Showing papers by "Volkmar Falk published in 2011"

Comprehensive assessment of frailty for elderly high-risk patients undergoing cardiac surgery

Abstract: Objective Cardiosurgical operative risk can be assessed using the logistic European system for cardiac operative risk evaluation (EuroSCORE) and the Society of Thoracic Surgeons (STS) score. Factors other than medical diagnoses and laboratory values such as the 'biological age' are not included in these scores. The aim of the study was to evaluate an additional assessment of frailty in routine cardiac surgical practice. Methods 'The comprehensive assessment of frailty' test was applied to 400 patients≥74 years who were admitted to our centre between September 2008 and January 2010. For comparison, the STS score and the EuroSCORE were calculated. The primary end point was the correlation of Frailty score to 30-day mortality. A total of 206 female and 194 male patients were included. Results Median Frailty score was 11 [7,15]. Median of logistic EuroSCORE was 8.5% [5.8%; 13.9%]. Median of STS score was 3.3% [2.1%; 5.1%]. There were low-to-moderate albeit significant correlations of Frailty score with STS score and EuroSCORE (p Conclusions The comprehensive assessment of frailty is an additional tool to evaluate elderly patients adequately before cardiac surgical interventions. The Frailty score combines characteristics of the Fried criteria [1], of patient phenotype, of his physical performance and laboratory results. Further analysis on a larger patient population is warranted. A combination of the new Frailty score and the traditional scoring systems may facilitate a more accurate risk scoring in elderly high-risk patients scheduled for conventional cardiac surgery or trans-catheter aortic valve replacement.

Minimally invasive versus conventional open mitral valve surgery: a meta-analysis and systematic review.

Abstract: ObjectiveThis meta-analysis sought to determine whether minimally invasive mitral valve surgery (mini-MVS) improves clinical outcomes and resource utilization compared with conventional open mitral...

Adenosine stress high-pitch 128-slice dual-source myocardial computed tomography perfusion for imaging of reversible myocardial ischemia: comparison with magnetic resonance imaging.

Abstract: Background— Coronary computed tomography angiography (CTA) enables accurate anatomic evaluation of coronary artery stenosis but lacks information about hemodynamic significance. The aim of this study was to evaluate 128-slice myocardial CT perfusion (CTP) imaging with adenosine stress using a high-pitch mode, in comparison with cardiac MRI (CMR). Methods and Results— Thirty-nine patients with intermediate to high coronary risk profile underwent adenosine stress 128-slice dual source CTP (128×0.6 mm, 0.28 seconds). Among those, 30 patients (64±10 years, 6% women) also underwent adenosine stress CMR (1.5T). The 2-step CTP protocol consisted of (1) adenosine stress-CTP using a high-pitch factor (3.4) ECG-synchronized spiral mode and (2) rest-CTP/coronary-CTA using either high-pitch (heart rate 63 bpm). Results were compared with CMR and with invasive angiography in 25 patients. The performance of stress-CTP for detection of myocardial perfusion defects compared with CMR was sensitivity, 96%; specificity, 88%; positive predictive value (PPV), 93%; negative predictive value (NPV), 94% (per vessel); and sensitivity, 78%; specificity, 87%; PPV, 83%; NPV, 84% (per segment). The accuracy of stress-CTP for imaging of reversible ischemia compared with CMR was sensitivity, 95%; specificity, 96%; PPV, 95%; and NPV, 96% (per vessel). In 25 patients who underwent invasive angiography, the accuracy of CTA for detection of stenosis >70% was (per segment): sensitivity, 96%; specificity, 88%; PPV, 67%; and NPV, 98.9%. The accuracy improved from 84% to 95% after adding stress CTP to CTA. Radiation exposure of the entire stress/rest CT protocol was only 2.5 mSv. Conclusions— Adenosine-induced stress 128-slice dual-source high-pitch myocardial CTP allows for simultaneously assessment of reversible myocardial ischemia and coronary stenosis, with good diagnostic accuracy as compared with CMR and invasive angiography, at a very low radiation exposure.

