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Background Obtaining hemostasis during cardiovascular procedures can be a challenge, particularly around areas with a complex geometry or that are difficult to access. While several topical hemostats are currently on the market, most have caveats that limit their use in certain clinical scenarios such as pulsatile arterial bleeding. The aim of this study was to assess the effectiveness and safety of Veriset™ hemostatic patch in treating cardiovascular bleeding. Methods Patients (N=90) scheduled for cardiac or vascular surgery at 12 European institutions were randomized 1:1 to treatment with either Veriset™ hemostatic patch (investigational device) or TachoSil® (control). After application of the hemostat, according to manufacturer instructions for use, time to hemostasis was monitored. Follow-up occurred up to 90 days post-surgery. Results Median time to hemostasis was 1.5 min with Veriset™ hemostatic patch, compared to 3.0 min with TachoSil® (p<0.0001). Serious adverse events within 30 days post-surgery were experienced by 12/44 (27.3%) patients treated with Veriset™ hemostatic patch and 10/45 (22.2%) in the TachoSil® group (p=0.6295). None of these adverse events were device-related, and no reoperations for bleeding were required within 5 days post-surgery in either treatment group. Conclusion This study reinforces the difference in minimum recommended application time between Veriset™ hemostatic patch and TachoSil® (30 s versus 3 min respectively). When compared directly at 3 min, Veriset™ displayed no significant difference, showing similar hemostasis and safety profiles on the cardiovascular bleeding sites included in this study.

David Glineur,1 Marc Hendrikx,2 Dainis Krievins,3 Peteris Stradins,3 Bernhard Voss,4 Thomas Waldow,5 Luc Haenen,6 Martin Oberhoffer,7 Caroline M Ritchie8 1Saint Luc Cliniques Universitaires, Brussels, Belgium; 2Faculty of Medicine and Life Sciences, Jessa Hospital, Hasselt University, Hasselt, Belgium; 3Pauls Stradins Clinical University Hospital, Riga, Latvia; 4German Heart Center Munich, Department of Cardiovascular Surgery, Technische Universität München, Munich, Germany; 5Heart Center Dresden GmbH, University Hospital Dresden, Dresden, Germany; 6Imelda Hospital, Bonheiden, Belgium; 7Asklepios Klinik St. Georg, Herzchirurgische Abteilung, Hamburg, Germany; 8Covidien, Medical Affairs, Bedford, MA, USA Background: Obtaining hemostasis during cardiovascular procedures can be a challenge, particularly around areas with a complex geometry or that are difficult to access. While several topical hemostats are currently on the market, most have caveats that limit their use in certain clinical scenarios such as pulsatile arterial bleeding. The aim of this study was to assess the effectiveness and safety of Veriset™ hemostatic patch in treating cardiovascular bleeding.Methods: Patients (N=90) scheduled for cardiac or vascular surgery at 12 European institutions were randomized 1:1 to treatment with either Veriset™ hemostatic patch (investigational device) or TachoSil® (control). After application of the hemostat, according to manufacturer instructions for use, time to hemostasis was monitored. Follow-up occurred up to 90 days post-surgery. Results: Median time to hemostasis was 1.5 min with Veriset™ hemostatic patch, compared to 3.0 min with TachoSil® (p<0.0001). Serious adverse events within 30 days post-surgery were experienced by 12/44 (27.3%) patients treated with Veriset™ hemostatic patch and 10/45 (22.2%) in the TachoSil® group (p=0.6295). None of these adverse events were device

