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Objective: This study aimed to assess the prognostic ability of SYNTAX score II in left main and/or 3-vessel disease patients undergoing revascularization either by coronary artery bypass grafting or percutaneous coronary intervention in a national registry., Methods: This prospective registry included consecutive patients with multivessel disease enrolled between January and April 2013 from all 22 hospitals in Israel that perform coronary angiography. Of the 1112 study patients, 368 patients (33%) had a low (<25), 372 (33%) had an intermediate (25-35) and 372 patients (33%) a high (≥35) SYNTAX score II., Results: Patients with a high SYNTAX score II had higher 30-day mortality compared with those with an intermediate or low SYNTAX score II (2.8% vs 0.6% vs 0% respectively, P = .001). Each 1-unit increment in SYNTAX score II increased the odds for death at 30 days by 11% (95% CI, 1.02-1.22; P = .026). Six-year mortality was higher among patients with a high compared with an intermediate or low SYNTAX score II (34.9% vs 11% vs 3.8%; log-rank P < .001). By adding a SYNTAX score II to standard prognostic factors, we showed a significant improvement of 40.1% (P < .001) for predicting 6-year mortality. The area under the curve of the SYNTAX score II (continuous) yielded 0.79 (95% CI, 0.75-0.82) in predicting 6-year mortality., Conclusions: Our findings show that the admission SYNTAX score II is a powerful marker of short- and long-term mortality, and therefore may be used as a risk stratification tool in patients with multivessel coronary artery disease who are candidates for revascularization., (Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The last decade has witnessed an increased number of stand-alone interventional cardiology units due to the consolidation of cardiac surgery services. We aimed to explore the impact of a heart team on the midterm outcomes of patients with multivessel coronary artery disease., Methods: This prospective registry included 1063 consecutive patients with multivessel disease enrolled between January and April 2013 from all 22 hospitals in Israel that perform coronary angiography and percutaneous coronary intervention, with or without on-site cardiac surgery services., Results: Of the 1063 patients, 576 (54%) and 487 (46%) were admitted to centers with or without on-site cardiac surgery services, respectively. Centers with cardiac surgery services compared with those without had more male patients (82% vs 77%, P = .026) and more patients who were taking aspirin (75% vs 67%, P = .008) before admission. Other characteristics were similar between the groups, including mean SYNTAX score (22.5 ± 9.6 vs 22.2 ± 10, P = .680). Late outcomes revealed a higher 6-year survival probability in centers with on-site cardiac surgery services (85.1% vs 81.3%, P = .047). Although coronary artery bypass grafting (vs percutaneous coronary intervention) was associated with a survival advantage among patients from hospitals with cardiac surgery services (89.9% vs 81.5%, P = .004), in the absence of on-site cardiac surgery services there were no differences between the 2 revascularization approaches (81.8% vs 81.1%, P = .9)., Conclusions: Patients with multivessel coronary artery disease treated in centers without on-site cardiac surgery services receive a lower rate of appropriate guideline-based intervention with coronary artery bypass grafting, which is associated with less favorable outcomes. These findings suggest that a heart-team approach should be mandatory even in centers with stand-alone interventional cardiology units., (Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: To compare short- and long-term outcomes of patients hospitalized with non-ST-segment myocardial infarction (NSTEMI) or unstable angina (UA) who were referred for revascularization by either coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) in a real-world national cohort., Methods: This observational study included 5112 patients, who underwent either CABG or PCI, admitted for NSTEMI or UA and were enrolled in the Acute Coronary Syndrome Israeli Survey between 2000 and 2016. Propensity score-matching analysis compared early outcomes and all-cause mortality in patients who underwent revascularization by PCI with revascularization by CABG., Results: Of the 5112 patients, 4327 (85%) underwent PCI and 785 (15%) CABG. Following propensity score analysis, 447 pairs were chosen (1:1). Independent predictors for CABG referral included 3-vessel CAD (odds ratio [OR], 5.5; 95% confidence interval [CI], 4.5-6.7, P < .001), absence of on-site cardiac surgery (OR, 1.3; 95% CI, 1.1-1.6, P = .004), no previous PCI (OR, 