Minimally Invasive versus Open Mitral Valve Surgery a Consensus Statement of the International Society of Minimally Invasive Coronary Surgery (ISMICS) 2010

Abstract: ObjectiveThe purpose of this consensus conference was to deliberate the evidence regarding whether minimally invasive mitral valve surgery via thoracotomy improves clinical and resource outcomes co...

Injectable living marrow stromal cell-based autologous tissue engineered heart valves: first experiences with a one-step intervention in primates

Abstract: Aims A living heart valve with regeneration capacity based on autologous cells and minimally invasive implantation technology would represent a substantial improvement upon contemporary heart valve prostheses. This study investigates the feasibility of injectable, marrow stromal cell-based, autologous, living tissue engineered heart valves (TEHV) generated and implanted in a one-step intervention in non-human primates. Methods and results Trileaflet heart valves were fabricated from non-woven biodegradable synthetic composite scaffolds and integrated into self-expanding nitinol stents. During the same intervention autologous bone marrow-derived mononuclear cells were harvested, seeded onto the scaffold matrix, and implanted transapically as pulmonary valve replacements into non-human primates ( n = 6). The transapical implantations were successful in all animals and the overall procedure time from cell harvest to TEHV implantation was 118 ± 17 min. In vivo functionality assessed by echocardiography revealed preserved valvular structures and adequate functionality up to 4 weeks post implantation. Substantial cellular remodelling and in-growth into the scaffold materials resulted in layered, endothelialized tissues as visualized by histology and immunohistochemistry. Biomechanical analysis showed non-linear stress–strain curves of the leaflets, indicating replacement of the initial biodegradable matrix by living tissue. Conclusion Here, we provide a novel concept demonstrating that heart valve tissue engineering based on a minimally invasive technique for both cell harvest and valve delivery as a one-step intervention is feasible in non-human primates. This innovative approach may overcome the limitations of contemporary surgical and interventional bioprosthetic heart valve prostheses.

One-year follow-up of patients undergoing elective cardiac surgery assessed with the Comprehensive Assessment of Frailty test and its simplified form.

Abstract: Assessment of perioperative risk of elderly patients in cardiac surgery is demanding. Most of the commonly used cardiac surgery risk scores over-or underestimate individual risk. Therefore, we recently developed a 'frailty score', the comprehensive assessment of frailty (CAF) score that showed a good prediction of 30-day mortality. The aim of the study was to evaluate the ability of the new score predicting one-year outcome. CAF was preoperatively applied to 400 patients ≥ 74 years that were admitted to cardiac surgery between September 2008 and January 2010. For 213 of these patients one-year follow-up was assessed by telephone interview until April 2010. One hundred and ten male and 103 female patients were included. Twenty-five percent underwent isolated coronary revascularization, 35% isolated valve procedures and 26% underwent combined procedures. One-year mortality was 12.2%. Patients who died within one year had a median frailty score of 16 [5;33] compared to 11 [3;33] to the one-year survivors (P=0.001). A new, easily applicable score ('Frailty predicts death One yeaR after Elective Cardiac Surgery Test') was built out of the basic score and showed a promising ability to predict one-year mortality. CAF is a new additional tool to assess prognosis of elderly patients before cardiac surgical interventions. The 'CAF' score facilitates prediction of mid-term outcome of high-risk elderly patients.

Transapical aortic valve implantation with a self-expanding anatomically oriented valve

