venous revascularization was established, cardiac output and stroke volume increased and ST elevations decreased. The grafts showed adequate flow (26.15 ± 2.08 mL/min), and reversed blood flow in the grafted vein was proved by coronary angiography. Conclusion Retrograde venous revascularization is possible and improves cardiac function in a state of acute ischemia caused by a combination of microangiopathy and macroangiopathy.

Objective: Intraoperative radiofrequency ablation of atrial fibrillation (IRAAF) is a recently developed procedure being performed in an increasing number of patients. We have performed left atrial IRAAF in 387 patients since August 1998. The purpose of this article is to describe a serious complication of this procedure, namely IRAAF-induced esophageal perforation, in detail to identify possible risk factors. Methods: Left atrial IRAAF was performed with a commercially available unipolar probe as an isolated procedure (n = 129) or in combination with mitral valve surgery (n = 163) or other surgical procedures (n = 95). Operations were performed either through a conventional sternotomy or right minithoracotomy. Results: Four (1%) patients had esophageal perforation after radiofrequency ablation. All 4 patients presented after an initially unremarkable postoperative course, with sudden neurologic symptoms from esophagoatrial air embolization occurring in 3 of the patients. Three patients were successfully treated with extensive esophageal resection, and one died from massive air embolism. All perforations occurred in patients undergoing minimally invasive IRAAF. Comparison with other patients undergoing isolated minimally invasive IRAAF (n = 129) failed to reveal any reliable predictors of esophageal injury, including patient body size, operating times, or radiofrequency biophysical parameters. Conclusions: Left atrial IRAAF is associated with a small but definite risk of esophageal perforation. Unfortunately, we were unable to identify any risk factors for this life-threatening complication. A high degree of vigilance must be maintained for esophageal injury after IRAAF, particularly in patients with new neurologic deficits. Until safer methods of ablation are developed, we currently recommend against the use of IRAAF in patients undergoing cardiac surgery. J Thorac Cardiovasc Surg 2003;125:836-42

A 63-year-old woman had a diagnosis of aneurysm of the arch and the descending aorta. Medical history included a Bentall procedure for aortic regurgitation and ascending aortic aneurysm in 2006. The patient underwent redo surgery owing to progression of the diameter of the aneurysm. Replacement of the arch by the frozen elephant trunk technique with implantation of an E-vita prosthesis (JOTEC GmbH, Hechingen, Germany) was performed. The procedure was completed with stent implantation (Valiant 42-200 mm; Medtronic, Inc, Minneapolis, Minn) in the descending aorta. On postoperative day 34 the patient had severe dyspnea. A bronchoscopic examination showed a significant decrease of left main bronchus diameter to less than 2 mm owing to exterior compression. Computed tomography (CT) revealed a large hematoma around the endoprosthesis ranging from the distal part of the subclavian artery to the diaphragm (Figures 1 and 2). After an interdisciplinary discussion of the therapeutic options, the decision for surgery over bronchial stenting was made. Surgerywas performedwith the patient in a right-sided position through a left minithoracotomy in the third intercostal space. Intraoperatively, a large and heavily tensioned aneurysmal sac of the descending aorta surrounding the E-vita prosthesis was opened with subsequent removal of the hematoma. The aneurysmal sac was left open to prevent development of subsequent hematoma.Multiple drainswere inserted. The postoperative course was uneventful with rapid respiratory weaning and the patient was discharged free of symptoms. Follow-up CT and bronchoscopy 1 month later showed a normal bronchus diameter.

