Invasive Coronary Artery Bypass Surgery Research Articles

Analysis of the effectiveness of intrapleural analgesia after minimally invasive coronary artery bypass grafting on a beating heart

<b>Purpose</b>: To determine the effectiveness of intrapleural analgesia (IPA) for pain relief after minimally invasive coronary artery bypass surgery on a beating heart.<br /> <b>Methods</b>: We prospectively studied 35 patients who underwent coronary artery bypass grafting on a beating heart through a mini thoracotomy access on the left. Patients were divided into two groups: group I received IPA with a catheter (n=16) and group II patients were not introduced intrapleural analgesia (n=19). Postoperative pain was assessed according to the visual analogue scale (VAS), consumption of analgesics, extubation time, arterial blood gas parameters. Adequacy of respiration and lung ventilation were estimated by electrical impedance tomography.<br /> <b>Results</b>: Extubation time after surgery did not differ in both groups. Arterial oxygen partial pressure was higher (p<0.05) in the first group (160.82±46.98) compared to the second group (111.42±49.26). Regarding the EIT in the quadrant mode, distribution of tidal volume was better in the first group (p<0.05) in the 2nd, 3rd quadrant and in the layer mode, the second layer of the first group showed better results compared to the same layer of the second group. After extubation, average pain score according to VAS was four points for the first group and six points for the second group. On the 1<sup>st</sup> and 2<sup>nd</sup> day pain scores were the same in both groups. Postoperative analgesia by promedol was required only for 1 patient (6.25%) from the first group, and 14 patients from the second group (73.7%). Additionally, tramadol was administered to 43.5% (7 patients) of the first group and 26.3% (5 patients) of the second group.<br /> <b>Conclusion</b>: IPA can be used as one of the effective treatments for postoperative pain in minimally invasive coronary artery bypass surgeries. IPA promotes less use of opioids. An improvement in respiration was observed with reduction in postoperative pain.

Efficacy of ultrasound-guided erector spinae plane block on analgesia and quality of recovery after minimally invasive direct coronary artery bypass surgery: protocol for a randomized controlled trial

BackgroundMinimally invasive direct coronary artery bypass (MIDCAB) surgery offers an effective option for coronary artery disease (CAD) patients with the avoidance of median sternotomy and fast postoperative recovery. However, MIDCAB is still associated with significant postoperative pain which may lead to delayed recovery. The erector spinae plane block (ESPB) is a superficial fascial plane block. There have not been randomized controlled trials evaluating the effects of ESPB on analgesia and patient recovery following MIDCAB surgery. We therefore designed a double-blind prospective randomized placebo-controlled trial, aiming to prove the hypothesis that ESPB reduces postoperative pain scores in patients undergoing MIDCAB surgery.MethodsThe study protocol has been reviewed and approved by the Ethical Review Committee of Peking University People’s Hospital. Sixty adult patients of either sex scheduled for MIDCAB surgery under general anesthesia (GA) will be included. Patients will be randomly allocated to receive either a preoperative single-shot ESPB with 30 mL of ropivacaine 0.5% (ESPB group) or normal saline 0.9% (control group). The primary outcomes are the difference between the two groups in numeric rating scale (NRS) scores at rest at different time points (6, 12, 18, 24, 48 h) after surgery. The secondary outcomes include NRS scores on deep inspiration within 48 h, postoperative hydromorphone consumption, and quality of patient recovery at 24 h and 48 h, using the Quality of Recovery-15 (QoR-15) scale. The other outcomes include intraoperative fentanyl requirements, the need for additional postoperative rescue analgesics, time to tracheal extubation and chest tube removal after surgery, incidence of postoperative nausea and vomiting (PONV) and postoperative cognitive dysfunction (POCD), intensive care unit (ICU) length of stay (LOS), hospital discharge time, and 30-day mortality. Adverse events will be also evaluated.DiscussionThis is a novel randomized controlled study evaluating a preoperative ultrasound-guided single-shot unilateral ESPB on analgesia and quality of patient recovery in MIDCAB surgery. The results of this study will characterize the degree of acute postoperative pain and clinical outcomes following MIDCAB. Our study may help optimizing analgesia regimen selection and improving patient comfort in this specific population.Trial registrationThe study was prospectively registered with the Chinese Clinical Trial Registry (trial identifier: ChiCTR2100052810). Date of registration: November 5, 2021.

The Feasibility and Early Results of Multivessel Minimally Invasive Coronary Artery Bypass Grafting for All Comers.

Cardiovascular surgery advancements have emerged with various minimally invasive approaches for treating multivessel coronary disease to improve outcomes and minimize the burden associated with conventional cardiac surgery. We present our clinical experience and minimally invasive coronary bypass techniques through minithoracotomy, which we apply without selection to patients who have decided to have elective surgery for multivessel isolated coronary artery disease. It consists of 230 consecutive patients operated by the same team with this method between July 2020 and September 2022. The patients were assigned to one of the two methods preoperatively to their accompanying comorbidities and operated on either with blood cardioplegia via 5 to 7 cm left anterior minithoracotomy, with on-pump clamped technique or without pump via left anterolateral minithoracotomy. Mortality was observed in two of our patients (0.9%), but myocardial infarction was not observed in our patients in the early postoperative period. None of our patients required conversion to sternotomy (0%). Five patients' needed reoperation from the same incision due to postoperative bleeding (2.2%), and atrial fibrillation developed in 17 patients in the postoperative period (7.4%). The mean number of bypasses was found to be 3.0 ± 0.9. Minimally invasive coronary artery bypass surgery via minithoracotomy can be routinely reproduced safely. More long-term results and more multicenter studies are needed for more widespread acceptance of the technique.