1.5; 95% CI, 1.2-1.9, P = .002) and no previous myocardial infarction (OR, 1.3; 95% CI, 1-1.7, P = .022). The 10-year mortality risk was significantly lower among those who underwent CABG compared with PCI (20.4% vs 28.4%, P = .006). Consistent with these findings, multivariable analysis showed that referral to CABG was independently associated with a significant 65% reduction in the risk of 10-year mortality (P < .001). This long-term advantage was seen among male patients (P < .001) and not female patients (P = .910)., Conclusions: In a real-life setting, revascularization by CABG provides excellent long-term outcomes in patients with NSTEMI or UA. The advantage of CABG over PCI was seen only in male patients., (Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The regional needs and consolidation of cardiac surgery services (CSS) result in an increased number of stand-alone interventional cardiology units. We aimed to explore the impact of a heart team on the decision making and outcomes of patients with multivessel coronary artery disease referred for coronary revascularization in stand-alone interventional cardiology units., Methods: This prospective study included 1063 consecutive patients with multivessel disease enrolled between January and April 2013 from all 22 hospitals in Israel that perform coronary angiography and percutaneous coronary intervention (PCI), with or without on-site CSS., Results: Of the 1063 patients, 487 (46%) underwent coronary artery bypass grafting (CABG) and 576 (54%) underwent PCI. A higher proportion of patients underwent PCI in hospitals without on-site CSS compared with those with on-site CSS (65% vs 46%; P < .001). Furthermore, patients referred to CABG from hospitals without on-site CSS had a significantly higher mean SYNTAX score compared with those who underwent CABG in centers with on-site CSS (29 vs 26; P = .018). Multivariate logistic regression analysis consistently showed that the absence of on-site cardiac surgery and a heart team was independently associated with a 2.5-fold increased likelihood for predicting the referral of PCI rather than CABG (odds ratio, 2.54; 95% confidence interval, 1.8-3.6)., Conclusions: Patients with multivessel coronary artery disease treated in centers without on-site cardiac surgery services receive a lower rate of appropriate guideline-based intervention with CABG. These findings suggest that a heart team approach should be mandatory even in centers with stand-alone interventional cardiology units., (Copyright © 2017 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Training the next generation of cardiothoracic surgeons is a global persistent challenge. Major issues, including length of training, decreasing volume of cases, shift toward high-risk, complex, and less-invasive procedures, increased specialization, and uncertainty with regard to future employment, are relevant and affect residency training programs in the United States, Europe, and other parts of the world. To produce high-quality, mature, and qualified surgeons, these challenges mandate an ongoing effort by our specialty leadership aimed at identifying creative solutions and adapting the current residency training curricula and methodology to the dynamic changes in our field. The current situation in Israel is discussed with the hope that sharing our experience might be useful and lead to adoption of some of our solutions by other countries., (Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Mitral valve repair for myxomatous Barlow disease is a challenging procedure requiring complex surgery with less than optimal results. The use of ring-only repair has been previously reported but never analyzed or followed-up. We investigated this simple valve repair approach for patients with Barlow disease and multisegment involvement causing mainly central jet., Methods: Of 572 patients who underwent mitral valve repair for mitral regurgitation at our medical center, 24 with Barlow disease (aged 47 ± 14 years; 46% male) underwent ring-only repair. Patients were characterized by severely enlarged mitral valve annulus, multisegment prolapse involving both leaflets, and demonstrated mainly a central wide regurgitant jet. Surgical technique included only the implantation of a large mitral annuloplasty ring. Early and late outcome results were compared with those of the remaining patients who underwent conventional mitral valve repair for degenerative disease (controls)., Results: All ring-only patients presented with moderate-severe/severe mitral regurgitation (vena contracta, 0.6 ± 0.1 cm; regurgitation volume, 52 ± 17 mL), with mainly a central jet and almost preserved ejection fraction (59% ± 6%). Cardiopulmonary