Publications by authors named "Jos G Maessen"

183 Publications

Ablation of persistent atrial fibrillation: the added value of hybrid.

Eur J Cardiothorac Surg 2021 Apr 11. Epub 2021 Apr 11.

Department of Cardiothoracic Surgery, Maastricht University Medical Centre, Maastricht, Netherlands.

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http://dx.doi.org/10.1093/ejcts/ezab170DOI Listing
April 2021

A hybrid approach to complex arrhythmias.

Europace 2021 Apr;23(Supplement_2):ii28-ii33

Department of Cardiothoracic Surgery, Maastricht University Medical Center, Maastricht, the Netherlands.

Despite many years of research, the different aspects of the mechanism of atrial fibrillation (AF) are still incompletely understood. And although the latest guidelines recommend catheter ablation with pulmonary vein isolation as a rhythm control strategy, long-term results in persistent and long-standing persistent AF are suboptimal. Historically, a mechanistic-based patient-tailored approach for the treatment of AF was impossible because of the lack real-time mapping techniques and advanced ablation tools. Therefore, surgeons created lesion sets based upon the anatomy of both atria and the safety of the incisions made by the knife. These complex open-heart procedures had to be performed through a sternotomy on the arrested heart and where therefore not generally adopted. The use of controlled energy sources such as cryothermy and radiofrequency where the first step to make the creation of these lesions less complex. With the development and improvement of electrophysiology techniques and catheters, this invasive and solely anatomical approach could again be partially redesigned. Now less invasive, it prepared the way for collaboration between electrophysiologists working on the endocardial side of the heart and cardiac surgeons providing epicardial access. The introduction of video-assisted technology and hybrid procedures has further increased the possibilities of new successful therapies. Now more than 40 years since the beginning of this exciting maze of AF procedures and still working towards a less aggressive and more comprehensive approach we give an overview of the history of the different minimally invasive surgical solutions and of the hybrid approach.
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http://dx.doi.org/10.1093/europace/euab027DOI Listing
April 2021

Effect of a dedicated mitral heart team compared to a general heart team on survival: a retrospective, comparative, non-randomized interventional cohort study based on prospectively registered data.

Eur J Cardiothorac Surg 2021 Mar 30. Epub 2021 Mar 30.

Department of Cardiothoracic Surgery, Maastricht University Medical Center (MUMC+), Maastricht, Netherlands.

Objectives: Although in both the US and European guidelines the 'heart team approach' is a class I recommendation, supporting evidence is still lacking. Therefore, we sought to provide comparative survival data of patients with mitral valve disease referred to the general and the dedicated heart team.

Methods: In this retrospective cohort, patients evaluated for mitral valve disease by a general heart team (2009-2014) and a dedicated mitral valve heart team (2014-2018) were included. Decision-making was recorded prospectively in heart team electronic forms. The end point was overall survival from decision of the heart team.

Results: In total, 1145 patients were included of whom 641 (56%) were discussed by dedicated heart team and 504 (44%) by general heart team. At 5 years, survival probability was 0.74 [95% confidence interval (CI) 0.68-0.79] for the dedicated heart team group compared to 0.70 (95% CI 0.66-0.74, P = 0.040) for the general heart team. Relative risk of mortality adjusted for EuroSCORE II, treatment groups (surgical, transcatheter and non-intervention), mitral valve pathology (degenerative, functional, rheumatic and others) and 13 other baseline characteristics for patients in the dedicated heart team was 29% lower [hazard ratio (HR) 0.71, 95% CI 0.54-0.95; P = 0.019] than for the general heart team. The adjusted relative risk of mortality was 61% lower for patients following the advice of the heart team (HR 0.39, 95% CI 0.25-0.62; P < 0.001) and 43% lower for patients following the advice of the general heart team (HR 0.57, 95% CI 0.37-0.87; P = 0.010) compared to those who did not follow the advice of the heart team.

Conclusions: In this retrospective cohort, patients treated for mitral valve disease based on a dedicated heart team decision have significantly higher survival independent of the allocated treatment, mitral valve pathology and baseline characteristics.
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http://dx.doi.org/10.1093/ejcts/ezab065DOI Listing
March 2021

Do Women Require Less Permanent Pacemaker After Transcatheter Aortic Valve Implantation? A Meta-Analysis and Meta-Regression.