Using the blockade of interfascial space of the <i>erector spinae</i> muscle (<i>erector spinae</i> plane block) in minimally invasive coronary bypass surgery: prospective randomized study

BACKGROUND: Despite the successful development of cardio-anesthesiology, no consensus exists on the preferred anesthesia method for coronary artery bypass grafting.
 OBJECTIVE: To evaluate the effectiveness of perioperative analgesia in minimally invasive coronary artery bypass surgery (MIDCAB) using ultrasound-assisted blockade in erector spinae plane (ESP).
 MATERIALS AND METHODS: A prospective, two-center, randomized study included 37 patients who underwent MIDCAB surgery. In group 1, before the induction of general anesthesia, an ESP block was performed; in group 2, the operation was performed only under general anesthesia.
 RESULTS: The consumption of fentanyl for anesthesia differed in groups 1 (ESP block) and 2 (general anesthesia): 0.9 (0.8; 1.0) mg vs 3.0 (2.6; 3.2) mg (p 0.01). The norepinephrine dosage was higher in group 2 than in group 1: 0.18 (0.16; 0.22) mcg/kg/min vs 0.05 (0.04; 0.06) mcg/kg/min (p 0.01). Postoperatively, the pain score was lower in group 1 than in group 2, and no additional opioids were required during the first 34 h after extubation. Thereafter, no differences in pain scores were observed between the groups.
 CONCLUSION: The use of an ESP block with a single injection of a local anesthetic is effective in reducing the total dosage of fentanyl used during surgery, dosage of norepinephrine, and mechanical ventilation and improve the quality of postoperative analgesia during MIDCAB.

Chronic post-thoracotomic pain syndrome in cardiothoracic surgery after minimally invasive coronary bypass surgery: prospective cohort study

BACKGROUND: No consensus has been established on the role of epidural anesthesia in relation to the prevention of chronic post-thoracotomic pain during minimally invasive coronary bypass surgery.
 OBJECTIVE: This study aimed to evaluate the effect of epidural anesthesia on the incidence of chronic post-thoracotomic pain syndrome after minimally invasive direct coronary artery bypass (MIDCAB) surgery.
 MATERIALS AND METHODS: The study included 87 patients who underwent MIDCAB surgery. In group 1, epidural anesthesia was performed before the induction of general anesthesia; in group 2, the operation was performed only under general anesthesia.
 RESULTS: The use of fentanyl for anesthesia varied: 0.5 (0.5; 0.6) mg in group 1 versus 3.5 (3.3; 3.6) mg in group 2 (p 0.01). The incidence of chronic post-thoracotomic pain in patients 3 months after surgery was higher in group 2 than in group 1 (39.1% vs 17.2%, p=0.005). The severity of pain at rest was 3 points (2; 3) in group 1 and 3 points (3; 3.5) in group 2 (p=0.018); however, during a deep breath, these differences became insignificant: 4 points (4; 4) in group 1 and 4 (4; 5) points in group 2 (p=0.453). At 6 months after surgery, chronic post-thoracotomic pain was present in 15.6% of the patients in group 1 and 34.8% in group 2 (p=0.011). After 6 months, the severity of pain at rest was 2.5 (2; 3) in group 1 and 3 (3; 3.75) in group 2 (p=0.01). No differences in cough were found: 4 (3.75; 4) points in group 1 and 4 (4; 4.5) points in group 2 (p 0.05).
 CONCLUSION: The use of epidural anesthesia led to a decrease in the incidence of chronic post-thoracotomic pain in patients undergoing MIDCAB surgery.

Erector spinae plane block for postoperative analgesia in robotically-assisted coronary artery bypass surgery: Results of a randomized placebo-controlled trial

Study objectiveTo investigate if an erector spinae plane (ESP) block decreases postoperative opioid consumption, pain and postoperative nausea and vomiting in patients undergoing robotically-assisted minimally invasive direct coronary artery bypass surgery (RAMIDCAB). DesignA single-center, double-blind, prospective, randomized, placebo-controlled trial. SettingPostoperative period; operating room, post-anesthesia care unit (PACU) and hospital ward in a university hospital. PatientsSixty-four patients undergoing RAMIDCAB surgery via left-sided mini-thoracotomy and enrolled in the institutional enhanced recovery after cardiac surgery program. InterventionsAt the end of surgery, patients received an ESP catheter at vertebra T5 under ultrasound guidance and were randomized to the administration of either ropivacaine 0.5% (loading dose of 30 ml and three additional doses of 20 ml each, interspersed with a 6 h interval) or normal saline 0.9% (with an identical administration scheme). In addition, patients received multimodal analgesia including acetaminophen, dexamethasone and patient-controlled analgesia with morphine. Following the final ESP bolus and before catheter removal, the position of the catheter was re-evaluated by ultrasound. Patients, investigators and medical personnel were blinded for the group allocation during the entire trial. MeasurementsPrimary outcome was cumulative morphine consumption during the first 24 h after extubation. Secondary outcomes included location and severity of pain, presence/extent of sensory block, duration of postoperative ventilation and hospital length of stay. Safety outcomes comprised the incidence of adverse events. Main resultsMedian (IQR) 24-h morphine consumption was not different between the intervention- and control-groups, 67 mg (35–84) versus 71 mg (52–90) (p = 0.25), respectively. Likewise, no differences were detected in secondary and safety endpoints. ConclusionsFollowing RAMIDCAB surgery, adding an ESP block to a standard multimodal analgesia regimen did not reduce opioid consumption and pain scores.

Safety and feasibility of minimally invasive coronary artery bypass surgery early after drug-eluting stent implantation due to acute coronary syndrome.