OBJECTIVES: We report the outcomes of robotic valve repair for degenerative mitral regurgitation (MR) in our Institution. METHODS: Between February 2012 and July 2016, 134 patients underwent robotic mitral valve (MV) repair with the da Vinci Si system. All the operations were performed through a mini-thoracotomy in the fourth right intercostal space, cardiopulmonary bypass and mild hypothermia. The clinical and echocardiographic follow-up was 100% complete. RESULTS: There was no hospital death. The mean cross-clamp and cardiopulmonary bypass time were 112±23 and 159±33 min, respectively. Pre-discharge echocardiograms showed none-to-mild residual MR in all patients. Median follow-up was 24.1 months. We observed 1 early and 4 late reoperations on the MV for an overall freedom from reoperation of 98.2% and 94.1% at 12 and 36 months, respectively. Furthermore, echocardiographic follow-up revealed freedom from recurrence of MR greater than Grade 1+ of 92.5% and 80.7% at 12 and 36 months, respectively. Nevertheless freedom from recurrence of MR greater than Grade 2+ was 97.2% at 12 and 36 months. CONCLUSIONS: Robotic MV repair is a feasible and safe option for the treatment of degenerative MR in selected patients with excellent perioperative outcomes. Early and midterm results are remarkable and are associated with low risk of late recurrence of MR and reoperation. Long-term follow-up is needed to confirm the durability of valve repair.

Background: Little evidence shows whether a third arterial graft provides superior outcomes compared with the use of 2 arterial grafts in patients undergoing coronary artery bypass grafting. A meta-analysis of all the propensity score-matched observational studies comparing the long-term outcomes of coronary artery bypass grafting with the use of 2-arterial versus 3-arterial grafts was performed. Methods: A literature search was conducted using MEDLINE, EMBASE, and Web of Science to identify relevant articles. Long-term mortality in the propensity score-matched populations was the primary end point. Secondary end points were in-hospital/30-day mortality for the propensity score-matched populations and long-term mortality for the unmatched populations. In the matched population, time-to-event outcome for long-term mortality was extracted as hazard ratios, along with their variance. Statistical pooling of survival (time-to-event) was performed according to a random effect model, computing risk estimates with 95% confidence intervals. Results: Eight propensity score-matched studies reporting on 10 287 matched patients (2-arterial graft: 5346; 3-arterial graft: 4941) were selected for final comparison. The mean follow-up time ranged from 37.2 to 196.8 months. The use of 3 arterial grafts was not statistically associated with early mortality (hazard ratio, 0.93; 95% confidence interval, 0.71-1.22; P=0.62). The use of 3 arterial grafts was associated with statistically significantly lower hazard for late death (hazard ratio, 0.8; 95% confidence interval, 0.75-0.87; P<0.001), irrespective of sex and diabetic mellitus status. This result was qualitatively similar in the unmatched population (hazard ratio, 0.57; 95% confidence interval, 0.33-0.98; P=0.04). Conclusions: The use of a third arterial conduit in patients with coronary artery bypass grafting is not associated with higher operative risk and is associated with superior long-term survival, irrespective of sex and dia

BACKGROUND: Bilateral internal thoracic arteries (BITA) have demonstrated superior patency and improved survival in patients undergoing coronary artery bypass grafting. However, the optimal configuration for BITA utilization and its effect on long-term outcome remains uncertain. METHODS AND RESULTS: We randomly assigned 304 patients undergoing coronary artery bypass grafting using BITA to either in situ or Y grafting configurations. The primary end point was 3-year angiographic patency. Secondary end points included major adverse cardiac and cerebrovascular events (ie, death from any cause, stroke, myocardial infarction, or repeat revascularization) at 7 years. More coronary targets were able to be revascularized using internal thoracic arteries in patients randomized to Y grafting versus in situ group (3.2±0.8 versus 2.4±0.5 arteries/patient; P<0.01). The primary end point did not show significant differences in graft patency between groups. Secondary end points occurred more frequently in the in situ group (P=0.03), with 7-year rates of 34±10% in the in situ and 25±12% in the Y grafting groups, driven largely by a higher incidence of repeat revascularization in the in situ group (14±4.5% versus 7.4±3.2% at 7 years; P=0.009). There were no significant differences in hospital mortality or morbidity or in late survival, myocardial infarction, or stroke between groups. CONCLUSIONS: Three-year systematic angiographic follow-up revealed no significant difference in graft patency between the 2 BITA configurations. However, compared with in situ configuration, the use of BITA in a Y grafting configuration results in lower rates of major adverse cardiovascular and cerebrovascular events at 7 years. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01666366.