Abstract: Aims The Medtronic Engager™ aortic valve bioprosthesis is a self-expanding valve with support arms facilitating anatomically correct positioning and axial fixation. Valve leaflets, made of bovine pericardium, are mounted on a Nitinol frame. Here, we report the first in man study with this new implant (Trial Identifier [NCT00677638][1]). Methods and results Thirty patients (mean age 83.4 ± 3.8 years; 83% female) with tricuspid aortic valve stenosis were included in the study. Mean logistic EuroSCORE was 23.4 ± 11.9. Mean aortic annulus diameter was 21.8 ± 1.4 mm. For this study, the Engager was available in only one size (23 mm), to fit aortic annuli of 19–23 mm. Standard transapical valve implantation was performed using predilation of the aortic valve and rapid ventricular pacing during ballon valvuloplasty and most valve deployments. Accurate valve placement was achieved in 29/30 cases (97%). Post-implant peak-to-peak gradient was 13.3 ± 9.3 mmHg. In 80% of the patients, no more than grade I paravalvular leakage was observed, in 13% grades I–II and in 3% grade II. Three patients (10%) required permanent pacemaker implantation for higher-degree or complete atrioventricular block. Four dissections (13%) occurred during positioning of the valve and were treated surgically in three cases. Thirty-day and in-hospital mortality were 20% and 23%, respectively, and 6-month survival was 56.7%. No structural failure occurred for up to 1 year. Conclusion This series established the feasibility of implanting a novel self-expanding transapical aortic valve prosthesis predictably into an anatomically correct position. Observed complications led to complete redesign of the delivery system for upcoming clinical studies with the goal of establishing safety and performance. [1]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT00677638&atom=%2Fehj%2F32%2F7%2F878.atom

High-pitch dual-source CT angiography of the aortic valve-aortic root complex without ECG-synchronization.

Abstract: To compare image quality and radiation dose of high-pitch computed tomography angiography(CTA) of the aortic valve-aortic root complex with and without prospective ECG-gating compared to a retrospectively ECG-gated standard-pitch acquisition. 120 patients(mean age 68 ± 13 years) were examined using a 128-slice dual-source CT system using prospectively ECG-gated high-pitch(group A; n = 40), non-ECG-gated high-pitch(group B; n = 40) or retrospectively ECG-gated standard-pitch(C; n = 40) acquisition techniques. Image quality of the aortic root, valve and ascending aorta including the coronary ostia was assessed by two independent readers. Image noise was measured, radiation dose estimates were calculated. Interobserver agreement was good(κ = 0.64–0.78). Image quality was diagnostic in 38/40 patients(group A), 37/40(B) and 38/40(C) with no significant difference in number of patients with diagnostic image quality among all groups (p = 0.56). Significantly more patients showed excellent image quality in group A compared to groups B and C(each, p < 0.01). Average image noise was significantly different between all groups(p < 0.05). Mean radiation dose estimates in groups A and B(each; 2.4 ± 0.3 mSv) were significantly lower compared to group C(17.5 ± 4.4 mSv; p < 0.01). High-pitch dual-source CTA provides diagnostic image quality of the aortic valve-aortic root complex even without ECG-gating at 86% less radiation dose when compared to a standard-pitch ECG-gated acquisition.

Is off-pump superior to conventional coronary artery bypass grafting in diabetic patients with multivessel disease?

Abstract: Objective: Diabetic patients often present with diffuse coronary disease than nondiabetic patients posing a greater surgical challenge during off-pump revascularization. In this study, the safety, feasibility, and completeness of revascularization for this subset of patients was assessed. Methods: From 2002 to 2008, 1015 diabetic patients underwent myocardial revascularization. Patients received either off-pump coronary artery bypass (OPCAB; n = 540; 53%) or coronary artery bypass grafting (CABG; n = 475; 47%). Data collection was performed prospectively and data analysis was done by propensity-score (PS)-adjusted regression analysis. Primary endpoints were mortality, major adverse cardiac and cerebrovascular events (MACCEs), and a composite endpoint including major noncardiac adverse events (MNCAEs) such as respiratory failure, renal failure, and rethoracotomy for bleeding was applied. An index of complete revascularization (ICOR) was defined to assess complete revascularization by dividing the total number of distal anastomoses by the number of diseased vessels. Complete revascularization was assumed when ICOR was >1. Results: OPCAB patients had a significantly lower mortality-rate (1.1% vs 3.8%; propensity-adjusted odds ratio (PAOR) = 0.11; p = 0.018) and displayed less frequent MACCE (8.3% vs 17.9%; PAOR = 0.66; p = 0.07) including myocardial infarction (1.3% vs 3.2%; PAOR = 0.33; p = 0.06) and stroke (0.7% vs 2.3%; PAOR = 0.28; p = 0.13). Similarly, a significantly lower occurrence of the noncardiac composite endpoint (MNCAE) (PAOR = 0.46; confidence interval (CI) 95% 0.35—0.91; p 1was achieved clearly indicating complete revascularization (94.3% vs 93.7%; p = 0.24). Conclusions: OPCAB offers a lower mortality and superior postoperativeoutcomesindiabeticpatientswithmultivesseldisease.Arterialgraftsareusedmorefrequentlythatmaycontributetobetterlong

Computed tomography of the lung in the high-pitch mode: is breath holding still required?

