Parwis Massoudy

Background: Minimally invasive and endoscopic techniques have expanded the surgical options for tricuspid valve repair. Conventional approaches often require manual snaring of the venae cavae, which can increase procedural complexity and invasiveness, especially in redo or advanced heart failure settings. This study describes a snare-free totally endoscopic approach to tricuspid valve repair utilizing percutaneous venous selfexpanding cannulation. Methods: Between 2020 and 2025, 32 consecutive patients with severe tricuspid regurgitation (TR) underwent totally endoscopic tricuspid valve repair using a standardized snare-free technique. Venous drainage was achieved via percutaneous femoral cannulation with a self-expanding venous cannula, providing optimal central venous decompression without external tourniquets or loops. All clinical, intraoperative, and early postoperative parameters were systematically collected and analyzed using descriptive statistical methodology. Results: Endoscopic tricuspid valve repair was successfully completed in all 32 patients. The mean total cardiopulmonary bypass (CPB) time was 145.9 ± 35.8 minutes, and the mean aortic cross-clamp duration was 92.4 ± 24.5 minutes. The early postoperative safety profile was characterized by an all-cause 30-day mortality rate of 3.1% (n = 1) and zero cases of clinically relevant hemolysis (0.0%)The mean intensive care unit stay was 6.0 ± 4.9 days, and the mean total hospital length of stay was 15.4 ± 9.7 days. Conclusion: Snare-free totally endoscopic tricuspid valve repair using a percutaneous self-expanding venous cannulation is a safe, technically feasible, and reproducible technique. This structural approach simplifies right atrial endoscopic visualization, eliminates the complications associated with deep caval-dissection, and demonstrates highly stable early clinical and electrophysiological outcomes.

Background: Minimally invasive cardiac valve surgery (MIVS) provides distinct clinical advantages, yet annular suturing remains a technically demanding step. Automated annular suturing devices (RAM^®) have been developed to standardize suture placement during valve replacement. This study evaluates the initial clinical feasibility, technical safety, and operational integration of automated suturing during its institutional adoption phase. Methods: We retrospectively evaluated 43 consecutive patients undergoing MIVS supported by the RAM^® system (2021–2025), stratified into mitral valve replacements (RAM-MVR, n = 26) and aortic valve replacements (RAM-AVR, n = 17). Technical parameters, procedural safety metrics, and perioperative outcomes were descriptively analyzed and contextualized against our broader institutional MIVS platform using percutaneous femoral cannulation (n = 182). Results: Automated annular suturing achieved a 100% technical feasibility rate (43/43, 95% CI: 91.8–100.0%) with zero mechanical device failures or intraoperative suture-line disruptions (0%, 95% CI: 0.0–8.2%). In the RAM-MVR cohort, median cross-clamp and cardiopulmonary bypass (CPB) times were 73.0 min (IQR 64.0–91.0) and 114.5 min (IQR 94.8–129.5), respectively. In RAM-AVR, median cross-clamp time was 75.0 min (IQR 71.0–83.0). Thirty-day mortality was 4.7% (2/43, 95% CI: 0.6–15.8%), secondary to non-device-related medical complications in high-risk baseline patients. Postoperative echocardiography demonstrated no paravalvular regurgitation (0%, 95% CI: 0.0–8.2%). Conclusions: Initial institutional experience demonstrates that automated annular suturing is technically feasible and safe in minimally invasive mitral and aortic valve replacement. The system enables consistent procedural execution across valve positions. These observational data support automated suturing as a feasible alternative to manual suturing in MIVS workflows.