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BACKGROUND AND AIM OF THE STUDY: Mitral annular calcification (MAC) represents a significant challenge in mitral valve (MV) surgery. Techniques to decalcify the mitral annulus significantly increase operative complexity and risk. MV repair can be particularly difficult in this setting. Mid-term outcomes following MV surgery with extensive annular decalcification were examined, with attention focused on the feasibility and outcomes of MV repair in this setting. METHODS: Among 1,485 patients undergoing MV surgery between 1999 and 2008 at the authors' institutions, 24 (1.6%) underwent complete posterior MV annular decalcification associated with either MV repair (n = 19) or replacement (n = 5). Extensive decalcification was performed from commissure to commissure in all patients. The annulus was reconstructed with pledgeted compression sutures in 17 patients, and with a bovine pericardial patch in seven. RESULTS: In-hospital mortality was 12.5%. One patient died in the operating room from atrioventricular groove rupture, and two patients died from low cardiac output postoperatively. During a mean follow up of 4.4 ± 2.7 years, eight patients died; five of these deaths were cardiovascular in nature. After five years the actuarial survival was 56 ± 11%, and freedom from cardiac death 63 ± 11%. Four patients underwent' reoperation because of failure of MV repair (n = 2), endocarditis (n = 1) or hemolysis (n = 1). All survivors were in NYHA class ≤ 2, with none to trivial mitral regurgitation in all MV repairs. The five-year freedom from MV reoperation was 82 ± 8%. CONCLUSION: fter aggressive decalcification of the posterior MV annulus, both MV repair and replacement were feasible, with acceptable procedure-related mortality. It was clear however, that decalcification increased both complexity and risk. In well-selected patients, an aggressive approach to MV repair might facilitate a high rate of repair with acceptable midterm outcome in this patient population.

OBJECTIVE: To compare 2 different surgical approaches to treatment of patients with isolated predivisional stenosis of the left main coronary artery (IOSLM) and to evaluate the effect of chronic competitive flow from a patent arterial or venous graft to the circumflex system on the long-term patency of internal thoracic artery (ITA) to left anterior descending grafts. METHODS: Thirty-two patients with IOSLM were treated at our institutions during a 9-year period: 14 patients received double ITA grafts, whereas 18 underwent ITA graft plus saphenous vein (SV) bypass. All patients were reviewed clinically and angiographically at long-term follow-up. RESULTS: No patient died during hospitalization. At a mean follow-up of 96±9 months 7 patients had died (6 from noncardiac causes) and 5 had experienced angina/ischemia recurrence, without differences between the 2 revascularization strategies. At control reangiography all ITA and SV grafts were found to be fully patent, without evidence of caliber reduction or string sign in the ITA. CONCLUSIONS: In patients with IOSLM, long-term ITA to left anterior descending artery patency is not jeopardized by chronic flow competition from a concomitant arterial or venous graft to the circumflex system. Notably, the addition of a second ITA graft or of a SV to the first ITA does not lead to differences in long-term angiographic patency. Our results minimize the role of flow competition in this setting and should be kept in mind when choosing the appropriate graft configuration.

OBJECTIVES: This study evaluated the effect of preoperative symptoms on long-term survival and valve reintervention in patients undergoing aortic valve repair (AVr) for severe degenerative aortic insufficiency (AI). METHODS: Between March 1996 and June 2010, 274 patients underwent AVr for severe AI. Seventy-seven were performed in asymptomatic patients (Group I) and 197 were performed in symptomatic (Group II). Patients in Group I were younger (43.9 ± 15.0 vs 54.1 ± 15.5 years; P < 0.001) with a higher proportion of bicuspid valves (n = 40, 51.9% vs n = 68, 30.4%; P = 0.008). Group II had more patients with impaired left ventricular (LV; n = 36, 18.3% vs n = 5, 6.4%; P = 0.013). The mean follow-ups for Group I and Group II were 43.0 ± 34.0 and 61.3 ± 39.5 months, respectively. RESULTS: There was no in-hospital mortality. Overall, leaflet repair and reimplantation were higher in Group I (P = < 0.001 and P = 0.002, respectively), whereas subcommissural annuloplasty for tricuspid AV was higher in Group II (P = 0.002). Leaflet shaving and plication were performed in more patients in Group I (P = 0.002 for both). There was no difference in early complications, but during follow-up atrial fibrillation was more frequent in Group II (P = 0.03). There were 10 late cardiac deaths, all in Group II (P = 0.04). Overall, 10-year cardiac survival was better in Group I (100 vs 77.3 ± 8.6%) but not significant (P = 0.1). At 10 years, freedom from ≥AI2+ was 63.2 ± 8.1 vs 56.4 ± 4.5% (P = 0.4), and freedom from AV reintervention was 81.8 ± 7.1 vs 89.0 ± 2.8% (P = 0.36), in Groups I and II, respectively. In the whole cohort, 10-year freedom from AV reintervention was greater in patients with an end-diastolic diameter of <60 mm (90.0 ± 7.6 vs 76.3 ± 5.5%; P = 0.003). Multivariate analysis identified increasing age as the only independent predictor of overall survival (P = 0.03). The incidence of valve-related complications was similar. CONCLUSION: In asymptomatic patients with