ObjectiveMitochondrial dysfunction has been suggested as a potential cause for heart failure. Pressure overload is a common cause for heart failure. However, implementing pressure overload in mice is considered a model for compensated hypertrophy but not for heart failure. We assessed the suitability of minimally invasive transverse aortic constriction to induce heart failure in C57BL/6 mice and assessed mitochondrial biogenesis and function.MethodsMinimally invasive transverse aortic constriction was performed through a ministernotomy without intubation (minimally invasive transverse aortic constriction, n = 68; sham operation, n = 43). Hypertrophy was assessed based on heart weight/body weight ratios and histologic analyses, and contractile function was assessed based on intracardiac Millar pressure measurements. Expression of selected metabolic genes was assessed with reverse transcription–polymerase chain reaction and Western blotting. Maximal respiratory capacity (state 3) of isolated mitochondria was measured with a Clark-type electrode.ResultsSurvival was 62%. Within 7 weeks, minimally invasive transverse aortic constriction induced significant hypertrophy (heart weight/body weight ratio: 10.08 ± 0.28 mg/g for minimally invasive transverse aortic constriction vs 4.66 ± 0.07 mg/g for sham operation; n = 68; P

Objective Adult postcardiotomy cardiogenic shock potentially requiring mechanical circulatory support occurs in 0.5% to 1.5% of cases. Risk factors influencing early or long-term outcome after extracorporeal membrane oxygenation implantation are not well described. Methods Between May 1996 and May 2008, 517 adult patients received extracorporeal membrane oxygenation support for postcardiotomy cardiogenic shock. Procedures were isolated coronary artery bypass grafting (37.4%), isolated valve surgery (14.3%), coronary artery bypass grafting plus valve surgery (16.8%), thoracic organ transplantion (6.5%), and other combinations (25.0%). Fifty-four preoperative and 42 procedural risk factors concerning in-hospital mortality were evaluated by logistic regression analyses. Results Mean age was 63.5 years, 71.5% were male, ejection fraction was 45.9% ± 17.6%, logistic EuroSCORE was 21.6% ± 20.7%. Extracorporeal membrane oxygenation was established through thoracic (60.8%) or extrathoracic (39.2%) cannulation. Extracorporeal membrane oxygenation support was 3.28 ± 2.85 days. Intra-aortic balloon pumps were implanted in 74.1%. Weaning from extracorporeal membrane oxygenation was successful for 63.3%, and 24.8% were discharged. Cerebrovascular events occurred in 17.4%, gastrointestinal complications in 18.8%, and renal replacement therapy in 65.0%. Risk factors for hospital mortality were age older than 70 years (odds ratio, 1.6), diabetes (odds ratio, 2.5), preoperative renal insufficiency (odds ratio, 2.1), obesity (odds ratio, 1.8), logistic EuroSCORE greater than 20% (odds ratio, 1.8), operative lactate greater than 4 mmol/L (odds ratio, 2.2). Isolated coronary artery bypass grafting (odds ratio, 0.44) was protective. Cumulative survivals were 17.6% after 6 months, 16.5% after 1 year, and 13.7% after 5 years. Conclusions Extracorporeal membrane oxygenation support is an acceptable option for patients with postcardiotomy cardiogenic shock who otherwise would die and is justified by good long-term outcome of hospital survivors. Because of high morbidity and mortality, extracorporeal membrane oxygenation must be decided by individual risk profile.

Objective The hand-sewn anastomosis is the "gold standard" for performing coronary artery bypass grafts. However, performing a hand-sewn anastomosis is more demanding and time-consuming when used in less invasive approaches such as small access, totally endoscopic or beating heart surgery. In conjunction with attempts to reduce the surgical trauma of coronary artery bypass grafts by using these less invasive approaches, alternative methods for constructing distal anastomoses should be explored. These data report on predischarge angiographic findings and 30-day clinical follow up of patients who have received a new distal anastomotic device. Methods In a multicenter trial, 32 patients (mean age: 65 ± 9 years; 85% men) requiring multivessel coronary artery bypass surgery had 1 of the anastomoses performed using a novel anastomotic technology. The Magnetic Vascular Positioner System was used in 1 of the bypass grafts and the other bypasses were completed by conventional hand-sewn technique. The Magnetic Vascular Positioner System consists of 4 magnetic, gold-plated implants and 2 delivery devices that facilitate the creation of a functional end-to-side anastomosis. A predischarge angiogram was performed to evaluate graft patency. Results There were no device-related major adverse events. The application of the Magnetic Vascular Positioner device was successful in 32 of 41 cases (78%). Nine patients were intended for treatment but did not receive the Magnetic Vascular Positioner System. In 5 of the cases the coronary artery was too small; 1 case had a posterior wall plaque in the target artery; and 3 patients had a nonhemostatic anastomosis after coupling of the port and were subsequently converted to hand-sewn anastomoses. The median total Magnetic Vascular Positioner anastomotic time was 137 seconds with a range from 65 to 370 seconds. Overall patency rate of the Magnetic Vascular Positioner anastomosis was 93.5% versus 91.7% ( P = not significant) in hand-sewn grafts. One patient (3.1%) died due to low cardiac output but had patent grafts at autopsy. One myocardial infarction (3.1%) occurred the day after a percutaneous transluminal coronary angioplasty of a hand-sewn graft. One prolonged mechanical ventilation (3.1%) was required because of pneumonia and adult respiratory distress syndrome. Conclusions Magnetic vascular coupling in coronary surgery is safe and effective and has acceptable early patency rates. This new technique may facilitate beating heart and minimally invasive coronary artery bypass grafts.