The evidence on performing minimally invasive coronary artery surgery early after drug-eluting stent (DES) implantation due to acute coronary syndrome (ACS) is limited. The study aimed to determine the safety and feasibility of this approach. This registry included 115 (78% male) patients treated from 2013 to 2018, who underwent non-left anterior descending (LAD) percutaneous coronary intervention (PCI) due to ACS with contemporary DES implantation (39% diagnosed with myocardial infarction at baseline), followed by endoscopic atraumatic coronary artery bypass (EACAB) surgery within 180 days, after temporary P2Y12 inhibitor discontinuation. Primary composite endpoint of MACCE (major adverse cardiac and cerebrovascular events), defined as death, myocardial infarction (MI), cerebrovascular incident, and repeat revascularization was evaluated in long-term follow-up. The follow-up was collected via a telephone survey and in line with National Registry for Cardiac Surgery Procedures. The median (interquartile range [IQR]) time interval separating both procedures was 100.0 (62.0-136.0) days. Median (IQR) follow-up duration was 1338.5 (753.0-2093.0) days and was completed for all patients with regard to mortality. Eight patients (7%) died; 2 (1.7%) had a stroke; 6 (5.2%) suffered from MI, and 12 (10.4%) required repeat revascularization. Overall, the incidence of MACCE was 20 (17.4%). EACAB is a safe and feasible method of LAD revascularization in patients who received DES for ACS within 180 days before surgery despite early dual antiplatelet therapy discontinuation. The adverse event rate is low and acceptable.

A Single Center Initial Experience with Robotic-Assisted Minimally Invasive Coronary Artery Bypass Surgery (RA-MIDCAB).

Minimally invasive procedures have demonstrated their effectiveness in reducing the recovery times while ensuring optimal results and minimizing complications. Regarding the coronary artery surgical revascularization field, the evolution of techniques and technology is permitting new surgical strategies that are increasingly precise and suitable for each patient. We present an initial single center experience with a case series of patients successfully treated with combined robotic harvesting of the left internal mammary artery (LIMA) and minimally invasive direct coronary artery bypass graft (MIDCAB) for the anastomosis. We retrospectively reviewed the records of patients who underwent minimally invasive coronary artery revascularization with the use of two combined techniques at our Institution between January 2021 and October 2022. A total of 17 patients underwent coronary artery bypass grafting with the described approach. The median cardiopulmonary bypass (CPB) and cross-clamp times were 83 min (76-115) and 38 min (32-58), respectively. The median intensive care unit (ICU) and hospital stay were 2 days (1-4) and 8 days (6-11), respectively. The procedure's success was achieved in 100% of patients. The 30-day mortality was 0%. Considering all the limitations related to the small sample, the presented results of a hybrid approach for minimally invasive coronary artery bypass grafting (CABG) appears to be encouraging and acceptable. The main advantage of this approach is related to the reduction of postoperative pain and pulmonary complications.

Editorial introductions.

Current Opinion in Cardiology was launched in 1985. It is part of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of cardiology is divided into 15 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Section Editors for this issue. SECTION EDITORS Alan BravermanAlan BravermanDr Braverman is a graduate of the University of Missouri-Kansas City School of Medicine, USA. He completed a residency in internal medicine and cardiology fellowship at Brigham and Women's Hospital and Harvard Medical School, USA, and served as Chief Medical Resident. In 1991, Dr Braverman joined the faculty at Washington University School of Medicine in St. Louis, USA, where he is currently the Alumni Endowed Professor in Cardiovascular Diseases. Dr Braverman is actively involved in the education of students, house staff and fellows at Washington University and serves as a Director of the Inpatient Cardiology Firm at Barnes-Jewish Hospital, USA. He has been awarded Teacher of the Year Award by the internal medicine residents on five occasions, the Clinical Teacher of the Year Award by the Washington University Medical Students Class of 2004, and the Benico Barzilai Teaching Award by the cardiology fellows in 2016, and the Hugh McCullough Award from the American Heart Association. In 2010, Dr Braverman was bestowed the E. Grey Dimond Take Wing Award from the University of Missouri-Kansas City. He is a Clinical Cardiologist and has a particular interest in diseases of the aorta, Marfan syndrome and hereditary aneurysm conditions. He is the Director of the Marfan Syndrome Clinic at Washington University in St. Louis and serves on the Professional Advisory Board and the Board of Directors of the Marfan Foundation. He has been awarded the Antoine Marfan Award from the Marfan Foundation in 2003. Dr Braverman is actively involved in clinical research on Marfan syndrome and related aortic diseases, including genetically triggered aortopathy, aortic dissection, and bicuspid aortic valve aortopathy. Marc RuelMarc RuelDr Marc Ruel is the Head and Chair of Cardiac Surgery at the University of Ottawa, Canada. A seasoned heart surgeon, innovator and researcher, Dr Ruel is widely credited with the development of minimally invasive multivessel coronary artery bypass surgery worldwide, and with furthering other minimally invasive cardiac techniques. He has led extensive research and clinical trials in coronary and heart valve surgery. Dr Ruel has published over 400 scientific papers and book chapters, is the recipient of numerous academic and community awards, and is featured as one of the ’Giants of Cardiothoracic Surgery’. Dr Ruel is the President of the Canadian Cardiovascular Society (CCS), one of the most respected medical societies in the world. He is also the surgical Editor for the prestigious journal Circulation and the Canadian Director of the Society of Thoracic Surgeons. Peter H. StonePeter H. StonePeter H. Stone, MD, is a Professor of Medicine at Harvard Medical School, USA, Director of the Vascular Profiling Research Group, a Co-Director of the Center for Clinical Investigation, and Senior Physician at Brigham & Women's Hospital, USA. Dr Stone's research interests are in evaluating and managing patients with acute and chronic coronary artery disease. He is using new in-vivo methodologies to identify areas where human coronary disease will progress to determine if pre-emptive therapeutic strategies may avert adverse cardiac events. He received his undergraduate degree from Princeton University, USA, and his Medical Degree from Cornell University, USA. He completed internal medicine training at the University of California, San Francisco, USA, and then did a clinical cardiology fellowship at Pacific Medical Center in San Francisco, USA. He came to the Peter Bent Brigham Hospital as a Cardiology Research Fellow and he has remained at Brigham and Women's Hospital. He is past President of the Boston Chapter of the American Heart Association, past President of the International Society for Holter and Noninvasive Electrocardiology, and is a Fellow of the American College of Cardiology and the American Heart Association.

