Latest research has indicated a potential adverse effect on graft patency rates and clinical outcomes with skeletonizing the left internal thoracic artery. We aim to provide a prospective, randomized, multicentre trial to compare skeletonized versus pedicled harvesting technique of left internal thoracic artery concerning graft patency rates and patient survival. A total of 1350 patients will be randomized to either skeletonized or pedicled harvesting technique and undergo surgical revascularization. Follow-up will be performed at 30 days, 1 year, 2 years and 5 years after surgery. The primary outcome will be death or left internal thoracic artery graft occlusion in coronary computed tomography angiography or invasive angiography within 2 years (+/- 3 months) after surgery. The secondary outcome will be major adverse cardiac events (composite outcome of all-cause death, myocardial infarction and repeated revascularization) within 1 year, 2 years and 5 years after surgery. The primary end point will be compared in the modified intention-to-treat population between the two treatment groups using Kaplan-Meier graphs, together with log-rank testing. Hereby, we present the study protocol of the first adequately powered prospective, randomized, multicentre trial which compares skeletonized and pedicled harvesting technique of left internal thoracic artery regarding graft patency rates and patient survival.

OBJECTIVES: Myocardial hypertrophy results in increased levels of cardiac biomarkers in healthy individuals and in patients suffering from acute myocardial infarction. The influence of cardiac mass on postoperative cardiac biomarkers release remains unclear. This study investigated the correlation between myocardial mass and the release of high-sensitivity cardiac Troponin T (hs-cTnT) and creatine kinase-myocardial band (CK-MB) after isolated aortic valve replacement (AVR) or bypass surgery.METHODS: Myocardial mass of a consecutive retrospective series of patients was measured automatically using preoperative computer tomography scans (636 patients, AVR = 251; bypass surgery = 385). Levels of cardiac biomarkers were measured before and serially after surgery. Spearman and Pearson correlation and a multivariate regression model was performed to measure the degree of association between myocardial mass and the release of hs-cTnT and CK-MB.RESULTS: Patients were divided into 3 tertiles according to their myocardial mass index. Higher biomarker levels were measured preoperatively in the upper tertile of patients undergoing AVR (P = 0.004) or bypass surgery (P < 0.001). Patients with different heart sizes showed no differences in postoperative biomarker release neither after AVR nor bypass surgery. No statistical significant correlation was observed between myocardial mass index and postoperative release of hs-cTnT or CK-MB in any subgroup (rho maximum 0.106).CONCLUSIONS: Postoperative biomarker release is not correlated with myocardial mass. Patient factors leading to increased postoperative biomarker levels need to be elucidated in future studies.

ObjectiveIn patients with complex coronary artery disease (CAD) undergoing cardiac surgery, myocardial protection might be impaired due to microvascular obstruction, resulting in myocardial injury and subsequent biomarker release. Therefore, this study investigated the correlation between the complexity of CAD, reflected by the SYNTAX Score, and the release of cardiac biomarkers after CABG.MethodsIn a consecutive series of 919 patients undergoing isolated CABG SYNTAX scores I and II were calculated to assess the complexity of CAD. Levels of high sensitivity cardiac troponin T (hs-cTnT) and creatine kinase-myocardial band (CK-MB) were routinely measured once before and serially after surgery. Patients were divided into tertiles according to their SYNTAX Scores I and II. Spearman correlations and regression models were performed to measure the degree of association between the release of hs-cTnT and CK-MB and the SYNTAX Scores.ResultsPatients with a higher SYNTAX Score I had more comorbidities reflected in a higher EuroSCORE II. Preoperatively, higher levels of cardiac biomarkers were found in patients with higher SYNTAX Score II. No correlation was observed between hs-cTnT, CK-MB and SYNTAX Score I or II. Regression models did not show any association between cardiac biomarkers and the complexity of CAD.ConclusionThe complexity of CAD is not associated with the release of cardiac biomarkers after CABG. Factors influencing postoperative biomarker release need to be elucidated in future trials to include postoperative biomarker release into risk stratification models predicting outcome after cardiac surgery.