1. Pacifico AD, Mandke NV, McGrath LB, Colvin EV, Bini RM, Bargeron LM Jr. Repair of congenital pulmonary venous stenosis with living autologous atrial tissue. J Thorac Cardiovasc Surg 1985;89:604-9. 2. Van Praagh R, Harken AH. Total anomalous pulmonary venous drainage to the coronary sinus: a revised procedure for its correction. J Thorac Cardiovasc Surg 1972;64:132-5. 3. Van de Wal HJCM, Hamilton DI, Godman MJ, Harnick E, Lacquet LK, van Oort A. Pulmonary venous obstruction following correction for total anomalous pulmonary venous drainage: a challenge. Eur J Cardiothorac Surg 1992;6:545-9. 4. Coles JG, Yemets E, Najm HK, Lukanich JM, Perron J, Wilson GJ, et al. Experience with repair of congenital heart defects using adjunctive endovascular devices. J Thorac Cardiovasc Surg 1995;110:1513-20. 5. Van Son JAM, Danielson GK, Puga FJ, Edwards WD, Driscoll DJ. Repair of congenital and acquired pulmonary vein stenosis. Ann Thorac Surg 1995;60:144-50. 6. Wilson WR Jr, Ilbawi MN, DeLeon SY, Quinones JA, Arcilla RA, Sulayman RF, et al. Technical modifications for improved results in total anomalous pulmonary venous drainage. J Thorac Cardiovasc Surg 1992;103:861-71. 7. Lacour-Gayet F, Rey C, Planche C. Pulmonary vein stenosis: description of a sutureless surgical technique using the pericardium in situ. Arch Mal Coeur Vaiss 1996;89:633-6.

Objective There is a need for fast, minimally invasive sutureless replacement of mitral valves. Methods Unchanged FDA-approved biological valve prostheses were sutured to Nitinol attachment rings (Endosmart, Stutensee, Germany) that were covered with textile (devices). The lower flange of the device was stretched in ice water and maintained in a stretched position with stretching sutures. In 9 acute pig experiments through a limited left thoracotomy, a single suture was placed around the mitral annulus, the device was positioned, the annular suture tied, the stretching sutures retracted, and the device activated by warm saline. Position of the device, heart and valve function, coronary arteries, left ventricular outflow tract, and surrounding structures were observed with transoesophageal echocardiography, left ventricular and coronary angiograms, and pathologic examination at autopsy. Results The devices could be easily navigated to the mitral valve annulus and actuated within seconds. Three devices were placed with warm blood in the operative field and were tilted or dislocated at autopsy. In the other 6 devices, transesophageal echocardiography and left ventricular and coronary angiography demonstrated normal prosthetic valve and heart function, without valvular or para-device leakage, and with normal aortic valve and coronary arteries. At autopsy in these 6 cases, the devices were strongly fixed at the anatomic mitral valve annulus, without abnormalities of the device, heart valve prosthesis, left ventricular outflow tract, or aortic valve ostium. Conclusions Nitinol attachments rings combined with unchanged biological valve prostheses can make fast and strong sutureless replacement of the mitral valve feasible in acute pig experiments. Applicators that constrain and release the device mechanically need to be developed.