Minimally invasive surgery or stenting for left anterior descending artery disease - meta-analysis.

Minimally invasive direct coronary artery bypass (MIDCAB) surgery and percutaneous coronary intervention (PCI) are both well-established minimally invasive revascularization strategies in patients with proximal left anterior descending (LAD) lesions. We aimed to evaluate the 20-years’ experience by performing a systematic review and meta-analysis comparing MIDCAB versus PCI in adults with proximal LAD disease. We searched MEDLINE, EMBASE and Cochrane on October 1st, 2021 for articles published in the year 2000 or later. The primary outcome was all-cause mortality. Secondary outcomes included cardiac mortality, repeat target vessel revascularization (rTVR), myocardial infarction (MI), and cerebrovascular accident (CVA). Outcomes were analysed at short-term, mid-term, and long-term follow-up. Random effects meta-analyses were performed. Events were compared using risk ratios (RR) with 95% confidence intervals (CI). Our search yielded 17 studies pooling 3847 patients. At short-term follow-up, cardiac mortality was higher with MIDCAB than with PCI (RR 7.30, 95% CI: 1.38 to 38.61). At long-term follow-up, MIDCAB showed a decrease in all-cause mortality (RR 0.66, 95% CI: 0.46 to 0.93). MIDCAB showed a decrease in rTVR at mid-term follow-up (RR 0.16, 95% CI: 0.11 to 0.23) and at long-term follow-up (RR 0.25, 95% CI: 0.17 to 0.38). MI and CVA comparisons were not significant. In conclusion, in patients with proximal LAD lesions, MIDCAB showed a higher short-term mortality in the RCTs, but the cohort studies suggested a lower all-cause mortality at long-term follow-up. We confirm a decreased rTVR at mid-term follow-up in the RCTs and long-term follow-up in the cohort studies.

A Rare Cause of Severe Biventricular Dyssynchrony During Venoarterial Extracorporeal Membrane Oxygenation for COVID-19 Respiratory Failure