BACKGROUND:Extracorporeal membrane oxygenation (ECMO) is frequently used for emergency support in patients with profound cardiogenic shock (CS) of all etiologies. However, no controlled study investigating ECMO in myocardial infarction (AMI)-induced CS is available.METHODS:Retrospective analysis of patients experiencing AMI induced CS; ECMO therapy vs. non ECMO therapy. A total of 476 patients with AMI-induced CS were investigated. One hundred twenty-seven patients (26.7%) received emergency veno-arterial ECMO support, 349 patients did not receive ECMO support. Patients were propensity score matched based on relevant clinical and laboratory factors and revealed 127 matched pairs.RESULTS:Mean age of patients was 65.0±12.3 years and mean Syntax score was 25.9±7.3 in the full unmatched patient population. Survival at 1, 3 and 5 years after CS was 45.6%, 43.5%, and 41.3% in the ECMO group and 17.4%, 15.8%, and 14.9% in the full unmatched control group (log-rank: P<0.001). After propensity score matching, 1-, 3-, and 5-year survival was 14.4%, 13.5%, and 11.2% in the matched control group (P<0.001). Cox regression analysis identified ECMO support (HR: 2.57; 95% CI: 1.89-3.50; P<0.001) and completeness of revascularization (HR: 1.89; 95% CI: 1.74-2.34, P=0.003) to be independent predictors for long term survival.CONCLUSIONS:Extracorporeal life support by ECMO significantly increased survival in patients with AMI-induced CS. ECMO insertion increased survival probability 2.57-fold and should be considered as first line treatment in patients with profound AMI-induced CS.

Background The relevance of perioperative myocardial injury (PMI) after cardiac surgery for 30-day mortality and long-term survival remains to be determined.Objectives This study assessed the association of PMI after cardiac surgery, reflected by postoperative troponin release, with 30-day mortality and long-term survival after: 1) coronary artery bypass grafting (CABG); 2) isolated aortic valve replacement (AVR) surgery; and 3) all other cardiac surgeries.Methods A consecutive cohort of 8,292 patients undergoing cardiac surgery with serial perioperative high-sensitivity cardiac troponin T (hs-cTnT) measurements was retrospectively analyzed. The relationship between postoperative hs-cTnT release and 30-day mortality or 5-year mortality was analyzed after adjustment with EuroSCORE II using a Cox proportional hazards model. hs-cTnT thresholds for 30-day and 5-year mortality were determined for isolated CABG (32.3%), AVR (14%), and other cardiac surgery (53.8%).Results High postoperative hs-cTnT levels were associated with higher 30-day mortality but not 5-year mortality. In CABG, median peak concentration of postoperative hs-cTnT was 1,044 ng/L, in AVR it was 502 ng/L, and in other cardiac surgery it was 1,110 ng/L. hs-cTnT thresholds defining mortality-associated PMI were as follows: for CABG, 2,385 ng/L (170x the upper reference limit of normal in a seemingly healthy population [URL]); for AVR, 568 ng/L (41x URL); and for other cardiac procedures, 1,873 ng/L (134x URL). hs-cTnT levels above the cutoffs resulted in an HR for 30-day mortality for CABG of 12.56 (P < 0.001), for AVR of 4.44 (P = 0.004), and for other cardiac surgery of 3.97 (P < 0.001).Conclusions PMI reflected by perioperative hs-cTnT release is associated with the expected 30-day mortality but not 5-year mortality. Postoperative hs-cTnT cutoffs to identify survival-relevant PMI are higher than suggested in current definitions.

Background: Despite numerous advantages of skeletonized left internal thoracic artery grafts, latest research shows adverse patency rates and clinical outcome of skeletonized versus pedicled left internal thoracic artery harvesting after coronary artery bypass grafting.

Background: SYNTAX Score II has been internally and externally validated according to predictive capability for mortality rates after coronary artery bypass grafting mainly in left-main and multivessel coronary artery disease.