J Am Heart Assoc 2021 Apr 27;10(7):e019429. Epub 2021 Mar 27.

Department of Cardio-Thoracic Surgery Heart and Vascular Centre Maastricht University Medical Centre (MUMC) Maastricht The Netherlands.

Background Limited clinical evidence and literature are available about the potential impact of sex on permanent pacemaker implantation (PPI) after transcatheter aortic valve implantation (TAVI). The aim of this work was to evaluate the relationship between sexes and atrioventricular conduction disturbances requiring PPI after TAVI. Methods and Results Data were obtained from 46 studies from PubMed reporting information about the impact of patient sex on PPI after TAVI. Total proportions with 95% Cls were reported. Funnel plot and Egger test were used for estimation of publication bias. The primary end point was 30-day or in-hospital PPI after TAVI, with odds ratios and 95% CIs extracted. A total of 70 313 patients were included, with a cumulative proportion of 51.5% of women (35 691 patients; 95% CI, 50.2-52.7). The proportion of women undergoing TAVI dropped significantly over time (<0.0001). The cumulative PPI rate was 15.6% (95% CI, 13.3-18.3). The cumulative rate of PPI in women was 14.9% (95% CI, 12.6-17.6), lower than in men (16.6%; 95% CI, 14.2-19.4). The risk for post-TAVI PPI was lower in women (odds ratio, 0.90; 95% CI, 0.84-0.96 [=0.0022]). By meta-regression analysis, age (=0.874) and ventricular function (=0.302) were not significantly associated with PPI among the sexes. Balloon-expandable TAVI significantly decrease the advantage of women for PPI, approaching the same rate as in men (=0.0061). Conclusions Female sex is associated with a reduced rate of PPI after TAVI, without influence of age or ventricular function. Balloon-expandable devices attenuate this advantage in favor of women. Additional investigations are warranted to elucidate sex-based differences in developing conduction disturbances after TAVI.
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http://dx.doi.org/10.1161/JAHA.120.019429DOI Listing
April 2021

Incidence, prevalence, and trajectories of repetitive conduction patterns in human atrial fibrillation.

Europace 2021 Mar;23(Supplement_1):i123-i132

Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands.

Aims: Repetitive conduction patterns in atrial fibrillation (AF) may reflect anatomical structures harbouring preferential conduction paths and indicate the presence of stationary sources for AF. Recently, we demonstrated a novel technique to detect repetitive patterns in high-density contact mapping of AF. As a first step towards repetitive pattern mapping to guide AF ablation, we determined the incidence, prevalence, and trajectories of repetitive conduction patterns in epicardial contact mapping of paroxysmal and persistent AF patients.

Methods And Results: A 256-channel mapping array was used to record epicardial left and right AF electrograms in persistent AF (persAF, n = 9) and paroxysmal AF (pAF, n = 11) patients. Intervals containing repetitive conduction patterns were detected using recurrence plots. Activation movies, preferential conduction direction, and average activation sequence were used to characterize and classify conduction patterns. Repetitive patterns were identified in 33/40 recordings. Repetitive patterns were more prevalent in pAF compared with persAF [pAF: median 59%, inter-quartile range (41-72) vs. persAF: 39% (0-51), P < 0.01], larger [pAF: = 1.54 (1.15-1.96) vs. persAF: 1.16 (0.74-1.56) cm2, P < 0.001), and more stable [normalized preferentiality (0-1) pAF: 0.38 (0.25-0.50) vs. persAF: 0.23 (0-0.33), P < 0.01]. Most repetitive patterns were peripheral waves (87%), often with conduction block (69%), while breakthroughs (9%) and re-entries (2%) occurred less frequently.

Conclusion: High-density epicardial contact mapping in AF patients reveals frequent repetitive conduction patterns. In persistent AF patients, repetitive patterns were less frequent, smaller, and more variable than in paroxysmal AF patients. Future research should elucidate whether these patterns can help in finding AF ablation targets.
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http://dx.doi.org/10.1093/europace/euaa403DOI Listing
March 2021

Predictors of lung recurrence and disease-specific mortality after pulmonary metastasectomy for soft tissue sarcoma.

Surg Oncol 2021 Feb 20;37:101532. Epub 2021 Feb 20.