Background: Minimally invasive cardiac valve surgery (MIVS) is established as a safe alternative to conventional sternotomy, yet the technical complexity of annular suturing remains a significant barrier to procedural efficiency. Automated annular suturing devices (RAM®) have been introduced to mechanize and standardize suture placement specifically during valve replacements. This study evaluates the clinical feasibility, safety, and device usability of automated suturing during its institutional introductory phase. Methods: We retrospectively reviewed 43 consecutive patients undergoing MIVS supported by the RAM® system between 2021 and 2025. The cohort was stratified into RAM-supported Mitral Valve Replacements (RAM-MVR, n=26) and Aortic Valve Replacements (RAM-AVR, n=17). Technical parameters, device configurations, and perioperative outcomes were descriptively analyzed and contextualized within our mature institutional percutaneous MIVS benchmark platform (n=182). Results: Automated annular suturing achieved 100% technical feasibility with zero mechanical malfunctions or suture-line failures. In the RAM-MVR group, the median aortic cross-clamp and cardiopulmonary bypass (CPB) times were 73.0 minutes (IQR 64.0–91.0) and 114.5 minutes (IQR 94.8–129.5), respectively. RAM-AVR cases demonstrated a median cross-clamp time of 58.0 minutes (IQR 50.0–63.0). Conclusion: Automated annular suturing represents a robust and predictable technology that integrates seamlessly into a mature percutaneous MIVS environment. The system provides reliable standardization of valve anchoring across varying positions, yielding stable procedural times and excellent hemodynamic performance without introducing device-specific morbidity.

Background: Femoral cannulation is essential for minimally invasive mitral valve surgery (MIMVS). Our center transitioned from open femoral cut-down to ultrasound-guided percutaneous cannulation supported by smart venous cannulas, ThruPort arterial access, and the MANTA closure device. This study evaluates how this transition affects procedural efficiency, vascular safety, and postoperative outcomes. Methods: We retrospectively analyzed 575 consecutive MIMVS patients (2014–2025). Patients treated before 2021 formed the cut-down group, while those from 2021 onward underwent percutaneous cannulation. The outcomes included operative times, groin and lymphatic complications, MANTA performance, and 30-day mortality. Propensity score matching (PSM) was performed to adjust for baseline differences. Results: Of 575 patients, 393 (68.3%) underwent cut-down and 182 (31.7%) percutaneous access. Percutaneous access was associated with shorter cardiopulmonary bypass times (115 vs. 128 min, p < 0.0001), total operative times (210 vs. 242 min, p < 0.0001), ICU stays (2 vs. 3 days, p = 0.0267), and hospital stays (8 vs. 11 days, p < 0.0001). Lymph fistula occurred in 4.3% of cut-down cases and in 0% after the adoption of percutaneous access (p = 0.0004). Overall groin complication rates were comparable (2.8% vs. 4.9%, p = 0.51). MANTA closure had a 2.2% device-related complication rate (1.1% bleeding; 1.1% ischemia) with no documented long-term sequelae. Regarding 30-day mortality, this was 4.6% in the cut-down group and 1.6% in the percutaneous group (p = 0.096). In PSM (72 matched pairs), percutaneous access retained significantly shorter operative, bypass, and ICU times, with identical groin complication rates. Conclusions: Ultrasound-guided percutaneous femoral cannulation was associated with improved procedural efficiency and elimination of lymphatic morbidity, without increasing vascular risk or mortality. It represented a safe and effective standard strategy for contemporary MIMVS.

