Background/Aim. Growing waiting lists for cardiac surgery have become a real problem in the Republic of Serbia, imposing serious difficulties in patient-surgeon communication. The aim of the study was to determine the current state of the institutional informed consent policy before elective cardiac surgical procedures in light of actual nation-al legislation. Methods. An anonymous, voluntary survey was conducted among 200 consecutive patients at the Clinic for Cardiac Surgery, University Clinical Centre of Serbia, from September to December 2019, after signing an official institutional consent form. A targeted questionnaire was created to determine the quantity and quality of patients? in-formation about general and the most important aspects of cardiac surgical care. Results. The mean age of respondents was 66.2 years, with male predominance (68.0%), homogenous ethnicity, and low-to-middle (84.0%) education levels. A significant percentage had no information on the type of surgery (16.0%), extracorporeal circulation (46.0%), anaesthesia (56.0%) and transfusion (51.5%). Of those having some information, 7.0?20.0% graded them sufficient. The worst situation was recorded concerning risks of disease and surgical treatment, where 88.0% of patients had no information and almost 90.0% had some information and graded them as non-sufficient. Surprisingly, 81.5% of patients signed the consent form without any prior discussion with the operating surgeon. For 56.0% of patients, the information in the actual consent form was clear and sufficient. While 85.5% of patients claimed the importance, the others (14.5%) were not interested to know the most relevant in-formation about their disease and surgery. Conclusion. The results unambiguously indicate an unacceptably low level of our patients? information about the cardiac surgical procedure, extracorporeal circulation, anesthesia, transfusion, and estimated risk. The majority of them (85.5%) comprehends the importance and expects timely and adequate information. An extremely high percentage (81.5%) of patients had no chance to discuss the procedure with the operating surgeon. Both surgical indifference and insufficient knowledge of professional, ethical, and legal importance are the most important reasons for the actual informed consent policy in cardiac surgery.

Mitral valve repair with artificial chordae is a widely accepted procedure for the majority of patients with degenerative mitral regurgitation (MR), rendering good long-term results.1Salvador L. Mirone S. Bianchini R. et al.A 20-year experience with mitral valve repair with artificial chordae in 608 patients.J Thorac Cardiovasc Surg. 2008; 135: 1280-1287Abstract Full Text Full Text PDF PubMed Scopus (112) Google Scholar A new technique for the treatment of extensive mitral prolapse/flail is described herein. After median sternotomy, cardiopulmonary bypass is established between the right atrium and the aorta. The pericardium is opened, and the apex is elevated with stay sutures. A purse-string suture is placed onto the posterior aspect of the left ventricular (LV) apex. The LV apex is punctured with the Seldinger technique through the string suture, and an 8F introducer sheath is placed into the LV cavity. After cross-clamping of the aorta and normothermic cardioplegia, the left atrium (LA) is opened in the usual manner. Two double-armed pledgeted 2-0 Prolene sutures (Ethicon, Somerville, NJ) are passed through the prolapsed/flail leaflet segment and traversed through the LV sheath out of the left ventricle. The heart is deaired, the LA is closed, and the aortic crossclamp is removed. A custom-made polymer elastic tube of premeasured length and a 2-mm external profile is advanced over the exteriorized suture arms to contact the target leaflet, thereby securing the suture loops to the leaflet on the beating heart and thus replacing intracardiac knotting (Figure 1A) . The introducer sheath is removed, and the LV entry site is closed with a custom-made polymer occluder placed over the suture arms. The sutures are pulled and released until a good coaptation of the prolapsed/flail segment is achieved on the beating heart with transesophageal echocardiographic (TEE) guidance (Figure 1B). The exteriorized suture lengths are locked with the separate loop knot and secured to the exterior of the myocardial entry site occluder (Figure 2).Figure 2Scheme of the technique. The exteriorized sutures are initially fixated at the desired level, with the preformed loop knot (eg, “bowline”) attached to the occluder. This loop knot does not slip. The additional “stopper” knots cannot slide through the solid occluder.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Between March and December 2007, 6 male patients aged 64 to 73 years with extensive prolapse, flail, or both of the posterior (n = 4) and anterior (n = 2) mitral leaflets underwent mitral repair with the described procedure. All 6 patients had significant heart failure (New York Heart Association class III–IV) caused by severe MR 2 to 6 weeks before surgical intervention. Degenerative mitral disease was present in all, although only 1 patient had concomitant coronary artery disease treated with percutaneous intervention. The mitral annulus and the LA were not significantly enlarged in any of the patients. Informed consent was obtained from each patient. The procedure was approved by the institutional review board. No other interventions were performed during the operation. Cardiopulmonary bypass time ranged from 40 to 70 minutes, and aortic cross-clamp time ranged from 5 to 15 minutes. MR was abolished in 2 patients, reduced to less than grade I in 3 patients, and reduced to grade II in 1 (coronary diseased) patient. Inappropriate leaflet tethering during the procedure resulted in significant residual MR in this patient. No complications occurred. At 6 months' follow-up, MR increased from grade II to grade III in the 1 patient with coronary artery disease, whereas no changes were observed in 5 patients, as seen with TEE analysis. No major events were reported at follow-up. The complexity during insertion of neochordae includes determining chordal length on a nonbeating heart, securing the neochordae to the leaflet, and knot sliding.2Gilinov M. Banbury K.M. Pre-measured artificial chordae for mitral valve repair.Ann Thorac Surg. 2007; 84: 2127-2129Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar The technique here described enables a dynamic adjustment of the chordal length on a beating heart controlled by TEE. External fixation of the neochordae on a beating heart under TEE guidance has been used for the tricuspid valve3Baufreton C. Laporte J. Langlais J. Mehreb M. Binuani P. De Brux J.L. Transesophageal echocardiography-guided chordal replacement for tricuspid regurgitation.Ann Thorac Surg. 2004; 77: 1811-1813Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar and also for repair of the prolapsed aortic valve leaflet.4Fattouch K. Sampognaro R. Bianco G. et al.Implantation of Gore-Tex chordae on aortic valve leaflet to treat prolapse using “the chordae technique”: surgical aspects and clinical results.Ann Thorac Surg. 2008; 85: 2019-2024Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar Use of the elastic polymer tube that covers the suture loops, longitudinally tightening them to the leaflet, replaces the intracardiac knots. The suture anchorage in the myocardial occluder–type plug contributes to the shock absorption. We used a biocompatible polymer tube, which is used for permanent pacemaker lead insulation and has a well-established safety record. Strong tube attachment to the mitral leaflet and the LV apical endocardium has been reported 10 years after inadvertent pacemaker lead placement through the perforated posterior mitral leaflet.5Konings T.C. Koolbergen D.R. Bouma B.J. et al.Iatrogenic perforation of the posterior mitral valve leaflet: a rare complication of pacemaker lead placement.J Am Soc Echocardiogr. 2008; 21 (512.e5-e7)PubMed Google Scholar The expanded polytetrafluoroethylene sutures were not available at our institution. The long-term intracorporal physical characteristics of the unit composed of 2-0 Prolene suture loops covered with the polymer tube have yet to be investigated. The breaking strength of this unit is about 10 kg. Long-term follow-up and extensive studies are needed to establish the real value of this technique. Its simplicity might enable less experienced centers to perform isolated chordal replacement, especially in patients with acute onset of MR without annulus enlargement.