Abstract: OBJECTIVES:: To prospectively investigate whether the high-pitch mode (HPM) for computed tomography (CT) enables the diagnostic visualization of the lung parenchyma without suspended respiration. MATERIALS AND METHODS:: A total of 40 consecutive patients (age, 67 ± 11 years) underwent 128-slice dual-source CT of the chest including nonenhanced, arterial, and venous phase of contrast. CT was performed in the HPM with a pitch of 3.2 during continuous breathing (group A) and during breath-hold (group B), and at standard pitch of 1 during deep-inspiratory breath-hold (group C). The 3 protocols were scanned in a random order in each patient. Two blinded readers independently assessed the image quality of 5 regions in both the lungs using a semiquantitative 3-point score. Image noise was measured as the standard deviation of attenuation. Presence and size of pulmonary nodules were noted and measured on each CT dataset. Lung volume was measured using dedicated semi-automated segmentation software. RESULTS:: Interobserver agreement for image quality ratings was excellent (κ = 0.91). There were no significant differences in the number of lung regions having an image quality other than excellent between group A (2.5%) and B (1.5%, P = 0.48), whereas significantly less regions had impaired image quality in group B compared with group C (5.5%, P < 0.01). Image quality impairment in group C was because of breathing in 36% and cardiac pulsation in 64%. Image noise in group C (9 ± 2 HU) was significantly lower than that in group B (30 ± 2 HU, P < 0.001) whereas no significant difference was found between group A and B (P = 0.52). There were no significant differences for the depiction (P = 1.0) and size (P = 0.94) of lung nodules among the 3 modes. Average lung volume in group A was 75% ± 15% of that in deep inspiration (group B/C) being significantly smaller (P < 0.05). Estimated effective radiation doses in group C and group B were 5.8 ± 0.5 mSv and 1.6 ± 0.1 mSv, respectively. CONCLUSIONS:: CT of the lung can be accomplished using the HPM at a low radiation dose with a diagnostic image quality even without suspended respiration.

Extracorporeal membrane oxygenation for acute respiratory distress syndrome: is the configuration mode an important predictor for the outcome?

Abstract: Extracorporeal membrane oxygenation (ECMO) is increasingly applied as rescue-therapy for patients with severe acute respiratory distress syndrome (ARDS) Here, we evaluate the effect of different configuration strategies (venovenous vs venoarterial vs veno-venoarterial) on the outcome From 2006 to 2008, 30 patients received ECMO for severe ARDS Patients were divided into three groups according to the configuration: veno-venous (vv; n = 11), venoarterial (va; n=8) or veno-venoarterial (vva; n = 11) Data were prospectively collected and endpoint was 30-day mortality To identify independent risk factors, univariate analysis was performed for clinical parameters, such as age, body mass index, gender, configuration, low-pH, oxygenation index (pO(2)/FiO(2)) and underlying disease Thirty-day mortality was 53% (n = 16) for all comers: 63% (n = 7) died in the vv-group, 75% (n = 6) in the va-group and 27% (n = 3) in the vva-group Although univariate analysis could not rule out a significant predictor for the outcome, there was a trend visible to decreased mortality in the vva-group when compared to vv- and va-groups (27% vs 63% vs 75%; P = 0057) ECMO provides a survival benefit in patients when considering a predicted mortality rate of 80% in ARDS The configuration mode appears to impact the outcome as the veno-venoarterial appears to further improve the survival in this subset of patients

Institutional report - Assisted circulation Extracorporeal membrane oxygenation for acute respiratory distress syndrome: is the configuration mode an important predictor for the outcome?

