Introduction: The aim of this study was to report the clinical implementation of the joint use of the Myocardial Protection System (MPS®) and the minimal extracorporeal circulation system (MiECC), in conjunction with an institutionally refined dose/volume-dependent microplegia in coronary artery bypass grafting (CABG). Methods: Patients with isolated CABG surgery were included. The final protocol to achieve cardioplegic arrest consisted of warm blood cardioplegia with 20 mmol potassium (K), 1.6 g magnesium (Mg) and 40 mg lidocaine per liter (L) blood. We prospectively collected intra- and postoperative data to monitor and validate this novel approach. Results: Eighty patients were operated accordingly. Mean (SD) aortic clamping time and extracorporeal perfusion time were 67.5 (22.6) and 101.1 (31.9) minutes, respectively. Failure to induce cardiac arrest was seen in six patients at the early stage of refinement of the formula. Median (IQR) high-sensitivity cardiac troponin T (hs-cTnT) on the first postoperative day (POD) and peak hs-cTnT were 262.5 ng/L (194.3–405.8) and 265.5 ng/L (194.3–405.8), respectively. Median (IQR) creatine kinase-myocardial type (CK-MB) on POD 1 and peak CK-MB were 14.2 µg/L (10.5–22.7) and 14.2 µg/L (10.7-23.2), respectively. Median (IQR) creatine kinase (CK) on POD 1 and peak CK were 517.5 U/L (389.3-849.8) and 597.5 U/L (455.0-943.0), respectively. No patient died during hospitalization. Conclusions: The combination of this cardioplegic formula with MPS® and MiECC in CABG was safe and feasible. With the final chemical makeup, cardiac arrest was reliably achieved. Remarkably low postoperative cardiac markers indicate shielded cardiac protection during surgery.

We report our experience with a low-volume (100 mL), single-shot crystalloid cardioplegia (Cardioplexol) in 61 consecutive patients undergoing isolated aortic valve replacement (AVR). Cardioplexol resulted in immediate cardiac arrest. Intraoperative courses were uneventful. Postoperative markers of myocardial damage, Troponin T and CK-MB levels, were low but steadily increased with longer cross-clamp time. Thirty-day mortality was 3% and all noncardiac. Cardioplexol not only simplifies and speeds up the procedure but also seems to be safe for patients undergoing AVR.

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Background In Switzerland, long-term circulatory support programs have been limited to heart transplant centers. In 2014, to improve the management of patients with end-stage heart failure not eligible for transplantation, we implemented a left ventricular assist device (LVAD) program for destination therapy at the University Hospital of Basel. Methods We described the program set-up with practical aspects. Patients aged 65 and above with therapy refractory end-stage heart failure without major contraindication for LVAD implantation were included. Younger patients with bridge-to-candidacy profile were also considered. Using the Kaplan-Meier estimate, we retrospectively analyzed the overall survival and freedom from major adverse events after LVAD implantation. We compared our results to internationally reported data. Results Between October 2014 and September 2019, 16 patients received an LVAD in our center. The mean age at implantation was 67.1 years. The mean EuroSCORE II was 24.4% and the median INTERMACS level was 4. Thirteen patients received an LVAD as destination therapy and three patients as bridge-to-candidacy. The overall survival was 87.5 and 70% at 1 and 2 years, respectively. Freedom from stroke was 81.3% at 1 and 2 years. Freedom from device infection was 67.7 and 58.7% at 1 and 2 years, respectively. Freedom from gastrointestinal bleeding was 75 and 56.3% at 1 and 2 years, respectively. Freedom from readmission was 50 and 31.3% and at 6 months and 1 year, respectively. Conclusions The Basel experience demonstrated the possible implementation of an LVAD program for destination therapy or bridge-to-candidacy in a non-transplant comprehensive heart-failure center with midterm survival results and freedom from major adverse events comparable to international registries. Patient selection remains crucial. Trial registration This study was registered on the ClinicalTrials.gov database (NCT04263012).

