Background: Minimally invasive heart valve surgery via anterolateral mini-thoracotomy with full endoscopic 3D visualization (MIS) has become the standard treatment of patients with valvular heart disease and low operative risk over the past two decades. It requires extracorporeal circulation and cardioplegic arrest. The most established form of arterial cannulation for MIS is through the femoral artery and is used by most surgeons, but it is suspected to increase the risk of stroke through retrograde blood flow. An alternative route of cannulation is the axillary artery, producing antegrade blood flow during extracorporeal circulation. Methods: Femoral or axillary cannulation for extracorporeal circulation during minimally invasive heart valve surgery (FAMI) is a multicenter randomized controlled trial designed to determine whether axillary cannulation is superior to femoral cannulation for the outcome of a manifest stroke within 7 days postoperatively. The target sample size was 848 participants. Patients ≥ 18 years of age, with valvular regurgitation or stenosis scheduled for minimally invasive surgery via anterolateral mini-thoracotomy, were randomized to axillary cannulation (treatment group) or to femoral cannulation (standard care). Patients were followed up for seven days postoperatively. A CT scan was performed pre-operatively to screen patients for vascular calcifications and to assess the safety of femoral cannulation. The standard of care is femoral artery cannulation, but is performed only in patients without significant vascular calcifications or severe kinking of the iliac arteries and in patients with sufficient vessel diameter. The cannulation is performed via Seldinger’s technique, and the vessel closed percutaneously using a plug-based vascular closure device. Only patients without significant vascular calcifications are considered for femoral cannulation, as an increased risk of stroke is assumed. In patients with vascular calcifications, axillary cannulation is the standard of care to avoid these risks. Retrospective studies have hinted that, even in patients without vascular calcifications, there may be a lower stroke risk with axillary cannulation compared to femoral cannulation. We present a protocol for a multi-center randomized trial to investigate this hypothesis. Discussion: To date, evidence on the best access for peripheral artery cannulation during minimally invasive heart valve surgery has been scarce. Patients may benefit from axillary cannulation for extracorporeal circulation in terms of stroke risk and other neurological and vascular complications, though femoral cannulation is the gold standard. The aim of this study is to determine the risks of peri-operative stroke in a prospective randomized comparison of femoral vs. axillary cannulation.

Objectives: Minimally invasive direct coronary artery bypass (MIDCAB) is an alternative for revascularisation of the isolated left anterior descending (LAD) artery or as a multi-vessel (MV) procedure for the diagonal branch (RD) or the left circumflex coronary artery (LCX) region. Methods: From 2021 to 2022, 91 patients underwent MIDCAB or multi-vessel MIDCAB procedures in our heart center. The left internal mammary artery (LIMA) was anastomosed to the left anterior descending artery via the left minithoracotomy approach in all patients. Results: Of the patients, a total of 86.8% were male. Eighty percent of the patients had two- or three-vessel coronary artery disease. The mean age was 65.1 ± 10.1 years. The mean operation time was 2.6 ± 0.8 h. The 30-day mortality was 0. The mean required packed red blood cells (pRBC) was 0.4 ± 1.2 unit. The mean intensive care unit stay (ICU) was 1.5 ± 1.6 days. The mean follow-up time was 1.5 ± 0.5 years. One patient received percutaneous coronary intervention due to de novo stenosis of the RCA. Late mortality was 2.2%. The Kaplan–Meier survival rate was 98.8% at 1 and 2 years. Conclusions: The postoperative complication rate of our MIDCAB cohort is low, and the short-term survival is favorable. Our postoperative and short-term clinical results demonstrate that this procedure is safe and feasible.

Objectives: Minimally invasive direct coronary artery bypass (MIDCAB) is an alternative for revascularisation of isolated left anterior descending (LAD) or as multi-vessel (MV) procedure for diagonal branch (RD) or circumflex artery (RCX) region. Methods: From 2021 to 2022 91 patients underwent MIDCAB procedure in our heartcenter. 80% were male. Eighty percent of the patients had two or three vessel coronary artery disease. Mean age was 65±10 years. The left internal mammary artery (LIMA) was anastomosed to the left anterior descending via left minithoracotomy approach in all patients. Fourteen patients received multi-vessel MIDCAB (15%) with two or three anastomoses a saphenous vein graft (as T-graft to LIMA) was anastomosed to RD or RCX. Results: Mean operation time was 2.6±0.8 hours. The 30-day mortality was 0. Mean required packed red blood cells (pRBC) was 0.4±1.2 unit. The intensive care unit stay (ICU) was 1.5±1.6 days mean. We observed two patients (2%) with wound infections postoperatively. Four patients underwent rethoracotomy because of bleeding. Mean follow-up time was 1.5±0.5 years. Seventy-eight patients (86%) were in New York Heart Association (NYHA) class 1, 11 patients (12%) were in NYHA class 2. One patient received percutaneous coronary intervention due to de novo stenosis of the RCA. Late mortality was 2%. The Kaplan-Meier survival rate was 98.8% at 1 and 2 years. Conclusion: MIDCAB is technically demanding. Our postoperative and short-term clinical results demonstrate that this procedure is safe and feasible. Optimal patient selection and an experienced surgical team are mandatory.