Abstract: Extracorporeal membrane oxygenation (ECMO) is increasingly applied as rescue-therapy for patients with severe acute respiratory distress syndrome (ARDS). Here, we evaluate the effect of different configuration strategies (venovenous vs. venoarterial vs. veno-venoarterial) on the outcome. From 2006 to 2008, 30 patients received ECMO for severe ARDS. Patients were divided into three groups according to the configuration: veno-venous (vv; ns11), venoarterial (va; ns8) or veno-venoarterial (vva; ns11). Data were prospectively collected and endpoint was 30-day mortality. To identify independent risk factors, univariate analysis was performed for clinical parameters, such as age, body mass index, gender, configuration, low-pH, oxygenation index (pO yFiO ) and underlying disease. Thirty-day mortality was 53% (ns16) 22 for all comers: 63% (ns7) died in the vv-group, 75% (ns6) in the va-group and 27% (ns3) in the vva-group. Although univariate analysis could not rule out a significant predictor for the outcome, there was a trend visible to decreased mortality in the vva-group when compared to vv- and va-groups (27% vs. 63% vs. 75%; Ps0.057). ECMO provides a survival benefit in patients when considering a predicted mortality rate of 80% in ARDS. The configuration mode appears to impact the outcome as the veno-venoarterial appears to further improve the survival in this subset of patients. 2011 Published by European Association for Cardio-Thoracic Surgery. All rights reserved.

How good patient blood management leads to excellent outcomes in Jehovah's witness patients undergoing cardiac surgery.

Abstract: Objectives The refusal of blood products makes open-heart surgery in Jehovah's witnesses (JW) an ethical challenge. We demonstrate how patient blood management strategies lead to excellent surgical outcomes. Methods From 2003 to 2008, 16 JW underwent cardiac surgery at our institution. Only senior surgeons performed coronary revascularization (n=6), valve (n=6), combined (n=1) and aortic surgery (n=3) of which two patients presented with acute type-A dissection. Off-pump surgery remained the method of choice for patients requiring a bypass procedure (n=5). Preoperative hematocrit (Hk) and hemoglobin (Hb) were 42.8±4.7% and 14.5±2 g/dl. In three patients with an Hb Results All patients survived, no major complications occurred and no blood transfusion was administered. The Cell Saver® system (transfused volume: 474±101 ml) and synthetic plasma substitutes [Ringer's Lactate: 873±367 ml and hydroxyethyl starch (HES) 6%: 700±388 ml] were used routinely as well as hemostaticas, such as bone wax, and fibrin glue. The decrease of Hk and Hb appeared to be the lowest after off-pump surgery when compared to all other procedures requiring cardiopulmonary bypass (CPB) (25±9% vs. 33±6%; P=0.01 and 22±9% vs. 31±6%; P=0.04). Similarly, the decrease of platelets was significantly lower (20±12% vs. 43±14%; P=0.01). In the follow-up period (52±34 months), one patient died due to a non-cardiac reason, whereas all others were alive, in good clinical condition and did not have major adverse cardiac events (MACE) or recurrent symptoms requiring re-intervention. Conclusion Patient blood management leads to excellent short- and long-term outcomes in JW. Combined efforts in regard to preoperative hematological parameter optimization, effective volume management and meticulous surgical techniques make this possible but raise the cautionary note why this is only possible in JW patients.

EH-myomesin splice isoform is a novel marker for dilated cardiomyopathy.

Abstract: The M-band is the prominent cytoskeletal structure that cross-links the myosin and titin filaments in the middle of the sarcomere. To investigate M-band alterations in heart disease, we analyzed the expression of its main components, proteins of the myomesin family, in mouse and human cardiomyopathy. Cardiac function was assessed by echocardiography and compared to the expression pattern of myomesins evaluated with RT-PCR, Western blot, and immunofluorescent analysis. Disease progression in transgenic mouse models for dilated cardiomyopathy (DCM) was accompanied by specific M-band alterations. The dominant splice isoform in the embryonic heart, EH-myomesin, was strongly up-regulated in the failing heart and correlated with a decrease in cardiac function (R = −0.86). In addition, we have analyzed the expressions of myomesins in human myocardial biopsies (N = 40) obtained from DCM patients, DCM patients supported by a left ventricular assist device (LVAD), hypertrophic cardiomyopathy (HCM) patients and controls. Quantitative RT-PCR revealed that the EH-myomesin isoform was up-regulated 41-fold (P < 0.001) in the DCM patients compared to control patients. In DCM hearts supported by a LVAD and HCM hearts, the EH-myomesin expression was comparable to controls. Immunofluorescent analyses indicate that EH-myomesin was enhanced in a cell-specific manner, leading to a higher heterogeneity of the myocytes’ cytoskeleton through the myocardial wall. We suggest that the up-regulation of EH-myomesin denotes an adaptive remodeling of the sarcomere cytoskeleton in the dilated heart and might serve as a marker for DCM in mouse and human myocardium.