BACKGROUND AND AIM OF THE STUDY: The study aim was to define the timing of cerebral embolization events during transcatheter aortic valve implantation (TAVI), and to determine if events were more closely associated with valve implantation or with balloon inflation. METHODS: Between January 2008 and November 2011, a total of 114 patients underwent TAVI at the author's institution. Of these patients, 44 had previously undergone imaging before and after TAVI, and were included in the study (26 transfemoral (TF); 18 transapical (TA)). Eleven patients who had only balloon valvuloplasty (BV) during the same period were included, as were 22 patients who had open aortic valve replacement (AVR), as controls. All 77 patients underwent neurological examination, and all had cerebral MRIs before and after their procedures. RESULTS: Fifty of the 77 patients who underwent postprocedural MRI had new cerebral lesions, as follows: 24/26 (92%) in TF patients; 17/18 (94%) in TA patients; 3/11 (27%) in BV patients; and 6/22 (27%) in AVR patients (TF and TA versus BV and AVR, p < 0.0001). The mean number and volume of embolic lesions per patient were respectively 5.4/438 mm3 for TF, 11.6/3414 mm3 for TA, 0.7/46 mm3 for BV, and 0.4/48 mm3 for AVR (TF versus TA and BV versus AVR, p = NS; TF and TA versus BV and AVR, p < 0.0001). No association was found between either the EuroSCORE or patient age and the number of events. CONCLUSION: In the present study, an incidence of silent cerebral embolic lesions after TAVI was identified which was significantly higher than that for BV or AVR. This indicated an association of embolism with valve implantation rather than with balloon inflation.

BACKGROUND: The spread of drug-eluting stents (DES) has reduced the incidence of early restenosis following percutaneous coronary interventions (PCI). Meanwhile, development of minimally invasive coronary artery bypass surgery (MIDCAB) has offered a valuable alternative to conventional sternotomy with preservation of the benefit of the internal mammary artery use. Therefore, the revascularization of the left anterior descending (LAD) artery is suitable for both techniques. However, few data with long-term comparison of these two techniques exist. METHODS: Prospective data were collected for 456 patients undergoing isolated LAD revascularization between 1997 and 2011. Two hundred and sixty patients were treated with MIDCAB and 196 with first-generation DES implantation. A propensity score model was created to adjust for 19 relevant confounding variables. Primary and secondary end-points were, respectively, 5-year survival and freedom from major adverse cerebro-cardiovascular events (MACCE). RESULTS: Both groups were similar in age, EuroSCORE and mean duration of follow-up. Five-year survival was similar after MIDCAB or DES (hazard ratio (HR): 0.95; P = 0.89). Freedom from MACCE was significantly in favour of the MIDCAB group (HR: 0.32, P < 0.0001), mainly triggered by high subsequent need for revascularization of the targeted vessel in the DES group (HR: 0.17, P < 0.0001). CONCLUSIONS: MIDCAB and DES implantation showed similar rates of survival but despite an expected lower rate of reintervention on the targeted vessel with DES use, a highly significant higher MACCE rate was observed in the PCI group at 5-year follow-up.