A 19-YEAR-OLD, 96 KG, 175 cm previously healthy man with COVID-19 pneumonia, sepsis, and adult respiratory distress syndrome was transferred from a community hospital to the authors’ institution for treatment with extracorporeal membrane oxygenation (ECMO). The patient had persistent hypoxemia and hypotension despite optimal mechanical ventilation and high-dose vasoactive drug support. He was cannulated for femoral-femoral venoarterial (VA) ECMO shortly after arrival in the intensive care unit. This intervention initially improved the patient's oxygenation and reduced his vasopressor requirements, but hypoxemia and hypotension recurred concomitant with ECMO suction events and reduced flow rates that were only transiently responsive to volume resuscitation and flow adjustment. Transesophageal echocardiography (TEE) was performed, and the following images were obtained (Figs 1-4; Video 1 and 2). What is the diagnosis? A midesophageal 4-chamber TEE view revealed diastolic flattening of the right and left ventricular (RV and LV, respectively) apices associated with dyssynchronous biventricular contraction (Figs 1 and 2; Video 1). A small pericardial effusion was also present. The midesophageal RV inflow-outflow view revealed pronounced RV outflow tract narrowing during diastole (Figs 3 and 4; Video 2). Similar findings were observed in the midesophageal aortic valve long axis view (Figs 5 and 6; Video 3). The transgastric midpapillary short axis view showed severely dyssynchronous LV contraction with apparent tethering of the LV anterior wall (Figs 7 and 8; Video 4). Collectively, the TEE findings strongly suggested that an extracardiac force was acting on the heart, as if cardiac compressions were being performed. The patient continued to experience hypoxemia (arterial oxygen saturations in the mid-80s), hypotension despite escalating infusion rates of vasoactive drugs, and frequent ECMO suction events that only could be managed with reduced flow rates. A chest radiograph was obtained to confirm position of a nasojejunal feeding tube that had been placed when the TEE examination was completed. A left pneumothorax was observed with notable flattening of the left heart border by the compressed lung parenchyma (Fig 9). A thoracostomy tube was inserted, which resulted in immediate improvement in the patient's arterial oxygen saturation and hemodynamics, a decrease in vasoactive drug requirements, and the ability to safely increase ECMO flow rates. A repeat TEE examination showed complete resolution of the abnormal cardiac motion.Fig 3Midesophageal right ventricular inflow-outflow transesophageal echocardiography view during diastole.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig 4Midesophageal right ventricular inflow-outflow transesophageal echocardiography view during systole.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig 5Midesophageal aortic valve long axis transesophageal echocardiography view during diastole.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig 6Midesophageal aortic valve long axis transesophageal echocardiography view during systole.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig 7Transgastric midpapillary short axis transesophageal echocardiography view showing left ventricular flattening during diastole.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig 8Transgastric midpapillary short axis transesophageal echocardiography view showing apparent tethering of the left ventricular anterior wall during systole.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig 9Chest radiograph showing large left pneumothorax.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Pneumothorax occurs in 0.16% to 2% of patients with COVID-19,1Marciniak SJ Farrell J Rostron A et al.Covid-19 pneumothorax in the UK: A prospective observational study using the ISARIC WHO clinical characterisation protocol.Eur Respir J. 2021; 582100929Crossref PubMed Scopus (1) Google Scholar but its incidence may be much higher (approaching 25%) in those who require mechanical ventilation.2Zantah M Dominguez Castillo E Townsend R Dikengil F Criner GJ Pneumothorax in COVID-19 disease - incidence and clinical characteristics.Respir Res. 2020; 21: 236Crossref PubMed Scopus (69) Google Scholar Tension pneumothorax during ECMO has been previously described in neonates,3Zwischenberger JB Cilley RE Hirschl RB et al.Life-threatening intrathoracic complications during treatment with extracorporeal membrane oxygenation.J Pediatr Surg. 1988; 23: 599-604Abstract Full Text PDF PubMed Scopus (32) Google Scholar but to the authors’ knowledge, the current report is the first description of this complication in an adult with COVID-19 treated with VA-ECMO. A triad of paradoxically increased arterial oxygen tension, evidence of reduced peripheral perfusion (as indicated by narrowed pulse pressure and decreases in mixed venous oxygen saturation), and declining flow rates accompanied by hemodynamic instability were the characteristic features of tension pneumothorax in neonates treated with ECMO.3Zwischenberger JB Cilley RE Hirschl RB et al.Life-threatening intrathoracic complications during treatment with extracorporeal membrane oxygenation.J Pediatr Surg. 1988; 23: 599-604Abstract Full Text PDF PubMed Scopus (32) Google Scholar These findings were replicated in a study of experimentally-induced tension pneumothorax in dogs receiving VA ECMO.4Zwischenberger JB Bowers RM Pickens GJ. Tension pneumothorax during extracorporeal membrane oxygenation.Ann Thorac Surg. 1989; 47: 868-871Abstract Full Text PDF PubMed Scopus (13) Google Scholar The current patient treated with VA-ECMO displayed 2 of 3 of these previously reported signs of tension pneumothorax: compromised peripheral perfusion and declining ECMO flows rates associated with suction events and hemodynamic instability requiring high-dose vasoactive drug support. However, the current patient also developed hypoxemia and not an increase in arterial oxygen tension. A difference in ECMO cannulation site and the resulting location of the mixing cloud were probably responsible for this discrepancy. The common carotid artery and internal jugular vein were cannulated in neonates3Zwischenberger JB Cilley RE Hirschl RB et al.Life-threatening intrathoracic complications during treatment with extracorporeal membrane oxygenation.J Pediatr Surg. 1988; 23: 599-604Abstract Full Text PDF PubMed Scopus (32) Google Scholar and dogs,4Zwischenberger JB Bowers RM Pickens GJ. Tension pneumothorax during extracorporeal membrane oxygenation.Ann Thorac Surg. 1989; 47: 868-871Abstract Full Text PDF PubMed Scopus (13) Google Scholar whereas femoral-femoral arterial and venous cannulation was used here. Thus, arterial blood gas sampling from a right radial arterial catheter and the decrease in arterial oxygen tension observed in the current patient probably reflected a more distal mixing cloud. The echocardiographic findings in patients with tension pneumothorax are rarely reported, most likely because of the emergent nature of the pathology. The major TEE findings in the current patient are similar to those that have been previously reported in the literature. Castro et al recently described their TEE findings in 2 ECMO patients with tension pneumothorax in whom dyssynchronous biventricular contraction and flattening of both ventricular apices were observed.5Morales Castro D Lung K Doufle G Straight curves: Incidental diagnosis of pneumothorax on transesophageal echocardiography.Am J Respir Crit Care Med. 2021; 204: e88-e91Crossref PubMed Scopus (2) Google Scholar Pneumopericardium was suspected initially in the first patient (who was receiving VA-ECMO after a pulmonary thromboembolectomy), but a chest radiograph revealed a large left pneumothorax. The RV of this patient also appeared to be tethered, similar to the current patient's LV in the transgastric midpapillary view (Figs 7 and 8). The other patient in the Castro et al series was undergoing venovenous ECMO cannulation under TEE guidance when acute changes in cardiac motion consisting of dyssynchronous contraction with diastolic flattening were observed. An iatrogenic pneumothorax after central venous catheter placement was suspected and subsequently confirmed with lung ultrasound imaging. A second case report described a patient undergoing minimally invasive coronary artery surgery who developed hypotension and elevated airway pressures during single-lung ventilation.6Agrawal DR Nambala SP A lethal tension pneumothorax during minimally invasive coronary artery bypass surgery: Can transesophageal echocardiography pick it up?.Ann Card Anaesth. 2016; 19: 747-749Crossref PubMed Scopus (4) Google Scholar TEE revealed a mass effect on the right atrium resulting from a right tension pneumothorax. This abnormality resolved after the right pleura was opened. None. https://www.jcvaonline.com/cms/asset/80454289-daa4-4ed4-a1af-c9153ce8f1c0/mmc1.mp4Loading ... Download .mp4 (2.52 MB) Help with .mp4 files Video 1Midesophageal 4-chamber transesophageal echocardiography video clip.https://www.jcvaonline.com/cms/asset/bd3659eb-7152-47d5-bf7a-264d764a57b4/mmc2.mp4Loading ... Download .mp4 (1.92 MB) Help with .mp4 files Video 2Midesophageal right ventricular inflow-outflow transesophageal echocardiography video clip.https://www.jcvaonline.com/cms/asset/32b86faf-1814-466b-a04e-4dcf6ce7f217/mmc3.mp4Loading ... Download .mp4 (1.48 MB) Help with .mp4 files Video 3Midesophageal aortic valve long axis transesophageal echocardiography video clip.https://www.jcvaonline.com/cms/asset/826ca4ea-5473-4bd5-926e-812c6b89d1a2/mmc4.mp4Loading ... Download .mp4 (1.37 MB) Help with .mp4 files Video 4Transgastric midpapillary short axis transesophageal echocardiography video clip.