Objectives: To investigate 3-year outcomes of surgical aortic valve replacement using the INSPIRIS RESILIA aortic valve bioprosthesis in patients with severe aortic stenosis. Methods: IMPACT registry is a prospective, multicentre, international registry with a 5-year follow-up. After 3 years, haemodynamic performance, all-cause mortality, and valve-related mortality were determined. Results: A total of 556 patients who underwent surgical aortic valve replacement with the INSPIRIS RESILIA aortic valve were enrolled between December 2019 and June 2021. The mean age was 63.4 ± 8.5 years, 29.0% were female, with a EuroSCORE II of 2.2 ± 2.5% and an STS score of 1.7 ± 2.2%. Hypertension (66.2%), coronary artery disease (34.7%), and diabetes (18.4%) were the most common comorbidities. A total of 49.3% of patients underwent full sternotomy, 58.3% isolated aortic valve replacement. The most commonly implanted valve sizes were 23 mm (35.4%) and 25 mm (30.9%). At 3 years, overall survival was 91.0%, freedom from valve-related mortality was 97.5%, from prosthetic endocarditis 96.0%, from stroke 91.5%, from valve-related dysfunction 98.0%, from reintervention 96.2%, from structural valve deterioration stage 2 96.8%, and from stage 3 99.4%. The mean transvalvular gradient was 11.9 mmHg at 3 years, with an indexed effective orifice area of 0.8 cm2/m2. Functional class improved from 41.2% class III or IV at baseline to 5.7% at 3 years. Conclusions: Three-year outcomes, including survival and haemodynamic and functional status after surgical aortic valve replacement using the INSPIRIS RESILIA bioprosthetic aortic valve, were reported in a real-world patient population with severe aortic stenosis. ClinicalTrials.gov: NCT04053088.

The long-term outcomes of combined rapid-deployment aortic valve replacement (RDAVR) with coronary artery bypass graft surgery (CABG) are not well explored. We report 3-year results from the INCA registry on combined RDAVR with CABG. INCA is a prospective, multicenter registry that enrolled 224 patients undergoing RDAVR with CABG at 10 cardiac institutions in Germany. Prosthetic valve hemodynamics, clinical outcomes, and quality of life (QoL) up to 3 years were assessed. The mean age of patients was 73.6 ± 6.1 years, and the mean logistic EuroSCORE was 7.8 ± 6.0%. The mean number of distal arterial and venous anastomoses was 3.13 ± 1.56, aortic cross-clamp time was 79.4 ± 24.1 minutes, cardiopulmonary bypass time was 109.6 ± 34.5 minutes, and operation time was 224.2 ± 62.7 minutes. The majority of implanted valve size was 25 mm. At baseline, 11 patients (4.9.%) had a permanent pacemaker. Postoperatively, 17 patients (7.6%) required a new pacemaker implantation (5.4% valve-related). All-cause mortality at 30 days was 2.2%, and 11.2% at 3 years. Patient QoL (SF-12v2) was significantly restored and maintained for up to 3 years (p < 0.001). Five patients (0.9%) underwent reoperation related to endocarditis. The postimplant mean gradient was 9.2 ± 3.7 at discharge and 8.9 ± 4.6 mm Hg at 3 years. Combined RDAVR with CABG procedure is safe and effective over time. It offers stable and low transvalvular gradients with satisfactory clinical outcomes at 3 years. The pacemaker rate appears to be slightly increased, with no significant clinical effect at 3 years.

Background/Objectives: Coronary artery bypass surgery (CABG) with multiple arterial grafting (MAG) has shown potential to improve patient survival compared to single arterial bypass grafting. Whether this superiority in survival also exists in diabetics is uncertain. We therefore aimed to compare short and long-term outcomes of MAG in diabetic versus non-diabetic patients. Methods: In this retrospective study, we investigated short- and long-term clinical outcomes of diabetic (n = 256) and non-diabetic (n = 800) patients undergoing CABG with MAG between January 1999 and December 2019 at our institution. Results: Diabetics had a significantly higher EuroScore II (1.37 ± 2.4 vs. 0.88 ± 1.58, p < 0.0001) and underwent significantly less bilateral internal thoracic artery (BITA) grafting (51.95% vs. 67.75%; p < 0.0001) compared to non-diabetics. The incidence of postoperative adverse events, such as pneumonia, stroke, and sepsis, did not differ between the two groups. However, diabetics suffered significantly more often from post-cardiotomy cardiogenic shock, renal failure requiring dialysis, and sternal wound infections over the entire follow-up period. Non-diabetics had a significantly higher median survival time of 19.6 years compared to 14.54 years found in diabetic patients (p < 0.0001). Conclusions: Among patients undergoing MAG, diabetic individuals were found to have a significantly lower overall median survival. This emphasizes the importance of diabetes as a risk factor in choosing individual surgical strategies.