Here, we describe the case of a 62-year old woman who required aortic and mitral valve replacement plus coronary artery bypass grafting. Transoesophageal echocardiogram revealed stenosis of the aortic valve (Ao valve area, 0.9 cm(2); PG, 45 mmHg; MG, 25 mmHg) and a diseased calcified mitral valve with stenosis and regurgitation (mitral valve area, 1.1 cm(2); MG, 10 mmHg; RV, 25 ml; ERO, 12 mm(2)). The mitral annulus calcifications were very deep into the left atrium and the left ventricle muscle, around the full annulus circumference. We decided to avoid complete deep mitral annulus decalcification. The left atrium was surgically exposed, and we deployed a 26-mm Edwards SAPIEN XT endovalve through the left atriotomy. To prevent paravalvular leakage, we then used a pericardial patch to close the gap between the endovalve and the calcified mitral annulus. The postoperative echocardiogram showed perfect anchoring of the endovalve in the mitral annulus without any paravalvular leakage.

To evaluate the effect of higher post-operative valve gradient on freedom from valve re-intervention and death in patients undergoing aortic valve repair (AVr).

Due to current medical improvements, more women with cardiac disease are being operated during pregnancy. Fetal loss has been found to be significant between 9-30% of them and the surgery is supposed to be done maximal in the first trimester.

OBJECTIVES: Studies have emphasized the importance of normal fibrinogen concentrations in surgical patients. The primary hypothesis of this study was that fibrinogen levels significantly decrease in on-pump coronary artery bypass graft (CABG) surgery versus off-pump coronary artery bypass graft (OPCAB) surgery. The second objective was to show that ROTEM (TEM International, GmbH, Munich, Germany) rapidly detects these abnormalities compared with standard tests. DESIGN: A prospective, nonrandomized study. SETTING: A university hospital. PARTICIPANTS: Forty-two and 62 patients in the CABG and OPCAB groups, respectively, undergoing first-time bypass surgery were included. INTERVENTIONS: CABG versus OPCAB surgery. MEASUREMENTS AND MAIN RESULTS: Routine coagulation tests and ROTEM values were measured before anesthesia (T0), after the first dose of heparin (T1), after protamine (T2), upon intensive care unit arrival (T3), and 4 hours postoperatively (T4). The outcome measures were followed until 4 hours postoperatively. Fibrinogen concentrations were significantly lower in the CABG versus the OPCAB group at T2 (170 ± 44 v 243 ± 73 mg/dL, p < 0.001) and T3 (179 ± 42 v 232 ± 68 mg/dL, p < 0.001). This was confirmed by significantly lower FIBTEM maximal clot firmness values at T2 (9 ± 4 v 14 ± 5 mm, p < 0.001) and T3 (9 ± 4 v 13 ± 6 mm, p < 0.001). In the CABG group, patients received significantly more transfusions of all blood products except fresh frozen plasma. CONCLUSIONS: Fibrinogen concentration significantly decreases after cardiopulmonary bypass. ROTEM helps in its fast detection.

OBJECTIVES: Because of the limited availability of pulmonary homografts (PH), porcine stentless xenografts (SX) have been proposed as an alternative for pulmonary valve replacement in the Ross operation. However, it is unknown whether they have similar good long-term durability. Therefore, we compared mid- to long-term outcomes between those two right ventricular outflow tract (RVOT) substitutes. METHODS: In 288 adults (>18 years) undergoing a Ross operation between 1991 and 2012, Freestyle(®) SX was used in 18 patients and a cryopreserved PH was used in 270 for RVOT reconstruction. Only patients with follow-up >2 years were included. According to the operative period, gender and age, 37 patients with PH could be matched with 17 SX patients. Clinical and echocardiographic follow-up were obtained. In a subset of patients (SX, n = 11 and PH, n = 25), a cardiac computed tomographic (CT) scan was performed to analyse graft calcification. RESULTS: The mean follow-up period was 8.2 ± 4.0 (range 2-14.6 years). During this period, 3 patients died from cancer, 2 in the SX group and 1 in the PH group (P = 0.15). No patient needed RVOT reoperation. At follow-up, RVOT peak gradient was 21 ± 5.9 mmHg in the SX and 16.3 ± 8.7 in the PH groups (P = 0.07). Peak gradient >40 mmHg was observed in only 1 patient in the PH group. Mean RVOT regurgitation was 0.1 ± 0.4 in the SX group and 0.8 ± 0.6 in the PH group (P = 0.008). CT scan analyses showed progressive calcification mainly of the graft wall, while the valve remained relatively free of calcium. Patients with the SX presented significantly higher calcium scores than those with PH (P = 0.01). CONCLUSIONS: In adult patients having the Ross operation, calcic degeneration is observed in both the PH and the SX used as pulmonary substitutes. Calcification progresses more rapidly in the SX compared with the PH. In both grafts, calcifications affect mainly the wall, while the valve remains relatively free of calcium. As a consequence, bo

