In patients 75 years of age or older, there was no significant difference between on-pump and off-pump CABG with regard to the composite outcome of death, stroke, myocardial infarction, repeat revascularization, or new renal-replacement therapy within 30 days and within 12 months after surgery. (Funded by Maquet; GOPCABE ClinicalTrials.gov number, NCT00719667.).

T he benefits of coronary artery bypass grafting (CABG) without cardiopulmonary bypass in the elderly has yet to be determined. Patients 75 years or older who were scheduled for elective first-time CABG were randomly assigned to undergo the procedure either without cardiopulmonary bypass (off-pump CABG) or with it (on-pump CABG). The primary end point was a composite of death, stroke, myocardial infarction, repeat revascularization, or new renal replacement therapy at 30 days and 12 months after surgery. A total of 2539 patients underwent randomization. Thirty days after surgery, there was no marked difference between patients who underwent off-pump surgery and those who underwent on-pump surgery in terms of the composite outcome (7.8% vs 8.2%; odds ratio, 0.95%; 95% confidence interval [CI], 0.71-1.28) or of the components (death, stroke, myocardial infarction, or new renal replacement therapy). Repeat revascularization took place more often after off-pump CABG than after on-pump CABG (1.3% vs 0.4%; odds ratio, 2.42; 95% CI, 1.03-5.72). At 12 months, no between-group difference existed in the composite end point (13.1% vs 14.0%; hazard ratio, 0.93; 95% CI, 0.76-1.16) or in any of the separate components. Similar results were seen in a per-protocol analysis that excluded the 177 patients who crossed over from the assigned treatment to the other treatment. The investigators concluded that in patients 75 years or older, no marked difference existed between on-pump and off-pump CABG regarding the composite outcome of death, stroke, myocardial infarction, repeat revascularization, or new renal replace ment therapy within 30 days and within 12 months after surgery. COMMENTThe on/off bypass debate has been the focus of CABG surgery for more than a decade. Off-pump surgery was performed as an alternative to on-pump surgery to avoid or decrease complications related to cardiopulmonary bypass and/or to avoid manipulation or cross clamping of the aortic root and ascending aorta. With appropriate expertise, this was extended to routine surgery for coronary artery disease. Thus, outcomes from trials in off-pump surgery were comparable to on-pump surgery, particularly from institutions with adequate expertise in this type of procedure. However, there have been increasing reports of inferior graft patency in the short term and intermediate term requiring repeat revascularization associated with off-pump coronary surgery.The current study is a multicenter randomized controlled trial in elderly patients (≥75 years old) undergoing elective first-time CABG, thus targeting a potentially high-risk operative group. The randomization was rather robust; nearly a third of all potentially eligible patients were excluded. Furthermore, the authors showed that patients were not excluded owing to surgical preference for one technique over another. An important inclusion criterion was surgeon expertise, thereby excluding a potential bias toward unfavorable outcomes related to surgical skill.In 2394 elderly patients randomized to on/off-pump...

OBJECTIVES: This study aims to examine the feasibility and clinical course after minimally invasive David procedure compared with those via a conventional median sternotomy. METHODS:One hundred and ninety-two consecutive patients who underwent elective valve-sparing aortic root replacement (David procedure) with or without additional cusp repair for aortic regurgitation (n = 17, 8.9%), dilatation of the aortic root (n = 95, 49.5%) or a combination of both pathologies (n = 80, 41.7%) were included. Patients with systemic disorders, such as Marfan's syndrome, and emergency cases were excluded. Assessment of quality of life was performed by modified Short Form Health Survey (SF-36) questionnaire. To minimize baseline differences, a matched pair analysis was conducted. RESULTS:One hundred and seventeen patients (60.9%) received a minimally invasive hemisternotomy (Group 1), 75 patients a conventional median sternotomy (39.1%, Group 2). Patients of Group 1 were significantly younger (56.5 ± 13.6 vs 64.8 ± 11.6, P < 0.001). Understandably, concomitant cardiac procedures were more frequent in Group 2 (n = 7 [6.0%] vs n = 48 [64.0%], P < 0.001). In hospital, mortality was 0.9% in Group 1 (1/117) and 2.7% in Group 2 (2/75; P = 0.562). Blood loss was significantly less in Group 1 (542.6 ± 441.8 vs 996.7 ± 822.6 ml, P < 0.001). Duration of mechanical ventilation (10.2 ± 21.8 vs 26.9 ± 109.0 h, P < 0.001) and ICU-stay (1.9 ± 3.6 vs 3.2 ± 5.6 days, P < 0.001) were significantly shorter in the minimally invasive group, but this differences did not remain after matching. According to SF-36 questionnaire, patients in the minimally invasive group tend to have a higher quality of life. CONCLUSIONS:Minimally invasive valve-sparing aortic root replacement can be done safely via an upper partial sternotomy in experienced hands even if additional cusp repair is required.