Background. To compare the performance of our institutionally refined microplegia protocol in conjunction with minimal extracorporeal circulation system (MiECC) with off-pump coronary artery bypass grafting (OPCAB). Methods. We conducted a single center study including patients undergoing isolated CABG surgery performed either off-pump or on-pump using our refined microplegia protocol in conjunction with MiECC. We used propensity modelling to calculate the inverse probability of treatment weights (IPTW). Primary endpoints were peak values of high-sensitivity cardiac troponin T (hs-cTnT) during hospitalization, and respective first values on the first postoperative day. Endpoint analysis was adjusted for intraoperative variables. Results. After IPTW, we could include 278 patients into our analyses, 153 of which had received OPCAB and 125 of which had received microplegia. Standardized differences indicated that treatment groups were comparable after IPTW. The multivariable quantile regression yielded a nonsignificant median increase of first hs-cTnT by 39 ng/L (95% CI -8 to 87 ng/L, p=0.11), and of peak hs-cTnT by 35 ng/L (CI -13 to 84, p=0.16), when microplegia was used, as compared to OPCAB. Major adverse cardiac and cerebrovascular events (MACCE) occurred with equal frequency in both groups (7.8% vs. 5.0%; p=0.51), and length of stay in the intensive care unit (ICU) was significantly shorter after the use of microplegia (geometric mean 1.6 days versus 1.3 days; p=0.01). Conclusion. The use of our institutionally refined microplegia in conjunction with MiECC was associated with similar results with regard to ischemic injury, expressed in hs-cTnT compared to OPCAB. MACCE was seen equally frequent. ICU discharge was earlier if microplegia was used.

I read with great interest the article, "Left Pulmonary Artery Stent Causes Ipsilateral Pulmonary Complication." 1 The author rightly pointed out the culprit: "trapped" and relatively fixed space under the curve of the aorta and the left pulmonary artery. The left recurrent laryngeal nerve travels between the pulmonary artery and aorta. There is only a 4-mm distance between the aorta and pulmonary artery in this aortic window. This anatomy makes the left recurrent laryngeal nerve vulnerable to compressive injury between the aorta and left pulmonary artery. 2 Ortnerʼs syndrome is well described in the literature as caused by compression or traction of this nerve due to cardiovascular diseases (eg, left atrial disorders). 2 Interventional procedures involving patent ductus arteriosus potentially can injure the nerve. 3 Thoracic aortic aneurysm and dissection can cause cardiovocal syndrome by compressing the left recurrent laryngeal nerve. 4 Even endoluminal treatment of a thoracic aortic aneurysm 5 has been reported to cause left vocal cord palsy. Similarly, left pulmonary artery stent in a child also has been reported to cause left recurrent laryngeal nerve palsy causing persistent hoarseness. It is essential to know that any procedure in the vicinity of this subaortic window space potentially can compress the left main bronchus and left recurrent laryngeal nerve.

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Background: Patients refusing blood product transfusion represent a particular cardiac surgery population in which bleedings and hemodilution should be maximally reduced. Case presentation: We present the case of a 60 years old, Jehovah witness patient refusing whole blood transfusion and primary blood components, who required surgery for severe and symptomatic mitral valve regurgitation. To avoid critical bleeding, we performed careful preoperative assessment, documenting coagulation anamnesis and accepted drugs using a standardized form. In case of a bleeding, the anesthesia team was prepared for a proactive and goal-oriented correction of the coagulation using artificial products. Should it be needed, measures to increase anemia tolerance would also have taken place, for example narcosis deepening. The operation was performed in a minimally invasive fashion using a right anterior thoracotomy and video-assistance. The cardiopulmonary bypass was conducted using 3/8 inches venous lines and small-sized oxygenator in order to reduce priming volume. Using a ring anuloplasty and plication of the anterior mitral valve leaflet, mitral valve repair was achieved with no sign of regurgitation or stenosis. The postoperative course was uneventful and the patient was discharged on postoperative day 8 with a hemoglobin level of 109g/l. Conclusion: Patient refusing blood transfusion represent a particular subset of the cardiac surgery population. In order to offer standard of care in such situations, a multidisciplinary, patient-centered concept based on close collaboration between cardiac surgeons, anesthetists and perfusionist is of utmost importance. In this case we, once again, demonstrated the safety and feasibility of minimally invasive mitral valve repair and its usefulness in patients where reduced hemodilution and fast recovery are needed.