Direct transaortic implantation (TAo) has been described as a new alternative approach for transcatheter aortic valve implantation in patients with unsuitable transfemoral access. TAo is usually achieved through an upper ministernotomy or, more recently, through a right thoracotomy in the second intercostal space. We describe here our first experience with a fully thoracoscopic approach that allowed successful deployment of a 23-mm Edwards SAPIEN valve.

OBJECTIVE: Preliminary data showed an increase in endogenous erythropoietin (EPO) concentrations after acute normovolemic hemodilution (ANH) in patients undergoing coronary artery bypass graft (CABG) surgery. Numerous studies have shown the organ protective properties of EPO. The aim of this study was to investigate the cardioprotective effects of these increased EPO concentrations that resulted from ANH during cardiac surgery. DESIGN: A prospective, randomized, blind study. SETTING: A university hospital. PARTICIPANTS: A total of 93 patients undergoing isolated CABG surgery with or without cardiopulmonary bypass (CPB). INTERVENTIONS: Subjects with CPB were randomized into the control (C) or ANH group. Those in the off-pump coronary artery bypass group underwent no treatment. In the ANH group, a precalculated amount of blood was withdrawn and replaced by colloids after the induction of anesthesia. MEASUREMENTS AND MAIN RESULTS: Hemodynamic parameters were recorded intra- and postoperatively. Troponin concentrations were measured as a routine parameter postoperatively. Upon intensive care unit arrival, the EPO levels were higher in the ANH group than in the C group. There was no significant difference between the troponin values of the C and the ANH groups at 4 hours postoperatively. CONCLUSIONS: In patients undergoing CABG surgery on CPB, an increase in endogenous EPO concentrations in the physiologic range has no cardioprotective effects.

Cardiac surgery is increasingly performed on elderly patients. This population has more co morbidities such as impaired ventricular function, coronary disease, peripheral vascular disease and renal insufficiency. These co morbid factors have been described as independent factors of mortality in this older population. Open heart surgery using cardiopulmonary bypass to replace the aortic valve is associated with a higher morbidity and mortality. Transcatheter Aortic Valve Implantation (TAVI) is a new approach to minimize the morbidity and mortality in selected high risk patients .In this technique, the calcified native valve remains in situ has to be squeezed between the transcatheter valve and the aortic wall. This leads to several problems: implantation of the valve into a non-circular calcified annulus with a risk of severe paravalvular leak , risk of coronary ostia occlusion, embolization of debris, increase the mitral insufficiency , too small effective aortic valve area. For this reason, resection of the native valve before implantation of the new valve makes sense for many surgeons who tried to develop an endovascular tool to remove the native valve. Several resection methods have been published using waterjet, laser cut or foldable cutting edges . In our study we describe a novel resection device designed for use in transapical and transaortic access. We also analyse the risk of cerebral embolisation during TAVI. We describe the development process and medical testing of the novel endovascular aortic valve resection device., (MED 3) -- UCL, 2012

Competition flow plays a crucial role in arterial grafting functionality. Grafting strategy should address this by appropriate graft choice and configuration in order to avoid graft attrition.

We developed a novel resection device to use during transapical transcatheter aortic valve implantation (TAVI) using a circular blade. We assessed the device in 15 human cadavers by transapical approach. After the resection, the aortic annulus was measured using standard probes. A careful examination of the aortic wall, left ventricular outflow tract, coronary ostia and mitral valve was performed using an endpoint checklist, developed specifically for the new device. The resection was successfully completed in 14 out of 15 (93%) cases. All the resected leaflets and debris have been successfully evaluated in 15 out of 15 (100%) cases. One case of a bicuspid valve had a prominent calcification of the median raphe. The resection tool could only perform a partial resection. The mean duration of the resection was 45 ± 30 s. The surrounding tissue examination did not reveal any injury to the anatomical structures. Endovascular resection of the native valve using transapical approach is feasible and effective. Further developments are necessary before the definitive clinical use during percutaneous aortic valve implantation.

