Maximilian Vondran

Background: The surgical ablation (SA) of atrial fibrillation (AF) during cardiac surgery is performed in only 8–40% of patients. We performed a subgroup analysis of the 1-year follow-up from the German CArdioSurgEry Atrial Fibrillation (CASE-AF) registry to determine how preoperative sinus rhythm (SR) prior to SA affected the outcomes. Methods: The CASE-AF registry enrolled AF patients scheduled for cardiac surgery with concomitant SA. The in-hospital and one-year follow-up data were collected prospectively and analyzed retrospectively. Results: From September 2016 to August 2020, 964 patients were enrolled in the CASE-AF registry. Among them, 333 patients were in SR immediately before surgery (study cohort). A complete follow-up was achieved for 95.6%. Both the severity of the AF (modified European Heart Rhythm Association symptom classification, p < 0.001) and the frequency of AF symptoms (p = 0.006) were significantly reduced at one year compared to the preoperative baseline. Almost 90 percent of the patients underwent left atrial appendage occlusion (LAAO) during the procedure. The one-year mortality (4.1%) and stroke rates (3.2%) were low. SR was evident in 70.3% of the patients at the one-year follow-up. Conclusions: Patients with AF who have SR at the time of surgery should not be excluded from SA, as it appears to be a safe and effective procedure.

Objectives: We evaluated the effect of preoperative chest computed tomography (CT) screening on the perioperative stroke rate in cardiosurgical patients at risk of aortic calcification. Methods: Between May 2019 and April 2020, 129 patients at risk of aortic calcification underwent non-contrast chest CT screening before their procedure. They were assigned to Group 1 and compared with a historical Group 2, who were treated the previous year without a preoperative CT scan. The primary endpoint was to determine postoperative stroke occurrence. The secondary outcomes were the rate reintubation/tracheostomy, the length of hospital stay, and any change in surgical strategy based on the CT findings. Results: Groups 1 and 2 comprised 129 and 261 patients, respectively. Group 1 had a lower left ventricular ejection fraction, less carotid stenosis, a history of carotid endarterectomy, and a longer cross-clamp time. The surgical strategy was changed for 6 patients in Group 1. Group 1 had a significantly lower stroke rate. No significant differences were observed in reintubation and tracheostomy rates, or length of hospital stay. Lack of CT screening, age, aortic valve surgery, aortic surgery, and rethoracotomy were identified as independent risk factors for a stroke. Conclusions: Preoperative non-contrast chest CT screening of patients at risk of aortic calcification reduces postoperative stroke through adaptation of the surgical approach and should be used routinely in these patients.

We evaluated the feasibility of hybrid percutaneous coronary intervention (PCI) and minimally invasive mitral valve surgery (MIMVS) in patients with concomitant coronary and mitral disease. Of 534 patients who underwent MIMVS at our institution between 2012 and 2018, those with combined mitral and single vessel coronary pathologies who underwent MIMVS and PCI were included. Patients were excluded if they had endocarditis or required emergency procedures. Preprocedural, procedural, and postprocedural data were retrospectively analyzed. In total, 10 patients (median age, 75 years; 7 males) with a median ejection fraction (EF) of 60% were included. Nine patients underwent PCI before and one after MIMVS. The success rate was 100% in both procedures. There were no postoperative myocardial infarctions or strokes. Two patients developed delirium and one required re-thoracotomy for bleeding. The median stay in intensive care and the hospital was 3 and 8 days, respectively. The 30-day survival rate was 100%. A hybrid PCI and MIMVS approach is feasible in patients with mitral valve and single vessel coronary disease. In combined pathologies, the revascularization strategy should be evaluated independent from the mitral valve pathology in the presence of MIMVS expertise. Extension of this recommendation to multivessel disease should be evaluated in future studies.

The left atrial appendage occlusion (LAAO) by endocardial suture is sometimes inadequate and thrombogenic with uncertain electrical competence. Moreover, epicardial LAAO clip placement through the transverse sinus can be technically challenging during minimally invasive atrioventricular valve surgery. Here, we describe our new endoscopic technique via an anterior access pathway in 5 patients with concomitant atrial fibrillation using an epicardial clip device (AtriClip Pro 1 or AtriClip Pro 2, AtriCure, Mason, OH, USA) for LAAO. The LAAO was successful in all patients without residual perfusion and surgical complications. Epicardial LAAO by clip via the anterior access pathway represents a novel and feasible endoscopic technique for minimally invasive atrioventricular valve surgery.

A 72-year old, intubated, and ventilated female patient was admitted to our hospital after out-of-hospital resuscitation after cardiopulmonary resuscitation and typical ST-segment elevation on the electrocardiogram for acute coronary syndrome. Since that morning, the patient had complained of severe chest pain at rest. After admission, the coronary angiography (Panel A, Video 1) revealed a heavy thrombotic burden extending from the left coronary artery (LCA) ostium into the circumflex artery (*). Despite the extreme thrombus burden, the blood flow to the aforementioned coronary segments appeared normal (thrombolysis in myocardial infarction flow grade III). Immediately afterwards, she underwent transoesophageal echocardiography (Panel B, Video 1), which showed a floundering structure (#) originating from the attachment of the anterior papillary muscle in the left ventricle (LV). It prolapsed during systole through the aortic valve well into the aortic root. While the patient was still in the cardiac catheterization laboratory, a bedside heart team, including interventional cardiologists, cardiac surgeons, and anaesthesiologists, decided to perform an emergency surgical thrombectomy, which was immediately done in the cardiac surgery operating theatre. Emergency cardiac surgery revealed a coral-shaped, solid pink structure located ∼3 cm above the aortic valve plane (Panels C and D). One arm of this structure (*) was extending into the LCA, with the rest continuing into the LV towards the anterior papillary muscle of the mitral valve, anchored between the attachments of the primary chords. On postoperative histopathological evaluation, the wholly removed structure presented as fibrin-rich white thrombus. Furthermore, we found the patient also had a persistent foramen ovale (PFO), deep vein thrombosis, and central bilateral pulmonary embolism. In combination with the PFO, the deep vein thrombosis probably led to paradoxical embolism. Postoperative exams for coagulopathies revealed that she had no other anomalies. However, her postoperative course was prolonged by a pulmonary infarction and pneumonia. She was finally discharged home 20 days after surgery under oral anticoagulation.