bypass and crossclamp times were significantly shorter compared with controls (P < .0001). At follow-up (ring-only, 38 ± 36 months and controls, 36 ± 29 months), there were no late deaths in the ring-only group compared with 19 (4%) in the controls. Late follow-up revealed New York Heart Association functional class I or II in 95% of ring-only patients, compared with 90% of controls. Freedom from recurrent moderate or severe mitral regurgitation was 100% and 89% in the ring-only and control groups, respectively., Conclusions: Mitral annuloplasty for Barlow disease patients with multisegment involvement and mainly central regurgitant jet is both simple and reproducible with excellent late outcomes., (Copyright © 2015 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Systolic anterior motion (SAM) after mitral valve repair with significant mitral regurgitation requires immediate reintervention. Transient SAM immediately after repair is usually managed by hemodynamic maneuvers. We investigated the late clinical and echocardiographic significance of postoperative transient SAM., Methods: Between 2004 and 2013, mitral valve repair was performed on 549 consecutive patients with degenerative mitral valve disease. Of the 45 patients (8.2%) identified with postrepair SAM, 5 needed immediate reintervention. Hemodynamic maneuvers, such as preload and afterload augmentation and rate control, effectively abolished SAM in 40 patients (SAM). They were followed and compared with the remaining 509 patients (non-SAM)., Results: Mean clinical follow-up was 54 ± 28 and 31 ± 26 months and was available in 100% and 95% (SAM and non-SAM) patients, respectively. One hospital death occurred in each group (P = .14). At follow-up, 2 patients (0.3%) showed significant SAM with left ventricular outflow tract obstruction, which resolved in 1 patient after beta-blocker therapy. SAM patients underwent exercise stress echocardiography: 1 patient showed left ventricular outflow tract obstruction that worsened after exercise. At 5 years, freedom from moderate or severe mitral regurgitation and New York Heart Association functional class III-IV was 85% versus 92% (P = .27) and 81% versus 92% (P = .15), and freedom from reoperation was 100% and 96% (P = .4), in SAM and non-SAM patients, respectively., Conclusions: Late postoperative exercise stress echocardiogram revealed low incidence of SAM in patients with immediate postrepair transient SAM. All other late clinical outcomes were similar to those of non-SAM repair patients. Conservative management of intraoperative transient SAM is both successful and reliable., (Copyright © 2015 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Cut-and-sew maze with a box lesion around the pulmonary veins is currently the criterion standard procedure for surgical ablation of atrial fibrillation. Recently, we changed our technique from standard bilateral epicardial pulmonary vein isolation with interconnecting lesions to a box lesion procedure with a bipolar radiofrequency ablation device. Our study describes this technique., Methods: Between March 2009 and June 2012, we performed 90 ablations by the box technique with a bipolar radiofrequency device. Fifty-five patients (61%) had persistent atrial fibrillation, and 21 (23%) had long-standing persistent atrial fibrillation. The left atriotomy was performed along the interatrial septum and the left atrial appendage amputated. The box was made by connecting the left atriotomy to the base of the amputated appendage with lines along the transverse and oblique sinuses by epicardial and endocardial application of a bipolar radiofrequency ablation device. The left atrial isthmus was ablated by cryoprobe., Results: There were no ablation-related complications. The box was easy to perform, with no dissection around the pulmonary veins. At 6-month, 1-year, and 2-year follow-ups, 80 (94%), 69 (93%), and 47 (91%) patients, respectively, were in sinus rhythm. Freedoms from antiarrhythmic medications in patients in sinus rhythm at 6 months, 1 year, and 2 years were 78%, 88%, and 85%, respectively., Conclusions: The box lesion provided excellent freedom from atrial fibrillation and may improve transmurality through ablation of 1 rather than 2 layers of atrial wall, as in epicardial pulmonary vein isolation. With the box lesion, dissection around the pulmonary veins is unnecessary., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: The aim of this study was to determine the influence of aortic annulus (AA) diameter and the ratio of the sinotubular junction (STJ) diameter to the AA diameter on aortic valve hemodynamics and tissue mechanics and to suggest optimal values., Methods: Sixteen cases of aortic roots