Objectives: The HOSTILE score was developed to assess femoral access challenges in transcatheter valve therapy. Similar vascular issues arise in femoral cannulation for minimally invasive valve surgery, making CT-based planning essential. We adapted the score for surgical use (MOD-HOSTILE) and evaluated its association with neurological and adverse outcomes. Methods: In this single-center retrospective study, the MOD-HOSTILE score (0–11 points) was calculated for 364 patients undergoing minimally invasive heart valve surgery from 2019 to 2023. Patients were stratified into low (0–2), mild (>2–5), and high (>5–11) score categories. Outcomes included 30-day stroke, other neurological events, and perioperative complications. Results: High MOD-HOSTILE patients were significantly older (70 [64.7–73.0] vs. 61 [60.0–63.0] years; p < 0.01) and had higher surgical risk (EuroSCORE II 1.79 [1.26–2.16] vs. 0.83 [0.75–0.94]; p < 0.01). Neurological complications were more frequent in the high MOD-HOSTILE group, including stroke (8.7% vs. 0.9%; p = 0.02) and hemiplegia (13.0% vs. 0.9%; p < 0.01). Axillary cannulated patients had higher MOD-HOSTILE scores than femoral cannulated patients. Stroke risk was highest in patients with high MOD-HOSTILE score undergoing axillary cannulation (high vs. low MOD-HOSTILE, 18.2% vs. 0%; p = 0.04). Thirty-day mortality was comparable between groups (p = 0.09). MOD-HOSTILE predicted stroke with an AUC of 0.78 (95% CI 0.73–0.82) and OR 1.4 per point (95% CI 1.1–2.0). Conclusions: The MOD-HOSTILE score identifies vascular and neurological risk in minimally invasive valve surgery, with scores ≥5 indicating elevated risk of stroke and delirium. Patients with high scores may benefit from alternative surgical strategies.

Background: The impact of obesity on outcomes following minimally invasive direct coronary artery bypass (MIDCAB) and multivessel MIDCAB (MV-MIDCAB) remains incompletely understood. Methods: This retrospective, single-centre analysis included 383 patients with available body mass index (BMI) data: 275 non-obese patients (BMI < 30 kg/m²) and 108 obese patients (BMI ≥ 30 kg/m²). Propensity score matching based on available preoperative covariates yielded 105 matched pairs. Baseline balance was assessed using standardized mean differences (SMDs). Results: Multivessel MIDCAB was performed in 41.9% of obese and 44.8% of non-obese patients (p = 0.755), while complete revascularization was achieved in 32.4% and 33.3%, respectively (p = 1.000). Acute kidney injury occurred in 6.7% of obese and 3.8% of non-obese patients (p = 0.549), while postoperative delirium occurred in 8.7% and 5.7%, respectively (p = 0.581). Wound infection was documented in 3 obese patients (2.9%) and 1 non-obese patient (1.0%; risk difference, 1.9 percentage points; approximate 95% confidence interval [CI], −1.8 to 5.7; exact paired p = 0.625). In-hospital mortality occurred in 1 obese patient and no non-obese patients (risk difference, 1.0 percentage point; approximate 95% CI, −0.9 to 2.8; exact paired p = 1.000). Conclusions: No statistically significant differences in early outcomes were detected.

Background/Objectives: Transcatheter mitral valve-in-valve (ViV) and valve-in-ring (ViR) procedures have emerged as alternative treatment options for failed mitral valves following prior bioprosthetic replacement or ring annuloplasty. However, redo surgical mitral valve replacement (redo-MVR) remains the standard therapy despite its perceived higher procedural risk. This study aimed to descriptively compare short- and long-term outcomes of ViV/ViR and redo-MVR. Methods: We retrospectively included patients older than 60 years who underwent treatment of failed mitral valve bioprostheses or repairs between 2000 and 2022 (n = 30; ViV/ViR cohort: 2008–2022). Patients treated with ViV/ViR (n = 15) were compared with those undergoing redo-MVR (n = 15). Endpoints were reported according to Mitral Valve Academic Research Consortium (MVARC) criteria. Technical, device, and procedural success were defined according to the MVARC criteria and applied identically to both groups. Owing to the small sample size and substantial baseline differences, this study is descriptive and hypothesis-generating. Results: Patients in the ViV/ViR group were significantly older than redo-MVR patients (76.9 ± 5.8 vs. 68.0 ± 8.4 years, p < 0.001). EuroSCORE II did not differ significantly between groups. Thirty-day mortality was comparable, with one death in the ViV/ViR group and none after redo-MVR (6.7% vs. 0%, p = 1.00). Device success at 30 days was significantly higher after redo-MVR compared with ViV/ViR (86.7% vs. 40.0%, p = 0.02). Neurological events were rare and similar between groups. Degenerated bioprostheses were more frequent in the ViV/ViR group (86.6%), whereas prior annuloplasty ring implantation predominated in redo-MVR patients (80.0%, p < 0.01). Pre-procedural and discharge mitral valve gradients were higher in ViV/ViR patients. Implanted valve size was smaller in the ViV/ViR cohort (28.2 ± 1.4 vs. 29.5 ± 1.8 mm, p = 0.03). Conclusions: In this small, retrospective, single-center cohort with substantial baseline differences (e.g., age), 30-day mortality was low in both groups. Device success was higher after redo-MVR, mainly because of higher postoperative gradients after ViV/ViR. These findings are descriptive and hypothesis-generating and do not constitute evidence of comparative treatment effectiveness. Both approaches may be considered complementary options guided by a multidisciplinary heart team.