Cardiovascular Research Institute Maastricht - CARIM, Maastricht University Medical Center, the Netherlands. Electronic address:

Background: We identified prognostic factors in a 30-year series of STS treated at a single Institution, using an advanced statistical approach.

Methods: From June 1988 to July 2019, 164 patients were referred to Rizzoli Orthopedic Hospital, Bologna, Italy) for STS lung metastasectomy (LMTS). The endpoints were lung metastasis recurrence (LMR) and lung metastasis-specific mortality (LMSM). The analysis included directed acyclic graphs, cubic splines, and a competing risk model in order to minimize bias.

Results: The 10- and 15- year LMR cumulative incidence were 0.77 (0.76-0.78) whereas 10- and 15- year freedom from LMSM were 0.60 [0.51-0.70] and 0.56 [0.47-0.67], respectively. The malignant peripheral nerve sheath tumor (MPNST) histotype (SHR 4.12 [2.05-8.27]), a disease-free interval (DFI) up to 68 months (HR from 2 [1.7-2.2] to 1.5 [1.1-1.9]) and a LM size ≥4 mm (3.1 [2.1-4.4]) predicted LMR. Myxofibrosarcoma (HR 2.52[1.64-3.86]), synovial sarcoma (2.53[1.22-5.23]), adjuvant chemotherapy (2.01[1.11-3.61]), DFI between 2 months and 20 months (HR from 1.5 [1.1-2.3] to 1.3 [1.1-1.7] and primary tumor size a primary tumor size comprised between 3.6 cm and 10 cm predicted LMSM. A sharp increase in LMSM was observed with a tumor size from ≥20 cm.

Conclusions: Our analysis corrected by potential confounders allowed us to identify specific histotypes and DFI intervals as predictors of both LMR and LMSM. Tumor size adjuvant chemotherapy adversely affected LM-related survival. Our findings need to be confirmed by larger randomized studies.
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http://dx.doi.org/10.1016/j.suronc.2021.101532DOI Listing
February 2021

Biparietal bidirectional bipolar radiofrequency in hybrid cardiac ablation: an in vitro evaluation.

Interact Cardiovasc Thorac Surg 2021 Feb 21. Epub 2021 Feb 21.

Cardiothoracic Department, Maastricht University Hospital, Maastricht, Netherlands.

Objectives: The aim of this study was to evaluate the lesion size and depth of radiofrequency (RF) ablation in a simultaneous biparietal bidirectional bipolar (SBB) approach, compared to a simultaneous and staged unipolar and uniparietal bipolar setup [simultaneous uniparietal bipolar (SiUB) and staged uniparietal bipolar (StUB), respectively].

Methods: Fresh left atrial porcine tissue was mounted into the ABLA-BOX simulator. Different ablation approaches were tested: (i) SBB: a concept consisting of SBB endo-epicardial ablation, (ii) SiUB: simultaneous epicardial uniparietal bipolar and endocardial unipolar ablation and (iii) StUB: staged epicardial uniparietal bipolar and endocardial unipolar ablation. In the StUB setup, a 1-h interval between the epi-endo ablation was respected.

Results: Transmural lesions were present in 90% of the bipolar biparietal ablations, yet no full transmurality was observed in the simultaneous nor in the staged unipolar with uniparietal bipolar ablation group. In SBB, the area and volume of the ablation lesions were smaller (523.33 mm2/mm and 52.33 mm3/mm, respectively) than in SiUB (588.17 mm2/mm and 58.81 mm3/mm, respectively) and StUB (583.76 mm2/mm and 58.37 mm3/mm, P = 0.044). Also, in SBB, the overall, epicardial and endocardial maximum diameters of the lesions (1.59, 1.57 and 1.52 mm; respectively) were smaller than in SiUB (2.38, 2.26 and 2.33 mm; respectively) and in StUB (2.36, 2.28 and 2.14 mm; respectively, all P < 0.001).

Conclusions: Although bipolar biparietal bidirectional RF ablation results in smaller lesions than uniparietal bipolar and unipolar ablation, their capacity to penetrate the tissue is much higher. Moreover, in uniparietal RF applications, the energy spreads in the superficial layers of the tissue but fails to penetrate. Therefore, the degree of transmurality is much higher when using such a 'truly bipolar' ablation approach.
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http://dx.doi.org/10.1093/icvts/ivab047DOI Listing
February 2021

Minimally invasive repair of pectus excavatum by the Nuss procedure: The learning curve.