Minimally invasive, sternum-sparing total coronary revascularization in multivessel disease via left anterior mini-thoracotomy (TCRAT) was introduced recently. Intra-aortic balloon occlusion is a conceivable option to avoid manipulation of the ascending aorta, to reduce the risk of stroke and to be able to treat patients with severe calcifications and unfavorable aortic anatomies. Background/Objectives: The aim of our study was to show that the use of the IntraClude^® device, as part of minimally invasive coronary artery bypass grafting (CABG) via left anterior mini-thoracotomy, is feasible. Methods: From May to December 2023, CABG via left anterior mini-thoracotomy on cardiopulmonary bypass and cardioplegic arrest was successfully performed in 20 patients (17 male, 67.6 ± 8.2 (51–82) years). All patients had significant coronary artery disease (three-vessel: n = 6; two-vessel: n = 11; one-vessel: n = 3) with indication for surgical revascularization. The mean EuroScore2 was 2.6. Results: All patients successfully underwent minimally invasive CABG using endo-aortic balloon occlusion. A total of 43 distal anastomoses (2.2 ± 0.6 (1–3) per patient) were performed by using left internal artery mammary (n = 20) and radial artery (n = 14) for grafting the left anterior descending (n = 19), circumflex (n = 15) and right (n = 6) coronary artery. There was no hospital mortality, no stroke, no myocardial infarction or repeat revascularization. A total of 15 out of 20 patients left hospital within 8 days after surgery. Conclusions: TCRAT by using the IntraClude^® device is feasible without compromising surgical principles while avoiding the external manipulation of the ascending aorta. The use of intra-aortic balloon occlusion instead of transthoracic clamps further reduces the invasiveness of the procedure.

Background The benefits of minimally invasive techniques in cardiac surgery remain poorly defined. We evaluated the short- and mid-term outcomes after surgical aortic valve replacement through partial upper versus complete median sternotomy (MS) in a large, German multicenter cohort. Methods A total of 2,929 patients underwent isolated surgical aortic valve replacement via partial upper sternotomy (PUS, n = 1,764) or MS (n = 1,165) at nine participating heart centers between 2016 and 2020. After propensity-score matching, 1,990 patients were eligible for analysis. The primary end point was major adverse cardiac and cerebrovascular events (MACCE), a composite of death, myocardial infarction, and stroke at 30 days and in follow-up, up to 5 years. Secondary end points were acute kidney injury, length of hospital stay, transfusions, deep sternal wound infection, Dressler's syndrome, rehospitalization, and conversion to sternotomy. Results Unadjusted MACCE rates were significantly lower in the PUS group both at 30 days (p = 0.02) and in 5-year follow-up (p = 0.01). However, after propensity-score matching, differences between the groups were no more statistically significant: MACCE rates were 3.9% (PUS) versus 5.4% (MS, p = 0.14) at 30 days, and 9.9 versus 11.3% in 5-year follow-up (p = 0.36). In the minimally invasive group, length of intensive care unit (ICU) stay was shorter (p = 0.03), Dressler's syndrome occurred less frequently (p = 0.006), and the rate of rehospitalization was reduced significantly (p < 0.001). There were 3.8% conversions to full sternotomy. Conclusion In a large, German multicenter cohort, MACCE rates were comparable in surgical aortic valve replacement through partial upper and complete sternotomies. Shorter ICU stay and lower rates of Dressler's syndrome and rehospitalization were in favor of the partial sternotomy group.

Symptoms of papillary fibroelastomas are often related to thromboembolic events but are rarely caused by a mechanical impairment of blood supply by the tumor itself. We describe a case of a papillary fibroelastoma in a 91-year-old female patient leading to a cardiac arrest through intermittent occlusion of the left coronary artery.