Aims The most appropriate definition of perioperative myocardial infarction (pMI) after coronary artery bypass grafting (CABG) and its impact on clinically relevant long-term events is controversial. We aimed to (i) analyse the incidence of pMI depending on various current definitions in a 'real-life' setting of CABG surgery and (ii) determine the long-term prognosis of patients with pMI depending on current definitions. Methods and results A consecutive cohort of 2829 coronary artery disease patients undergoing CABG from two tertiary university centres with the presence of serial perioperative cardiac biomarker measurements (cardiac troponin and creatine kinase-myocardial band) were retrospectively analysed. The incidence and prognostic impact of pMI were assessed according to (i) the 4th Universal Definition of Myocardial Infarction (4UD), (ii) the definition of the Society for Cardiovascular Angiography and Interventions (SCAI), and (iii) the Academic Research Consortium (ARC). The primary endpoint of this study was a composite of myocardial infarction, all-cause death, and repeat revascularization; secondary endpoints were mortality at 30 days and during 5-year follow-up. There was a significant difference in the occurrence of pMI (49.5% SCAI vs. 2.9% 4UD vs. 2.6% ARC). The 4th Universal Definition of Myocardial Infarction and ARC criteria remained strong independent predictors of all-cause mortality at 30 days [4UD: odds ratio (OR) 12.18; 95% confidence interval (CI) 5.00-29.67; P < 0.001; ARC: OR 13.16; 95% CI 5.41-32.00; P < 0.001] and 5 years [4UD: hazard ratio (HR) 2.13; 95% CI 1.19-3.81; P = 0.011; ARC: HR 2.23; 95% CI 1.21-4.09; P = 0.010]. Moreover, the occurrence of new perioperative electrocardiographic changes was prognostic of both primary and secondary endpoints. Conclusion Incidence and prognosis of pMI differ markedly depending on the underlying definition of myocardial infarction for patients undergoing CABG. Isolated biomarker release-based definitions (such as troponin) were not associated with pMI relevant to prognosis. Additional signs of ischaemia detected by new electrocardiographic abnormalities, regional wall motion abnormalities, or coronary angiography should result in rapid action in everyday clinical practice. Key question We aimed to (i) analyse the incidence of perioperative myocardial infarction (pMI) depending on different current definitions in a 'real-life' setting of coronary artery bypass graft surgery and (ii) determine the long-term prognosis of patients with pMI according to current definitions. Key finding There was a significant difference in the occurrence of pMI. The 4th Universal Definition of Myocardial Infarction and Academic Research Consortium criteria remained strong independent predictors for all-cause mortality at 30 days and during 5-year follow-up. Take-home message Isolated biomarker release-based definitions were not associated with pMI relevant to prognosis. Additional signs of ischaemia detected by new electrocardiogram abnormalities, regional wall motion abnormalities, or coronary angiography should result in rapid action in clinical practice.

Abstract   OBJECTIVES Surgical treatment of destructive infective endocarditis consists of extensive debridement followed by root repair or replacement. However, it remains unknown whether 1 is superior to the other. We aimed to analyse whether long-term results were better after root repair or replacement in patients with root endocarditis. METHODS A total of 148 consecutive patients with root endocarditis treated with surgery from 1997 to 2020 at our department were included. Patients were divided into 2 groups: aortic root repair (n = 85) or root replacement using xenografts or homografts (n = 63). RESULTS Patients receiving aortic root repair showed significantly better long-term survival compared to patients receiving aortic root replacement (log-rank: P = 0.037). There was no difference in terms of freedom from valvular reoperations among both treatment groups (log-rank: P = 0.58). Patients with aortic root repair showed higher freedom from recurrent endocarditis compared to patients with aortic root replacement (log-rank: P = 0.022). Patients with aortic root repair exhibited higher event-free survival (defined as a combination end point of freedom from death, valvular reoperation or recurrent endocarditis) compared to patients receiving aortic root replacement (log-rank: P = 0.022). Age increased the risk of mortality with 1.7% per year. Multi-variable adjusted statistical analysis revealed improved long-term event-free survival after aortic root repair (hazards ratio: 0.57, 95% confidence interval: 0.39–0.95; P = 0.031). CONCLUSIONS Aortic root repair and replacement are feasible options for the surgical treatment of root endocarditis and are complementary methods, depending on the extent of infection. Patients with less advanced infection have a more favourable prognosis. Clinical trial registration UN4232 382/3.1 (retrospective study).