Transapical aortic implantation of autologous marrow stromal cell-based tissue-engineered heart valves: first experiences in the systemic circulation.

Abstract: Within 1 procedure, tissue-engineered, living heart valves (TEHVs), fabricated from biodegradable scaffolds seeded with autologous bone marrow–derived mononuclear cells ([Fig. 1][1]A), were integrated into self-expanding nitinol stents (20 mm × 30 mm) and transapically delivered into the

Prediction of the annuloplasty ring size in patients undergoing mitral valve repair using real-time three-dimensional transoesophageal echocardiography.

Abstract: Aims We sought to investigate the additional value of real-time three-dimensional transoesophageal echocardiography (RT 3D TOE)-guided sizing for predicting annuloplasty ring size during mitral valve repair. Methods and results In 53 patients undergoing elective mitral valve repair, an RT 3D TOE was performed pre- and post-operatively. The digitally stored loops were imported into a software for mitral valve assessment. The annuloplasty ring size was predicted by superimposing computer-aided design (CAD) models of annuloplasty rings onto Live 3D zoom loops, measurement of the intercommissural distance, or the height of the anterior mitral leaflet. The surgeon implanted the annuloplasty ring according to the usual surgical technique and was blinded to the echocardiographic measurement results. Pre-operative correlation between the selected ring size with mitral valve assessment and the actual implanted annuloplasty ring size was 0.91. The correlation for measurement of the intercommissural distance was 0.55 and for measurement of the height of the anterior mitral leaflet 0.75. The post-operative correlation with the actual implanted ring size was 0.96 for mitral valve assessment, 0.92 for intercommissural distance, and 0.79 for the anterior mitral leaflet height. Conclusion Superimposition of annuloplasty ring CAD models on the Live 3D zoom loops of the mitral valve using mitral valve assessment is superior to two-dimensional measurements of the intercommissural distance or the height of the anterior mitral leaflet in predicting correct annuloplasty ring size.

Beating-heart implantation of adjustable length mitral valve chordae: acute and chronic experience in an animal model.

Abstract: Objective: This study aimed to determine the acute and chronic performance of a new system designed to conduct beating-heart implantation and off-pump adjustment of neochordal length.Methods:In 14 adult sheep(group A) selectedto undergo beating-heart cardiopulmonary bypass, the left atrium was opened through a left thoracotomy. Two or more primary chordae in the A2 region were severed to produce a model of a flail leaflet. A chordal adjustment mechanism (V-Chordal, Valtech Cardio Ltd., Or-Yehuda, Israel) was affixed to the head of the papillary muscle. The systemincludestwoadjustableneochordae.Thedistalendoftheneochordaewassuturedtotheflailsegmentwithoutestimatingtheappropriate length. The neochordal length was adjusted off-pump under real-time echo-guidance. The adjustment tool was removed and the atriotomy was closedwitha purse-stringsuture.Controlanimals(groupB,n = 4)wereimplantedwiththeconventionalneochordae.Animalsinbothgroupswere sacrificed 3 months after the procedure. Results: In both groups, prior to repair, mitral regurgitation (MR) was severe in all animals. In group A, following adjustment of neochordae, MR was absent in all animals, with the exception of two animals that had residual 2+ MR irresponsive to neochordae adjustments. In group B, MR was 2+ in two of the four animals following repair. At 3 months, mitral competence was stable in all animals. At necropsy, normal healing of the papillary head and leaflet was observed in both the groups. Conclusions: The V-Chordal system simplifies the process of neochordal implantation and precise off-pump adjustment of the neochordal length to correct MRoccurring due to a flail leaflet. This technology may improve the technical feasibility for adoption of chordal repair during open or minimally invasive surgical procedures.