J Thorac Cardiovasc Surg 2020 Dec 10. Epub 2020 Dec 10.

Division of General Thoracic Surgery, Department of Surgery, Zuyderland Medical Center, Heerlen, The Netherlands.

Objectives: To define the learning process of minimally invasive repair of pectus excavatum by the Nuss procedure through assessment of consecutive procedural metrics.

Methods: A single-center retrospective observational cohort study was conducted of all consecutive Nuss procedures performed by individual surgeons without previous experience between June 2006 and December 2018. Surgeons were proctored during their initial 10 procedures. The learning process after the proctoring period was evaluated using nonrisk-adjusted cumulative sum (ie, observed minus expected) failure charts of complications. An acceptable and unacceptable complication rate of 10% and 20% were used. Logarithmic trend lines were used to assess over-time performance regarding operation time.

Results: Two-hundred twenty-two consecutive Nuss procedures by 3 general thoracic surgeons were evaluated. Cumulative sum charts showed an average performance from the first procedure after being proctored onward for all surgeons, whereas surgeon B demonstrated a statistically significant complication rate equal to or less than 10% after 59 cases. Post-hoc sensitivity analyses using a stricter acceptable and unacceptable complication rate of 6% and 12% also showed an average performance for all surgeons. Although, the median time between consecutive procedures ranged from 7 to 35 days, no frequency-outcome relationship was observed. In addition, surgeons required the same average operation time throughout their entire experience.

Conclusions: After a 10-procedure proctoring period, repair of pectus excavatum by the Nuss procedure is a safe procedure to adopt and perform without a typical (complication based) learning curve while performing at least 1 procedure per 35 days.
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http://dx.doi.org/10.1016/j.jtcvs.2020.11.154DOI Listing
December 2020

New Biparietal Bipolar Catheter Prototype for Hybrid Atrial Fibrillation Ablation.

Innovations (Phila) 2021 Jan 7:1556984520981025. Epub 2021 Jan 7.

118066 Cardiovascular Research Institute Maastricht - CARIM, Maastricht University Medical Center, Maastricht, The Netherlands.

Objective: To evaluate the size and depth of linear lesions by in vitro testing with a custom-made radio frequency biparietal bipolar ablation catheter in a single-stage setting.

Methods: A custom-made catheter was created to generate linear lesions around the left atrium and pulmonary veins of an ex vivo pig. Two frames were made, 1 epicardial and 1 endocardial. A continuous copper braid electrode and an alignment system consisting of 2 parallel rows of neodymium magnets were embedded in a flexible plastic support. After 24 hours of formalin conservation, samples of the left atrium of a freshly slaughtered pig were sliced in a cryotome, thus obtaining a sequence of 100-µm thick layers extending from the endocardial to the epicardial side. After being digitized through a scanner, these layers were evaluated using morphometric computer software. For each slice, we evaluated the maximum length of the lesions, the maximum epicardial length, the maximum endocardial length, the total area of the lesion, and the total volume.

Results: Forty transmural lesions from 40 specimens were obtained. The results were the following (the number in parenthesis is the interquartile range in mm): lesion maximum length () was 7.297 mm (0.006), epicardial maximum length () was 7.291 mm (0.014), and endocardial maximum length was 7.291 mm (0.018). The total area and total volume were 1018.50 ± 36.51 mm and 101.85 ± 3.65 mm, respectively.

Conclusions: Our prototype showed very promising results. The next step will be to enhance the design for clinical application.
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http://dx.doi.org/10.1177/1556984520981025DOI Listing
January 2021

Aortic flow below and visceral circulation during aortic counterpulsation: Evaluation of an in vitro model.

Perfusion 2020 Dec 16:267659120978641. Epub 2020 Dec 16.

Cardiothoracic Department, Maastricht University Hospital, Maastricht, The Netherlands.

Introduction: This study aimed to test a computer-driven cardiovascular model for the evaluation of the visceral flow during intra-aortic balloon pump (IABP) assistance.