Objectives: The long-term advantages of multiple arterial grafts, particularly a third arterial conduit, for coronary artery bypass (CABG) are not clear. This study was designed to test whether multiple arterial grafts would provide better long-term outcomes when compared with approaches using fewer arterial conduits. Methods: Between 1985 and 1995, prospective data were collected for 588 patients undergoing isolated CABG at our institution. We examined long-term survival and freedom from cardiac death. The primary analysis compared patients receiving bilateral internal thoracic artery (BITA) vs. single ITA (SITA). In a subgroup analysis, BITA patients receiving a right gastroepiploic artery (RGEA) were compared with those receiving a saphenous vein graft (SVG) as a third conduit. Cox proportional hazard modelling was used to adjust for relevant confounders. The Kaplan-Meier method was used to create survival curves over the follow-up period. Results: The mean age was 59 ± 9 years and 49% received BITA. Mean follow-up was 16.1 ± 5.4 years. Multivariable analysis revealed that overall survival [hazard ratio (HR): 0.74, P = 0.017] and cardiac survival (HR: 0.61, P = 0.004) was significantly improved in the presence of BITA compared with SITA. The survival at 10 and 20 years was 90.2 ± 3.4 and 56.9 ± 6.4% for the BITA vs. 82 ± 4.4 and 40.9 ± 6% for the SITA, respectively. In the subgroup of BITA patients, those receiving the RGEA as a third conduit had superior overall survival (HR: 0.41, P = 0.0032) and cardiac survival (HR: 0.18, P = 0.004) compared with those receiving an SVG. The survival at 10 and 20 years was 98.9 ± 2 and 68.9 ± 18% for the BITA/RGEA vs. 87.2 ± 4.6 and 50.3 ± 7% for the BITA/SVG, respectively. Conclusions: In a single-institution experience, the use of multiple arterial grafting is independently associated with superior outcomes. Furthermore, the use of a third arterial conduit (RGEA) targeted to the right coronary artery should be considered to

Cusp prolapse causing aortic insufficiency is associated with unique echocardiographic, clinical, and surgical features. Recognition and appropriate surgical repair of this pathologic condition can not only treat affected patients but also improve results of aortic valve-sparing procedures, for which pre-existing or induced cusp prolapse is an important cause of failure.

Objective: Patients with supracoronary ascending aortic aneurysms can have aortic insufficiency (AI) due to dilatation of the sinotubular junction and/or associated cusp pathology. The incidence and types of cusp lesions as well as the effect of AI severity and cusp repair techniques on outcome in this patient population is not well defined. Methods: Since 1996, 55 patients (mean age: 65±13 years, 17 bicuspid valves) presented with supracoronary ascending aortic aneurysms and AI that was mild/moderate in 27 (49%) and severe in 28 (51%). Associated pathology included cusp prolapse in 18 (33%), cusp restriction in nine (16%) and both in three (5%). All patients underwent aortic replacement and remodeling of the sinotubular junction. Adjunctive techniques included subcommissural annuloplasty in 38(69%) and cusp repair in 28 (51%). Results: AI severity was not significantly associated with the presence of cusp pathology (p=0.35). Cusp disease was present in 100% of bicuspid aortic valves compared with only 34% of trileaflet valves (p<0.001). There was no hospital mortality and overall survival was 94±4% and 75±10%, respectively, at 5 and 7 years. Freedom from re-operation was 100% at 7 years and freedom from recurrent AI (>2+) was 87±7% at 5 years. Neither the presence of preoperative severe AI, nor the need for cusp repair was predictive of late outcome. Conclusions: Cusp pathology is frequently encountered in patients with ascending aortic dilatation and AI. Severe AI is not a contraindication to valve-preserving surgery, but careful identification and repair of cusp pathology, in addition to sinotubular junction reduction, is critical for durable, long-term outcome.