NICE guidance for off-pump CABG: turn off the pump

Abstract: Over the last 20 years, off-pump coronary artery bypass surgery (OPCAB) has evolved as a standard technique for surgical myocardial revascularisation, and although it is used routinely in many centres around the world, there is still debate over its safety and efficacy Proponents point to extensive research demonstrating superior outcomes in terms of death, stroke, myocardial infarction, intraoperative blood loss and need for transfusion, with benefits particularly magnified in high-risk groups of patients In stark contrast, critics of OPCAB surgery claim that it has no benefit on clinical outcome and is accompanied by a tendency for incomplete revascularisation and inferior bypass graft patency rates Consequently, while OPCAB is performed in up to 90% of patients in some Asian countries, in Europe, the rate varies between 10% and 30% The performance among individual surgeons and centres is very heterogeneous, ranging from a zero to 95% penetration rate While in some centres OPCAB is already the default approach for all patients requiring surgical coronary revascularisation, in some, it is reserved for ‘high-risk’ patients only Apart from the obvious problem of defining high risk, which in the context of coronary surgery may refer to the haemodynamic status of the patient, the severity of coronary disease, the impairment of cardiac function, urgency and the presence of comorbidities, the various approaches to the use of OPCAB reveal a fundamental ‘application bias’ This year, the National Institute for Health and Clinical Excellence (NICE) has issued an updated Interventional Procedure Guidance on Off-Pump Coronary Artery Bypass (IPG 377) that replaces the 2004 version (IPG 35) Specifically, the 2011 NICE review “was precipitated by recent evidence of higher graft occlusion rates in the longer term after off-pump CABG” Based on a “thorough literature review including approximately 531 000 patients” and an expert hearing, NICE concluded that “current evidence on the …

Live broadcasting in cardiac surgery does not increase the operative risk.

Abstract: Objective: Live broadcasting of cardiac surgical procedures has an educational intention. There is an ongoing debate whether live surgery increases risk. Aim of this study was to evaluate the outcomes of patients who underwent a cardiac surgical procedure during live broadcasting. Methods: A total of 250 cardiac operations were performed during 32 live broadcastings at four different clinical sites between 1999 and 2009. Data on patient characteristics, intra-operative procedures and patient short- and long-term outcome were collected and analyzed. All participating centers complied with the rules for the conduct of live surgery developed by the European Association of Cardiovascular and Thoracic Surgery (EACTS) Techno College Committee. Results: Primary educational focus was the mitral valve in 126 cases, aortic valve including transcatheter valve implantations in 34, coronary artery bypass grafting (CABG) in 29, congenital in 26, aortic (ascending, arch, and descending) in 15, atrial fibrillation in 13, and heart failure in seven. Mean EuroSCORE (European System for Cardiac Operative Risk Evaluation) was 8.7 11.5 (range: 0.8—72). Thirty-day mortality was 1.2% (3/250): reasons for death were multi-organ failure in two and respiratory failure in one patient, respectively. Stroke rate was 2.4% (6/250). Five patients (2%) required cardiac re-operations within 30 days. The rate of mitral valve repair was 96% (121) and compares favourably with repair rates presented in national registries. Mean follow-up of all patients was 3.7 2.8 years with an estimated survival of 92% (95% confidence interval (CI): 87—95%) at 5 years. Conclusions: Based on this large experience there is no evidence for an excess perioperative risk for patients operated under the conditions of live broadcasting. # 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Image-guided Transapical Aortic Valve Implantation: Sensorless Tracking of Stenotic Valve Landmarks in Live Fluoroscopic Images

Abstract: ObjectiveAortic valve stenosis is one of the most frequently acquired valvular heart diseases, accounting for almost 70% of valvular cardiac surgery. Transapical transcatheter aortic valve implanta...

Aortic valve prosthesis tracking for transapical aortic valve implantation.