Methods: The model includes a systemic and pulmonary circulation as well as a heart contraction model. The straight polyurethane tube aorta had a single visceral while four windkessel components mimicked resistance compliance of the brachiocephalic, renal and sub-mesenteric, pulmonary, and systemic circulation. Twelve flow probes were placed in the circuit to measure pressures and flows with the IABP on and off.

Results: With the balloon off, the meantime to reach the steady state was 48 ± 16 s; with the balloon on, this figure was 178 ± 20 s. The stability of pressure and flow signals was obtained after 72 ± 11 min. The number of cycles of stability of the system was 93 [86-103]. Measurements were reliable either with samples of 10 or 20 beats. Bland Altman method demonstrated the reliability of measurements. Finally, all measurements were comparable to published in vivo data.

Conclusion: The presented mock circulation was reliable and gave values with high accuracy both at baseline and during mechanical assistance. This system allows evaluation of the mesenteric flow during IABP, under different clinical/hemodynamic conditions. Nonetheless, its translational potential needs to be further evaluated.
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http://dx.doi.org/10.1177/0267659120978641DOI Listing
December 2020

The Role of Obesity in Early and Long-Term Outcomes after Surgical Excision of Lung Oligometastases from Colorectal Cancer.

J Clin Med 2020 Nov 5;9(11). Epub 2020 Nov 5.

Cardiovascular Research Institute, Maastricht University, 6229HX Maastricht, The Netherlands.

Obesity correlates with better outcomes in many neoplastic conditions. The aim of this study was to assess its role in the prognosis and morbidity of patients submitted to resection of lung oligometastases from colorectal cancer. Seventy-six patients undergoing a first pulmonary metastasectomy were retrospectively included in the study. Seventeen (22.3%) were obese (body mass index (BMI) >30 kg/m). Assessed outcomes were overall survival, time to recurrence, and incidence of post-operative complications. Median follow-up was 33 months (IQR 16-53). At follow-up, 37 patients (48.6%) died, whereas 39 (51.4%) were alive. A significant difference was found in the 3-year overall survival (obese 80% vs. non-obese 56.8%, = 0.035). Competing risk analysis shows that the cumulative incidence of recurrence was not different between the two groups. Multivariate analysis reveals that the number of metastases ( = 0.028), post-operative pneumonia ( = 0.042), and DFS ( = 0.007) were significant predictors of death. Competing risk regression shows that no independent risk factor for recurrence has been identified. The complication rate was not different between the two groups (17.6% vs. 13.6%, = 0.70). Obesity is a positive prognostic factor for survival after pulmonary metastasectomy for colorectal cancer. Overweight patients do not experience more post-operative complications. Our results need to be confirmed by large multicenter studies.
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http://dx.doi.org/10.3390/jcm9113566DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7694523PMC
November 2020

Three-Dimensional Imaging of the Chest Wall: A Comparison Between Three Different Imaging Systems.

J Surg Res 2021 Mar 27;259:332-341. Epub 2020 Oct 27.

Department of Thoracic Surgery, Zuyderland Medical Centre, Heerlen, the Netherlands. Electronic address:

Background: Three-dimensional (3D) imaging is being used progressively to create models of patients with anterior chest wall deformities. Resulting models are used for clinical decision-making, surgical planning, and analysis. However, given the broad range of 3D imaging systems available and the fact that planning and analysis techniques are often only validated for a single system, it is important to analyze potential intrasystem and intersystem differences. The objective of this study was to investigate the accuracy and reproducibility of three commercially available 3D imaging systems that are used to obtain images of the anterior chest wall.

Methods: Among 15 healthy volunteers, 3D images of the anterior chest wall were acquired twice per imaging device. Reproducibility was determined by comparison of consecutive images acquired per device while the true accuracy was calculated by comparison of 3D image derived and calipered anthropometric measurements. A maximum difference of 1.00 mm. was considered clinically acceptable.

Results: All devices demonstrated statistically comparable (P = 0.21) reproducibility with a mean absolute difference of 0.59 mm. (SD: 1.05), 0.54 mm. (SD: 2.08), and 0.48 mm. (SD: 0.60) for the 3dMD, EinScan Pro 2X Plus, and Artec Leo, respectively. The true accuracy was, respectively, 0.89 mm. (SD: 0.66), 1.27 mm. (SD: 0.94), and 0.81 mm. (SD: 0.71) for the 3dMD, EinScan, and Artec device and did not statistically differ (P = 0.085).