The effect of continuous intercostal nerve block vs. single shot on analgesic outcomes and hospital stays in minimally invasive direct coronary artery bypass surgery: a retrospective cohort study

BackgroundMinimally invasive direct coronary artery bypass (MIDCAB) grafting surgery is accompanied by severe pain. Although continuous intercostal nerve block (CINB) has become one of the multimodal analgesic techniques in single port thoracoscopic surgery, its effects on MIDCAB are unclear. The purpose of this study was to compare the effects of CINB and single shot on analgesic outcomes and hospital stays in patients undergoing MIDCAB in a real-world setting.MethodsA retrospective cohort study was carried out at Peking University Third Hospital, China. Two hundred and sixteen patients undergoing MIDCAB were divided into two groups: a CINB group and a single block (SI) group. The primary outcome was postoperative maximal visual analog scale (VAS); secondary outcomes included the number of patients with maximal VAS ≤ 3, the demand for and consumed doses of pethidine and tramadol, and the length of intensive care unit (ICU) and hospital stays. The above data and the area under the VAS curve in the 70 h after extubation for the two subgroups (No. of grafts = 1) were also compared.ResultsThe maximum VAS was lower in the CINB group, and there were more cases with maximum VAS ≤ 3 in the CINB group: CINB 52 (40%) vs. SI 17 (20%), P = 0.002. The percentage of cases requiring tramadol and pethidine was less in CINB, P = 0.001. Among all patients, drug doses were significantly lower in the CINB group [tramadol: CINB 0 (0–100) mg vs. SI 100 (0–225) mg, P = 0.0001; pethidine: CINB 0 (0–25) mg vs. SI 25 (0–50) mg, P = 0.0004]. Further subgroup analysis showed that the area under the VAS curve in CINB was smaller: 28.05 in CINB vs. 30.41 in SI, P = 0.002. Finally, the length of ICU stay was shorter in CINB than in SI: 20.5 (11.3–26.0) h vs. 22.0 (19.0–45.0) h, P = 0.011.ConclusionsCINB is associated with decreased demand for rescue analgesics and shorter length of ICU stay when compared to single shot intercostal nerve block. Additional randomized controlled trial (RCT) is needed to support these findings.

High-frequency ventilation in minimally invasive coronary artery bypass surgery

<h3>ЦЕЛЬ ИССЛЕДОВАНИЯ</h3> Оценить эффективность и безопасность струйной инжекционной высокочастотной вентиляции (ВЧВ) во время однолегочной ИВЛ (ОВЛ) при операциях MIDCAB/MICS. <h3>МАТЕРИАЛ И МЕТОДЫ</h3> В исследование включены 44 пациента с ишемической болезнью сердца, подвергшиеся оперативному вмешательству по методике MIDCAB/MICS. В зависимости от типа респираторной поддержки коллабированного легкого во время ОВЛ были сформированы две группы пациентов: группа А (<i>n</i>=21) — контрольная, легкое коллабируется; группа Б (<i>n</i>=23) — легкое вентилируется с помощью ВЧВ. Проведен сравнительный анализ течения интраоперационного и раннего послеоперационного периодов. <h3>РЕЗУЛЬТАТЫ</h3> В период ОВЛ в группе Б наблюдали более высокие и оптимальные показатели оксигенирующей функции легких (PaO₂, SpO₂). Отличий в частоте и характере послеоперационных бронхолегочных осложнений, длительности ИВЛ и пребывания в отделении интенсивной терапии не было. <h3>ВЫВОД</h3> Применение струйной инжекционной высокочастотной вентиляции коллабированного легкого во время кардиохирургических операций MIDCAB/MICS способствует улучшению артериальной оксигенации, снижению частоты значимого снижения сатурации (SpO₂&lt;94%) и уменьшению общего числа послеоперационных легочных осложнений.

Editorial introductions.

Current Opinion in Cardiology was launched in 1985. It is part of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of cardiology is divided into 15 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Section Editors for this issue. SECTION EDITORS Alan BravermanAlan BravermanDr Braverman is a graduate of the University of Missouri-Kansas City School of Medicine, USA. He completed a residency in internal medicine and cardiology fellowship at Brigham and Women's Hospital and Harvard Medical School, USA, and served as Chief Medical Resident. In 1991, Dr Braverman joined the faculty at Washington University School of Medicine in St. Louis, USA, where he is currently the Alumni Endowed Professor in Cardiovascular Diseases. Dr Braverman is actively involved in the education of students, house staff and fellows at Washington University and serves as a Director of the Inpatient Cardiology Firm at Barnes-Jewish Hospital, USA. He has been awarded Teacher of the Year Award by the internal medicine residents on five occasions, the Clinical Teacher of the Year Award by the Washington University Medical Students Class of 2004, and the Benico Barzilai Teaching Award by the cardiology fellows in 2016, and the Hugh McCullough Award from the American Heart Association. In 2010, Dr Braverman was bestowed the E. Grey Dimond Take Wing Award from the University of Missouri-Kansas City. He is a Clinical Cardiologist and has a particular interest in diseases of the aorta, Marfan syndrome and hereditary aneurysm conditions. He is the Director of the Marfan Syndrome Clinic at Washington University in St. Louis and serves on the Professional Advisory Board and the Board of Directors of the Marfan Foundation. He has been awarded the Antoine Marfan Award from the Marfan Foundation in 2003. Dr Braverman is actively involved in clinical research on Marfan syndrome and related aortic diseases, including genetically triggered aortopathy, aortic dissection, and bicuspid aortic valve aortopathy. Marc RuelMarc RuelDr Marc Ruel is the Head and Chair of Cardiac Surgery at the University of Ottawa, Canada. A seasoned heart surgeon, innovator and researcher, Dr Ruel is widely credited with the development of minimally invasive multivessel coronary artery bypass surgery worldwide, and with furthering other minimally invasive cardiac techniques. He has led extensive research and clinical trials in coronary and heart valve surgery. Dr Ruel has published over 400 scientific papers and book chapters, is the recipient of numerous academic and community awards, and is featured as one of the ’Giants of Cardiothoracic Surgery’. Dr Ruel is the President of the Canadian Cardiovascular Society (CCS), one of the most respected medical societies in the world. He is also the surgical Editor for the prestigious journal Circulation and the Canadian Director of the Society of Thoracic Surgeons. Peter H. StonePeter H. StonePeter H. Stone, MD, is a Professor of Medicine at Harvard Medical School, USA, Director of the Vascular Profiling Research Group, a Co-Director of the Center for Clinical Investigation, and Senior Physician at Brigham & Women's Hospital, USA. Dr Stone's research interests are in evaluating and managing patients with acute and chronic coronary artery disease. He is using new in-vivo methodologies to identify areas where human coronary disease will progress to determine if pre-emptive therapeutic strategies may avert adverse cardiac events. He received his undergraduate degree from Princeton University, USA, and his Medical Degree from Cornell University, USA. He completed internal medicine training at the University of California, San Francisco, USA, and then did a clinical cardiology fellowship at Pacific Medical Center in San Francisco, USA. He came to the Peter Bent Brigham Hospital as a Cardiology Research Fellow and he has remained at Brigham and Women's Hospital. He is past President of the Boston Chapter of the American Heart Association, past President of the International Society for Holter and Noninvasive Electrocardiology, and is a Fellow of the American College of Cardiology and the American Heart Association.