with AA diameters between 22 and 28 mm and an STJ/AA diameter ratio between 0.8 and 1.4 were numerically modeled. Average coaptation height and mechanical stresses were calculated from 3-dimensional finite element analysis of the aortic valve and root. Five additional fluid structure interaction (FSI) models with an AA diameter of 24 mm and an STJ/AA ratio between 0.6 and 1.4 were also constructed. The material properties of the tissues were from porcine valves and boundary conditions were physiologic and normal blood pressures., Results: In most cases, average coaptation height decreased with an increase in the STJ/AA ratio. Those cases with AA diameters between 24 and 26 mm and an STJ/AA ratio between 0.8 and 1.0 had a relatively large average coaptation height (>3 mm) and similar stress distribution during diastole. The flow shear stress values on the cusps at peak systole increased at the same time as the STJ/AA ratio decreased, similar to the opening area., Conclusions: Relatively large coaptation, low stress in the tissues during diastole, and low flow shear stress during systole is the best combination for cases of AA diameter between 24 and 26 mm with identical STJ diameter. Valve-sparing procedures that prevent AA expansion are preferable., (Copyright © 2013 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: The aim of the present study was to determine the influence of the aortic annulus (AA) diameter in order to examine the performance metrics, such as maximum principal stress, strain energy density, coaptation area, and effective height in the aortic valve., Methods: Six cases of aortic roots with an AA diameter of 20 and 30 mm were numerically modeled. The coaptation height and area were calculated from 3-dimensional fluid structure interaction models of the aortic valve and root. The structural model included flexible cusps in a compliant aortic root with material properties similar to the physiologic values. The fluid dynamics model included blood hemodynamics under physiologic diastolic pressures of the left ventricle and ascending aorta. Furthermore, zero flow was assumed for effective height calculations, similar to clinical measurements. In these no-flow models, the cusps were loaded with a transvalvular pressure decrease. All other parameters were identical to the fluid structure interaction models., Results: The aortic valve models with an AA diameter range of 20 to 26 mm were fully closed, and those with an AA diameter range of 28 to 30 mm were only partially closed. Increasing the AA diameter from 20 to 30 mm decreased the averaged coaptation height and normalized cusp coaptation area from 3.3 to 0.3 mm and from 27% to 2.8%, respectively. Increasing the AA diameter from 20 to 30 mm decreased the effective height from 10.9 to 8.0 mm., Conclusions: A decreased AA diameter increased the coaptation height and area, thereby improving the effective height during procedures, which could lead to increased coaptation and better valve performance., (Copyright © 2013 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objectives: We sought to compare early and late clinical and echocardiographic outcomes of patients undergoing minimally invasive mitral valve repair by means of the port-access and median sternotomy approaches., Methods: Between 2000 and 2009, 503 patients had mitral valve repair, of whom 143 underwent surgical intervention for isolated posterior leaflet pathology: 61 through port access and 82 through median sternotomy. The port-access group had better preoperative New York Heart Association functional class (P = .007) and a higher rate of elective cases (97% vs 87%, P = .037). Other preoperative characteristics were similar between the groups, including mitral valve pathology and repair techniques., Results: Operative, bypass, and clamp times were significantly longer in the port-access group. Mean hospital stay was 5.3 +/- 2.5 days in the port-access group versus 5.7 +/- 2.5 days in the median sternotomy group (P = .4). Early postoperative echocardiographic analysis showed that most patients in both groups had none or trivial mitral regurgitation and none of the patients had greater than grade 2 mitral regurgitation. Follow-up extended for up to 100 months (mean, 34 +/- 24 months). New York Heart Association class improved in both groups (P = .394). Freedom from reoperation was 97% and 95% in the port-access and median sternotomy groups, respectively. Late echocardiographic analysis revealed that 82% (49/60) in the port-access group and 91% (73/80) in the median sternotomy group were free from moderate or severe mitral regurgitation (P = .11)., Conclusions: In isolated posterior mitral valve pathology, quality of