Conclusions: Three-dimensional imaging of the anterior chest wall utilizing the 3dMD and Artec Leo is feasible with comparable reproducibility and accuracy, whereas the EinScan Pro 2X Plus is reproducible but not clinically accurate.
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http://dx.doi.org/10.1016/j.jss.2020.09.027DOI Listing
March 2021

The Impact of Preoperative Inflammatory Markers on the Prognosis of Patients Undergoing Surgical Resection of Pulmonary Oligometastases.

J Clin Med 2020 Oct 21;9(10). Epub 2020 Oct 21.

Cardiovascular Research Institute, Maastricht University, 6229 ER Maastricht, The Netherlands.

The aim of this study was to assess the prognostic value of preoperative neutrophil-to-lymphocyte ratio (NLR) and C-reactive protein (CRP) levels in patients undergoing resection of pulmonary oligometastases. A retrospective analysis on 141 patients undergoing a first pulmonary metastasectomy in a single center was carried out. Two distinct analysis were performed subdividing patients according to their NLR ratio and CRP level. The main outcomes were survival and time to recurrence. At completion of follow-up 74 patients were still alive (52.5%). Subdividing patients according to their NLR yielded a significant difference in five-year progression-free survival (PFS, NLR < 4:32% vs. NLR ≥ 4:18%, = 0.01). When subdivided by their CRP levels, patients with preoperative CRP < 5 mg/L demonstrated higher values of five-year overall survival (OS, 57% vs. 34%, = 0.006) and five-year PFS (35% vs. 22%, = 0.04). At multivariate analysis, level of neutrophils ( = 0.009) and lung comorbidities ( = 0.021) were independent predictors of death, whereas preoperative CRP ( = 0.002), multiple metastases ( = 0.003) and presence of lung comorbidities ( = 0.001) were independent predictors of recurrence. NLR and CRP are important predictors of prognostic outcome in patients undergoing pulmonary metastasectomy.
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http://dx.doi.org/10.3390/jcm9103378DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7590166PMC
October 2020

The learning curve of video-assisted mediastinoscopic lymphadenectomy for staging of non-small-cell lung carcinoma.

Interact Cardiovasc Thorac Surg 2020 10;31(4):527-535

Department of Surgery, Division of General Thoracic Surgery, Zuyderland Medical Centre, Heerlen, Netherlands.

Objectives: The objective of this study was to define the learning process of video-assisted mediastinoscopic lymphadenectomy (VAMLA) by the assessment of consecutive procedural metrics.

Methods: We conducted a single-centre retrospective observational study of all consecutive VAMLAs performed between 2011 and 2018 for the staging of non-small-cell lung carcinoma. Learning curves were assessed using non-risk adjusted cumulative observed minus expected (CUSUM) failure charts of complications. Boundary lines were defined by the acceptable and unacceptable complication rates of 4.5% and 15.0%. The Kruskal-Wallis test with post hoc analysis was used to assess trends in operation time and blood loss.

Results: Two-hundred-thirty-six unique VAMLAs by 4 surgeons performing their first procedures were evaluated. CUSUM charts of surgeons A and B showed a typical learning curve with an initial incline, followed by a turning point towards lower complications rates after 16-17 cases, whereas surgeons C and D showed an average performance. The median time between consecutive VAMLAs was shorter for surgeons A and B (13.0 vs 28.5-38.0 days for surgeons C and D). Overcoming the learning curve, complication rates of surgeons A and B decreased from 19% to 3% and from 18% to 5%, respectively. Operation time and blood loss showed a significant improvement after, respectively, 81-100 and 61-80 procedures compared to the first 20 procedures.

Conclusions: VAMLA is a safe procedure to adopt and perform with acceptable complication rates from the first operation onward, regardless of the caseload. To overcome its learning curve, 16-17 cases are required, preferably at least 1 per 2 weeks.
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http://dx.doi.org/10.1093/icvts/ivaa146DOI Listing
October 2020

Epicardial and Endocardial Validation of Conduction Block After Thoracoscopic Epicardial Ablation of Atrial Fibrillation.