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BackgroundCoronary artery bypass grafting (CABG) on cardiopulmonary bypass (CBP) is associated with significant morbidity and mortality. In high-risk patients, doomed for reoperation the adverse effects of CBP may be more striking. We evaluated the results of reoperative CABG (redo-CABG) by either off-pump (OPCAB) or on-pump (ONCAB). Clinical endpoints were perioperative myocardial infarction, mortality, survival and as the most striking difference between prior studies the quality of life (QoL).MethodsWe performed a prospective, non-randomized assessment for patients who underwent redo-CABG by redo-OPCAB (n = 40) or redo-ONCAB (n = 40) at our institution between January 2007 and December 2010. For evaluation of QoL the SF-36 health survey was used with self-administered assessment.ResultsDuring follow-up 37 of 40 patients were alive in the redo-OPCAB group versus 32 of 40 patients in the redo-ONCAB group (p < 0.05). The shorter operation time, less blood loss, fewer perioperative myocardial infarctions, the higher rate of totally arterial revascularisation and shorter intensive care stay were the significantly beneficial differences for patients in the redo-OPCAB group (p < 0.05). The 3-year survival rate was higher in the redo-OPCAB group with 81 ± 12% versus 63 ± 9%in the redo-ONCAB group. The quality of life survey did not reveal any significant differences between both groups.ConclusionIn conclusion, with our present retrospective study, we could demonstrate the safety and efficacy of the redo-OPCAB technique with even higher 3-year survival rate. Both techniques seem to have similar impact on the outcome of patients.

Hybrid aortic repair using the FET in acute DeBakey type I aortic dissection does not elevate the perioperative risk of mortality and provides excellent aortic remodelling with low distal re-intervention rate in mid-term follow-up.

Objective Median sternotomy is still the standard approach for aortic arch surgery. Minimally invasive techniques promise faster recovery with shorter hospital stay due to thoracic stability, reduced pain, and superior cosmetic results. However, safety is a concern in complex aortic surgery. The aim of our study was to demonstrate that aortic arch surgery via partial upper sternotomy is viable, safe, and equivalent to standard procedure both in terms of its safety and the risk of major adverse cardiac and cerebrovascular events. Methods We interrogated our prospectively collected database and identified a total of 21 nonemergent patients operated on at our center between October 2008 and February 2015. Indication for operation was aneurysmatic disease in 18 and aortic dissection in 3 patients. Data were analyzed for in-hospital mortality, stroke, bleeding complications, and acute kidney injury. Results Mean ± standard deviation age of patients was 69.3 ± 14.4 years, 57.1% were female, and mean ± standard deviation logistic EuroSCORE was 17.0 ± 7.2%. Surgery on the aortic arch comprised proximal arch in 9, hemiarch in 9, and total arch replacement plus frozen elephant trunk in 3 patients. Concomitant procedures included aortic root repair in 10, aortic root replacement in 2, and aortic valve replacement in 3 patients. We lost one patient because of septic shock, no stroke occurred, but a transient neurologic deficit in three and a postoperative delirium in four patients. Re-exploration for bleeding was necessary in two patients, and one patient had acute kidney injury. Conclusions Minimally invasive aortic arch surgery via partial upper sternotomy does not increase the risk of morbidity or mortality. Thus, in experienced hands, it is viable, safe, and therefore favorable and as a result should be offered to more patients.

A 74-year-old woman underwent an abdominal computed tomography scan for work-up of unclear recurring abdominal discomfort because abdominal ultrasound had not been diagnostic on account of a poor acoustic window and obesity (body mass index 31). Computed tomography did not detect any abdominal pathology but revealed an unclear mass located at a left anterior position on the cranial side of the diaphragm, most likely related to the apical portions of the heart (Figure 1). Thus, the patient was referred to our hospital for further cardiological work-up.Interestingly, the patient had been hospitalized twice at intervals of 4 months because of 2 episodes of severe chest pain 28 years previously, but no diagnosis could be made at that time. Routine ECG on admission revealed an abnormal electrical axis as well as high R-wave amplitudes in V2 and V3 (Figure 2). Consequently, additional right ventricular leads were obtained, demonstrating discrete ST-segment elevations (rV1 to rV4) and negative T waves (rV2 to rV6) (Figure 3), indicating possible right ventricular pathology. Because transthoracic echocardiography could not reveal any right ventricular abnormality (Figure 4 and online-only Data Supplement), the patient was referred to cardiovascular magnetic resonance (CMR) imaging (1.5 Tesla "Sonata", Siemens Medical Systems, Erlangen, Germany).Cine images were acquired using fast gradient echo steadystate free precession sequences demonstrating normal global left and right ventricular function (left ventricular ejection fraction 64%, end-diastolic volume 100 mL, right ventricular ejection fraction 67%, and right ventricular end-diastolic volume 99 mL). However, the mass previously seen on computed tomography was also present on CMR images (37ϫ27 mm), originating from the apical region of the right ventricle ( Figure 5 and online-only Data Supplement). Timeresolved gadolinium contrast bolus tracking revealed contrast passage from the right ventricle into the mass (Figure 6 and online-only Data Supplement), which was connected directly to the right ventricular cavity by a thin mouth (5 mm in diameter). Ten minutes after injection of 0.2 mmol/kg gadodiamide, contrast images were obtained using an inversion recovery gradient echo technique (inversion-recovery fast low-angle shot), constantly adjusting inversion time to null normal myocardium. Contrast images showed late gadolinium enhancement in large portions of the mass ( Figure 5). Thus, the diagnosis of apical right ventricular aneurysm was made.Invasive angiography revealed only minor coronary plaque formation without significant stenosis. However, 1 prominent plaque located in the dominant left circumflex artery supplying the infero-apical myocardium might have been the culprit lesion for an apical right ventricular myocardial infarction, explaining the occurrence of the aneurysm as well as the 2 episodes of severe chest pain 28 years previously (Figure 7 and online-only Data Supplement).For further patient management it is important to differentiate false from true ...