Effect of Dexmedetomidine on The Neuroglobin Expression in Elderly Patients With Minimally Invasive Coronary Artery Bypass Graft Surgery.

To study the effect of dexmedetomidine (Dex) on the expression of Neuroglobin (Ngb) and postoperative cognitive function in elderly patients undergoing minimally invasive coronary artery bypass surgery. Forty patients, who underwent elective minimally invasive off-pump coronary artery bypass grafting in our hospital from January 2018 to December 2019, were randomly divided into the Dex group (N = 20) and control group (N = 20). Venous blood samples were taken to determine the expression level of Ngb in both groups. Mini mental status examination (MMSE) was used to detect the cognitive function of patients. The expression level of Ngb in the Dex group was significantly higher than that in the control group at 6h after one-lung ventilation and postoperative 24h (P < .01). The MMSE score of the Dex group was significantly higher than the control group at postoperative 7 days and postoperative 30 days (P < .01). Although with no statistical significance, the MMSE score of the Dex group was higher than the control group at postoperative 90 days (P > .05). The incidence of postoperative cognitive dysfunction (POCD) in the Dex group was significantly lower than that in the control group at postoperative 7 days and postoperative 30 days (P < .05). Dex used in elderly patients undergoing minimally invasive coronary artery bypass graft surgery can effectively increase the expression level of Ngb and reduce the incidence of POCD.

Early Outcome of Minimally Invasive Direct Coronary Artery Bypass Surgery- A hospital based study

Background: coronary artery bypass surgery (CABG) is expensive, uses disposable appliances and patients require more perioperative intensive care, long stay in hospital and often have a lengthy recovery time. These complications, together with the growing trend towards less invasive techniques in other areas of surgery, have encouraged cardiac surgeons to see if minimally invasive cardiac surgery can become a reality with improved outcomes and costs.&#x0D; Methods: This is a prospective nonrandomized comparative clinical study done at the Department of Cardiac Surgery in National Institute of Cardiovascular Diseases (NICVD) Sher-E- Bangla Nagar, Dhaka from July 2006 to June 2008 among routine CABG patients. Purposive sampling was done with 26 patients in group A selected for MIDCAB and 24 patients in Group B selected for conventional CABG surgery. Patients were followed up for three months. Postoperative outcomes were assessed to evaluate the safety and efficacy of MIDCAB in relation to conventional CABG.&#x0D; Results: Mean age were 54.19 vs 53.87 in group A and Group B. 92.3% vs 87.5% were male respectively. Mean duration of operation, per operative blood loss transfusion and arrythmia were lower in MIDCAB group (p&lt;0.05) number of grafts were also statistically significant (p&lt; 0.001). Regarding post-operative outcome ventilation time in hours ICU stay post-operative hospital stay in days, postoperative MI and stroke rate were lower in favor of group A MIDCAB patients (p&lt;0.001). Three months postoperatively six-meter walking distance is also statistically significant in favor of Group A MIDCAB (p&lt;0.01) patients. However, pain score in early post-operative period was higher in group A significantly but it decreased significantly in late post-operative period which is also highly statistically different (p&lt;0.001). However, mortality and quality of life at three months were similar in both groups.&#x0D; Conclusion: No difference in mortality rates detected between MIDCAB and CCABG group. But there was evidence that MIDCAB is associated with less perioperative and early postoperative morbidity and improved quality of life. The MIDCAB surgery is an effective procedure of complete revascularization in ischemic heart diseases like CCABG. The procedure is associated with shorter operating time, shorter ICU stay time, shorter hospital stays and better quality of life than for CCABG.&#x0D; Cardiovasc. j. 2021; 13(2): 135-143

Minimally invasive coronary artery bypass grafting via a lower ministernotomy for left anterior descending artery myocardial bridging: mid-term results.