Background: Female sex is protective against coronary artery disease (CAD). However, CAD is still underdiagnosed in women, and current data on their outcome after CABG remain controversial. The aim of this study was to (1) determine the impact of sex on outcome after CABG surgery and (2) identify responsible factors.

OBJECTIVES: A treatment dilemma arises when surgery is indicated in patients with infective endocarditis (IE) complicated by stroke. Neurologists recommend surgery to be postponed for at least 1 month. This study aims to investigate the neurological complication rate and neurological recovery potential in patients with IE-related stroke. METHODS: A total of 440 consecutive patients with left-sided IE undergoing surgery were investigated. During follow-up, neurological recovery was assessed using the modified Rankin scale and the Barthel index. Mortality was assessed with regression models adjusting for age. RESULTS: The median follow-up time was 9.0 years. Patients with previous strokes were more likely to suffer from mitral valve endocarditis (29.5% vs 47.4%, P < 0.001). Symptomatic stroke was found in 135 (30.7%) patients; of them, 42 patients presented with complicated stroke (additional meningitis, haemorrhagic stroke or intracranial abscess). Driven by symptomatic stroke, the age-adjusted hospital mortality risk was 1.4-fold [95% confidence interval (CI) 0.74-2.57; P = 0.31] higher and the long-term mortality risk was 1.4-fold higher (95% CI 1.003-2.001; P = 0.048). Hospital mortality was higher in patients with complicated stroke (21.4% vs 9.7%; P = 0.06) only; however, mortality rates were similar comparing uncomplicated stroke versus no stroke. Among patients with complicated ischaemic strokes, the observed risk for intraoperative cerebral haemorrhage was 2.3% only and the increased hospital mortality was not driven by cerebral complications. In the long-term follow-up, full neurological recovery was observed in 84 out of 118 survivors (71.2%), and partial recovery was observed in 32 (27.1%) patients. Neurological recovery was lower in patients with complete middle cerebral artery stroke compared to other localization (52.9% vs 77.6%; P = 0.003). CONCLUSIONS: Contrary to current clinical practice and neurological recommendations, early surgery in IE is safe and neurological recovery is excellent among patients with IE-related stroke.

OBJECTIVES Parental cardiovascular disease (CVD) is a known risk factor for premature CVD. It is unknown whether a positive family history (PFH) affects outcomes after coronary artery bypass grafting (CABG). METHODS Data come from a retrospective longitudinal study of CABG patients consecutively recruited from 2001 to 2018 (n = 5389). From this study, 2535 patients with premature CVD undergoing CABG under the age of 60 years and information on parental CVD were identified. The Framingham offspring study criteria were used to identify PFH of CVD. Multivariable Cox proportional hazards regression models were used to assess the effect of PFH on overall and major adverse cardiovascular and cerebrovascular event-free survival. RESULTS A total of 273 deaths and 428 major adverse cardiovascular and cerebrovascular events occurred during follow-up. PFH of CVD was found in 54.2% of patients (n = 1375). Within these patients, 66.1% had a father who experienced a premature cardiovascular event (n = 909), 27.8% a mother (n = 382) and 6.1% both a mother and a father (n = 84). In the majority of cases, the patient's parent had experienced a cardiac event (85.9%, n = 1181) and 14.1% of patients with PFH reported parental stroke (n = 194). Following CABG, PFH was associated with improved overall [adjusted hazards ratio (HR) 0.67, 95% confidence interval (CI) 0.50-0.90; P = 0.008] and major adverse cardiovascular and cerebrovascular event-free survival (adjusted HR 0.73, 95% CI 0.68-0.89; P = 0.01). Among the covariates adjusted for age, diabetes, renal insufficiency, peripheral arterial disease, ejection fraction, previous cerebrovascular events and previous mediastinal radiation were all associated with poorer outcomes. CONCLUSIONS Although it is well established that a PFH increases the risk of requiring CABG at younger ages, this study shows that, paradoxically, PFH is also protective regarding long-term outcomes. REGISTRATION NUMBER LOCAL IRB UN4232 297/4.3 (retrospective study).