mitral valve repair with the port-access approach can compare with that with the conventional median sternotomy approach., (2010 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objectives: The aim of this study was to investigate the long-term clinical and hemodynamic outcomes after aortic valve replacement with the Carpentier-Edwards Perimount bioprosthesis (Edwards Lifesciences, Irvine, Calif), which has been used in our institution since 1984., Methods: From January 1984 to December 1995, the Carpentier-Edwards pericardial bioprosthesis was used for aortic valve replacement in 254 patients (male/female ratio 117:137) with a mean age of 71 years (range 25-87 years). Before the operation, 216 patients (85%) were in New York Heart Association functional class III or IV. The predominant diagnosis was aortic stenosis (n = 219, 86%). Associated surgical procedures included coronary artery bypass grafting in 130 cases (51%), mitral valve replacement in 11 cases (4%), and tricuspid or mitral valve repair in 12 cases (5%). Previous cardiac operations had been performed in 36 cases (14%). Follow-up was 100% complete at a mean of 60 +/- 31 months. Univariate estimates of time-related cumulative probabilities were calculated by the Kaplan-Meier method. Multivariable adjustment was performed by Cox proportional hazards regression. Echocardiography was performed in 61% of long-term survivors., Results: There were 11 early deaths (4%) and 58 late deaths. Actuarial survivals at 5, 10, and 12 years were 80% +/- 3%, 50% +/- 8%, and 36% +/- 9%, respectively. At 12 years the freedom from cardiac death was 73% +/- 7%, the freedom from valve-related death was 84% +/- 11%, the freedom from valve reoperation was 83% +/- 9%, the freedom from primary tissue failure was 86% +/- 9%, the freedom from thromboembolism was 67% +/- 13%, and the freedom from endocarditis was 98% +/- 1%. Echocardiography was performed on long-term survivors (mean follow-up 67 +/- 25 months) and showed that transvalvular peak and mean pressure differences measured with Doppler echocardiography were 23.2 +/- 9.6 and 12.3 +/- 4.8 mm Hg, respectively. Aortic regurgitation was found by Doppler echocardiography to be none or trivial, mild, moderate, and severe in 64%, 30%, 3%, and 1% of patients, respectively. Mean left ventricular mass index was 107.2 +/- 35.3 g/m(2) (118.9 +/- 40.2 g/m(2) in men and 98.8 +/- 28.8 g/m(2) in women) at late follow-up. One third of all patients, regardless of sex (n = 26/64 women and n = 14/45 men), had evidence of left ventricular hypertrophy. However, our analyses indicate that the residual left ventricular hypertrophy was not caused by valve mismatch but was probably multifactorial., Conclusion: The Carpentier-Edwards Perimount bioprosthesis has provided satisfactory clinical and hemodynamic outcome. However, at long-term follow-up about one third of the patients being investigated still had left ventricular hypertrophy examined by echocardiography.

Reports have shown increased systemic levels of endothelins during coronary artery bypass grafting in human beings. It was not known whether increased endothelin levels during coronary artery bypass grafting reflect a general systemic response to the surgical procedure or increased myocardial production of endothelins in response to ischemia and reperfusion. We therefore measured endothelin levels in the right atrium and proximal aorta of 15 patients undergoing coronary artery bypass grafting for anginal syndrome immediately before aortic crossclamping and again after cessation of cardiopulmonary bypass. In five patients, we also measured coronary sinus levels of endothelins during cardiopulmonary bypass circulation. We found that endothelin levels were elevated throughout the surgical procedure. Right atrial endothelin levels were significantly elevated after cessation of cardiopulmonary bypass circulation with respect to values immediately before aortic crossclamping (11.1 +/- 3.1 vs 14.2 +/- 3.7 pg/ml, p = 0.008), whereas endothelin levels in the proximal aorta did not rise significantly (10.5 +/- 2.3 vs 11.6 +/- 2.4 pg/ml, p > 0.5). Coronary sinus endothelin levels tended to decline temporarily during cardiopulmonary bypass circulation (11.1 +/- 2.1 pg/ml before aortic crossclamping, 7.9 +/- 1.9 1 minute after release of aortic crossclamp, and 9.9 +/- 2.1 pg/ml after release of partial aortic crossclamping, p = 0.06). We conclude that the rise in right atrial endothelin levels during coronary artery bypass grafting reflects systemic production and secretion of endothelins, probably by vasculature or organs distal to the proximal aorta, and is not the result of increased myocardial production and secretion of endothelins.