Coronary artery bypass grafting or supra-arterial myotomy is now suggested as a better therapeutic option in myocardial bridging (MB) when medical treatment fails to control symptoms. For left anterior descending (LAD) MB, minimally invasive coronary artery bypass via a lower ministernotomy can be offered. Forty-four consecutive patients who underwent elective minimally invasive coronary artery bypass surgery from 2005 to 2014 via an inferior sternotomy using the left internal mammary artery as a bypass graft for LAD MB were evaluated retrospectively. The mean age was 59.1 ± 13.1 years with 26 (59%) men and 18 (41%) women. The mean body mass index was 27.2 ± 3.9 and the mean EuroSCORE II was 1.6 ± 1.8. Routine coronary multislice computed tomography angiography on the 6th postoperative day revealed 97.7% graft patency. During the initial hospital stay, 1 patient (2.3%) underwent a reoperation for early graft failure. Forty patients (91%) could be followed up for a mean period of 64.4 ± 24.5 months after the procedure, during which 2 patients (4.5%) died of non-cardiac causes and 9 patients (20.5%) underwent postoperative coronary angiography with confirmed graft occlusion in only 1 case (2.3%). The improvement in the distribution of patients in the Canadian Cardiovascular Society class 0 was from 4 patients (9%) preoperatively to 37 patients (84%) at the end of the follow-up period (P-value 0.001). Minimally invasive coronary artery bypass surgery via a lower ministernotomy may be safe and efficient for treating LAD artery MB with acceptable complication rates, cosmetic benefits and patency rates.

Does erector spinae plane block result in improved postoperative analgesia and enhanced recovery in adult patients after cardiac surgery?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether erector spinae plane block (ESPB) resulted in improved postoperative analgesia and enhanced recovery in adult cardiac surgical patients. A total of 333 papers were found using the reported search of which, 7 papers represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient groups studied, study type, relevant outcomes and results of these papers are tabulated. The cardiac surgical procedures included off-pump coronary artery bypass surgery (1 study), mitral/tricuspid valve repair (1 study), robotic minimally invasive coronary artery bypass surgery (1 study) and other cardiac surgeries (4 studies). ESPB was compared to intravenous analgesia (5 studies), thoracic epidural analgesia (1 study) and serratus anterior plane block and paravertebral block (1 study). With ESPB, there was significant improvement in postoperative pain scores (4 studies), decreased opioid requirement/rescue analgesia (3 studies), increased duration of analgesia (1 study), decreased time to extubation (3 studies), less increase in postoperative Troponin T (1 study), earlier ambulation (2 studies), earlier oral intake (1 study), earlier chest drain removal (1 study), better patient satisfaction (1 study), reduced adverse events (1 study) and decreased intensive care unit stay (3 studies). We conclude that ESPB may be associated with improved postoperative analgesia and enhanced recovery after adult cardiac surgery based on the available evidence. However, there is a need for better quality randomized controlled trials to consolidate these findings.

Twenty-year outcomes of minimally invasive direct coronary artery bypass surgery: The Leipzig experience

ObjectiveMinimally invasive direct coronary artery bypass (MIDCAB) surgery involving left anterior descending coronary artery grafting with the left internal thoracic artery through a left anterior small thoracotomy is being routinely performed in some specified centers for patients with isolated complex left anterior descending coronary artery disease, but very few reports regarding long-term outcomes exist in literature. Our study was aimed at assessing and analyzing the early and long-term outcomes of a large cohort of patients who underwent MIDCAB procedures and identifying the effects of changing trends in patient characteristics on early mortality. MethodsA total of 2667 patients, who underwent MIDCAB procedures between 1996 and 2018, were divided into 3 groups on the basis of the year of surgery: group A, 1996-2003 (n = 1333); group B, 2004-2010 (n = 627) and group C, 2011-2018 (n = 707). Groupwise characteristics and early postoperative outcomes were compared. Long-term survival for all patients was analyzed and predictors for late mortality were identified using Cox proportional hazards methods. ResultsThe mean age was 64.5 ± 10.9 years and 691 (25.9%) patients were female. Group C patients (log EuroSCORE I = 4.9 ± 6.9) were older with more cardiac risk factors and comorbidities than groups A (log EuroSCORE I = 3.1 ± 4.5) and B (log EuroSCORE I = 3.5 ± 4.7). Overall and groupwise in-hospital mortality was 0.9%, 1.0%, 0.6%, and 1.0% (P = .7), respectively. Overall 10-, 15-, and 20-year survival estimates for all patients were 77.7 ± 0.9%, 66.1 ± 1.2%, and 55.6 ± 1.6%, respectively. ConclusionsMIDCAB can be safely performed with very good early and long-term outcomes. In-hospital mortality remained constant over the 22-year period of the study despite worsening demographic profile of patients.

Graft patency and completeness of revascularization in minimally invasive multivessel coronary artery bypass surgery.

Graft patency and completeness of revascularization were analyzed in patients who underwent off-pump minimally invasive coronary artery bypass grafting via a left small thoracotomy. We retrospectively reviewed the invasive angiography findings and clinical data of 186 consecutive patients who underwent off-pump minimally invasive coronary artery bypass grafting via a left small thoracotomy. The left internal thoracic artery and saphenous vein were used to bypass two or more of three coronary artery systems: the left anterior descending artery, left circumflex artery, or right coronary artery. Before hospital discharge, invasive angiography was performed to assess graft patency. Clinical variables during hospitalization and follow-up were collected and analyzed. All 186 patients successfully underwent off-pump minimally invasive coronary artery bypass grafting without conversion to sternotomy or assistance of cardiopulmonary bypass. The mean graft number was 2.81 per patient (range, 2-5), and the total number of grafts was 522. The in-hospital mortality rate was 1.6% (3 of 186). A total of 181 of 186 (97.3%) patients underwent postoperative invasive angiography. Among the 510 grafts assessed by angiography, the total graft patency rate was 96.3% (491 of 510) (98.3% [171 of 174] for left internal thoracic artery grafts and 95.2% [318 of 334] for saphenous vein grafts). The rate of complete revascularization was 99.5% (185 of 186). Minimally invasive coronary artery bypass grafting using left internal thoracic artery and saphenous vein grafts provides acceptable graft patency and completeness of revascularization for selected patients with multivessel disease.