Abstract: Purpose Transapical aortic valve implantation (TA-AVI) is a new minimally invasive surgical treatment of aortic stenosis for high-risk patients. The placement of aortic valve prosthesis (AVP) is performed under 2D X-ray fluoroscopic guidance. Difficult clinical complications can arise if the implanted valve is misplaced. Therefore, we present a method to track the AVP in 2D X-ray fluoroscopic images in order to improve the accuracy of the TA-AVI.

Model-updated image-guided minimally invasive off-pump transcatheter aortic valve implantation

Abstract: This paper presents a method for assisting the placement of stented aortic valve prosthesis during minimally invasive off-pump transcatheter aortic valve implantation (TAVI) under live 2-D X-ray fluoroscopy guidance. The proposed method includes a dynamic overlay of an intra-operative 3-D aortic root mesh model and an estimated target area of valve implantation onto live 2- D fluoroscopic images. This is based on a template-based tracking procedure of a pigtail catheter without further injections of contrast agent. Minimal userinteraction is required to initialize the algorithm and to correct fluoroscopy overlay errors if needed. Retrospective experiments were carried out on ten patient datasets from the clinical routine of the TAVI. The mean displacement errors of the updated aortic root mesh model overlays are less than 2.0 mm without manual overlay corrections. The results show that the guidance performance of live 2-D fluoroscopy is potentially improved when using our proposed method for the TAVIs.

3D fusion of functional cardiac magnetic resonance imaging and computed tomography coronary angiography: accuracy and added clinical value

Abstract: PURPOSE:: To evaluate the accuracy and added diagnostic value of 3-dimensional (3D) image fusion of computed tomography coronary angiography (CTCA) and functional cardiac magnetic resonance (CMR) for assessing hemodynamically relevant coronary artery disease (CAD). METHODS:: Twenty-seven patients with significant coronary stenoses on prospectively electrocardiography-gated dual-source CTCA, confirmed by catheter angiography and perfusion defects on CMR at 1.5 T were included. Surface representations and volume-rendered images from 3D-fused CTCA/CMR data were generated using a software prototype. Fusion accuracy was evaluated by calculating surface distances of blood pools and Dice similarity coefficients. Two independent, blinded readers assigned myocardial defects to culprit coronary arteries with side-by side analysis of CTCA and CMR and using fused CTCA/CMR. Added value of fused CTCA/CMR was defined as change in assignment of culprit coronary artery to myocardial defect compared with side-by-side analysis. RESULTS:: 3D fusion of CTCA/CMR was feasible and accurate (surface distance of blood pools: 4.1 ± 1.3 mm, range: 2.4-7.1 mm; Dice similarity coefficients: 0.78 ± 0.08, range: 0.51-0.86) in all patients. Side-by-side analysis of CTCA and CMR allowed no assignment of a single culprit artery to a myocardial defect in 6 of 27 (22%) patients. Fused CTCA/CMR allowed further confinement of culprit coronary arteries in 3 of these 6 patients (11%). Myocardial defects were reassigned in 2 of 27 (7%) patients using fused CTCA/CMR, whereas the results remained unchanged in 22 of 27 (81%) patients. Interobserver agreement for assignment of culprit arteries to myocardial defects increased with fused CTCA/CMR (k = 0.66-0.89). CONCLUSION:: 3D fusion of low-dose CTCA and functional CMR is feasible and accurate, and adds, at a low radiation dose, diagnostic value for the assessment of hemodynamically relevant CAD as compared with side-by-side analysis alone. This technique can be clinically useful for the following: planning of surgical or interventional procedures in patients having a high prevalence of CAD and for improved topographic assignment of coronary stenoses to corresponding myocardial perfusion defects.

Cubic hermite bezier spline based reconstruction of implanted aortic valve stents from CT images

Abstract: Mechanical forces and strain induced by tran-scatheter aortic valve implantation are usually named as origins for postoperative left ventricular arrhythmia associated with the technique. No quantitative data has been published so far to substantiate this common belief. As a first step towards quantitative analysis of the biomechanic situation at the aortic root after transapical aortic valve implantation, we present a spline-based method for reconstruction of the implanted stent from CT images and for locally measuring the deformation of the stent.