Background Cardiac myxoma is the most common primary cardiac tumor. Although benign, it can cause life-threatening complications due to embolization. Case Presentation We describe an ST-elevation myocardial infarction (STEMI) involving a giant right atrial myxoma and persisting foramen ovale (PFO) in a 64-year-old male patient and report on emergency percutaneous interventional therapy and subsequent cardiac surgery to remove the right atrial myxoma. Conclusion A right atrial myxoma, combined with a PFO, can cause a STEMI. Therefore, every acute coronary syndrome patient should undergo ultrafast exploratory emergency echocardiography to protect the physician from unpleasant surprises.

Background: Despite excellent data on lowering long-term stroke and all-cause mortality rates, currently, only 25–40% of atrial fibrillation (AF) patients undergo simultaneous surgical ablation therapy (SA) during cardiac surgery. Surgeon’s fear exposing their patients to an additional, unjustified, and disproportionate risk when performing SA in AF patients presenting with sinus rhythm (SR) before surgery. To clarify the influence of preoperative SR before SA for AF, we conducted a subgroup analysis of the German Cardiosurgical Atrial Fibrillation (CASE-AF) register. Methods: Between September 2016 and August 2020, 964 AF patients with an underlying cardiac disease were scheduled for surgery with SA and enrolled in the CASE-AF register. Data prospectively were collected and analyzed retrospectively. We divided the entire cohort into an SR-group (38.2%, N = 368) and an AF-group (61.8%, N = 596), based on preoperative heart rhythm. Results: Over half of the patients were moderately affected by their AF, with no difference between the groups (European Heart Rhythm Association class ≥IIb: SR-group 54.2% versus AF-group 58.5%, P = .238). The AF-group had a higher preoperative EuroSCORE II (4.8 ± 8.0% versus 4.2 ± 6.3%, P = .014). In-hospital mortality (SR-group 0.8% versus AF-group 1.7%, P = .261), major perioperative adverse cardiac and cerebrovascular events (SR-group 2.7% versus AF-group 3.5%, P = .500), and the new pacemaker implantation rate (SR-group 6.0% versus AF-group 5.9%, P = .939) were low and showed and no group difference. Logistic regression analysis showed a protective effect for preoperative SR to perioperative complications in AF patients undergoing SA (odds ratio (OR) 0.72 (95% CI 0.52 - 0.998); P = .0485). Conclusions: Concomitant SA in AF patients presenting in SR before cardiac surgery is safe, has a low perioperative risk profile, and should be carried out with almost no exceptions.

Transcatheter aortic valve-in-valve implantation (VIV) is increasingly being used to successfully treat degenerated surgical aortic valve bioprostheses (SAVs). The new self-expanding transcatheter heart valve Allegra, from New Valve Technology with its special implantation mechanism, has proven its safety and feasibility for patients with degenerated SAVs, but it has never been used in the latest-generation sutureless SAV. To the best of our knowledge, this is the first description of the successful VIV of the Allegra prosthesis into a degenerated sutureless SAV, and the procedure yielded an excellent postinterventional hemodynamic results.

Postinfarction ventricular septal defect (pVSD) due to acute myocardial infarction complicated by cardiogenic shock (CS) is associated with high mortality. The aim of this study was to determine the outcome of primary surgical repair of pVSD in patients with CS and examine whether it is influenced by the use of mechanical circulatory support (MCS) devices. Between October 1994 and April 2016, primary surgical repair of pVSD complicated by CS was performed in 53 patients. Thirty‐six (68%) were implanted pre‐operatively with an intra‐aortic balloon pump (IABP), 4 (8%) with extracorporeal life support (ECLS), and 13 (24%) received no MCS device. Prospectively collected demographic and perioperative data were analyzed retrospectively. All‐cause, 30‐day mortality rates were analyzed and multivariate analysis was performed to differentiate independent risk factors. No pre‐operatively implanted MCS device was able to improve 30‐day survival, whereas pre‐operatively implanted ECLS tended to have a positive effect (P = .106). The post‐operative need for a MCS device or escalation of MCS invasiveness (IABP upgrade to ECLS) was associated with a higher 30‐day mortality (P = .001) compared with patients without any MCS device or those with pre‐operatively implanted MCS devices. An independent risk factor for 30‐day mortality was the interval between acute myocardial infarction and surgery P = .007). Pre‐operative implantation of ECLS for CS tends to improve the outcome of early primary surgical pVSD repair. The need for a post‐operative MCS device is associated with a worse 30‐day survival after early primary surgical pVSD repair.

Coronary artery perforation secondary to percutaneous coronary intervention (PCI) is a rare, but a potentially life-threatening complication. There is a misconception that cardiac tamponade rarely occurs in patients with prior coronary artery bypass grafting (CABG). We first describe a giant right ventricular intramural hematoma following PCI via a saphenous vein graft to treat a distal stenosis of the right coronary artery, and its successful treatment with redo cardiac surgery. Complex elective PCIs on patients after CABG should be performed in specialized centers with a well-established heart team that has the expertise to treat any of the potential complications.