Innovations (Phila) 2020 Nov/Dec;15(6):525-531. Epub 2020 Oct 14.

199236 Department of Cardiology, Maastricht University Medical Center, The Netherlands.

Objective: It is unknown whether epicardial and endocardial validation of bidirectional block after thoracoscopic surgical ablation for atrial fibrillation is comparable. Epicardial validation may lead to false-positive results due to epicardial tissue edema, and thus could leave gaps with subsequent arrhythmia recurrence. It is the aim of the present study to answer this question in patients who underwent hybrid atrial fibrillation ablation (combined thoracoscopic epicardial and endocardial catheter ablation).

Methods: After epicardial ablation of the pulmonary veins (PVs) and connecting inferior and roof lines (box lesion), exit and entrance block were epicardially and endocardially evaluated using an endocardial His Bundle catheter and electrophysiological workstation. If incomplete lesions were found, endocardial touch-up ablation was performed. Validation results were also compared to predictions about conduction block based on tissue conductance measurements of the epicardial ablation device.

Results: Twenty-five patients were included. Epicardial validation results were 100% equal to the endocardial results for the left superior, left inferior, and right inferior PVs and box lesion. For the right superior PV, 85% similarity was found. Based on tissue conductance measurements, 139 lesions were expected to be complete; however, in 5 (3.6%) a gap was present.

Conclusions: Epicardial bidirectional conduction block in the PVs and the box lesion corresponded well with endocardial bidirectional conduction block. Conduction block predictions by changes in tissue conductance failed in few cases compared to block confirmation. This emphasizes that tissue conduction measurements can provide a rough indication of lesion effectiveness but needs endpoint confirmation by either epicardial or endocardial block testing.
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http://dx.doi.org/10.1177/1556984520956314DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7715993PMC
October 2020

Intercostal nerve cryoablation versus thoracic epidural for postoperative analgesia following pectus excavatum repair: a systematic review and meta-analysis.

Interact Cardiovasc Thorac Surg 2020 10;31(4):486-498

Department of Thoracic Surgery, Zuyderland Medical Centre, Heerlen, Netherlands.

Objectives: Minimally invasive pectus excavatum repair via the Nuss procedure is associated with significant postoperative pain that is considered as the dominant factor affecting the duration of hospitalization. Postoperative pain after the Nuss procedures is commonly controlled by thoracic epidural analgesia. Recently, intercostal nerve cryoablation has been proposed as an alternative method with long-acting pain control and shortened hospitalization. The subsequent objective was to systematically review the outcomes of intercostal nerve cryoablation in comparison to thoracic epidural after the Nuss procedure.

Methods: Six scientific databases were searched. Data concerning the length of hospital stay, operative time and postoperative opioid usage were extracted. If possible, data were submitted to meta-analysis using the mean of differences, random-effects model with inverse variance method and I2 test for heterogeneity.

Results: Four observational and 1 randomized study were included, enrolling a total of 196 patients. Meta-analyses demonstrated a significantly shortened length of hospital stay [mean difference -2.91 days; 95% confidence interval (CI) -3.68 to -2.15; P < 0.001] and increased operative time (mean difference 40.91 min; 95% CI 14.42-67.40; P < 0.001) for cryoablation. Both analyses demonstrated significant heterogeneity (both I2 = 91%; P < 0.001). Qualitative analysis demonstrated the amount of postoperative opioid usage to be significantly lower for cryoablation in 3 out of 4 reporting studies.

Conclusions: Intercostal nerve cryoablation during the Nuss procedure may be an attractive alternative to thoracic epidural analgesia, resulting in shortened hospitalization. However, given the low quality and heterogeneity of studies, more randomized controlled trials are needed.
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http://dx.doi.org/10.1093/icvts/ivaa151DOI Listing
October 2020

Comparison between biparietal bipolar and uniparietal bipolar radio frequency ablation techniques in a simultaneous procedural setting.

J Interv Card Electrophysiol 2020 Aug 24. Epub 2020 Aug 24.

Cardiothoracic Department, Maastricht University Hospital, Maastricht, The Netherlands.

Purpose: To make an in vitro evaluation of the lesion size and depth produced in two different sets of radio frequency energy bipolar delivery: simultaneous biparietal bipolar (SBB) and simultaneous uniparietal bipolar (SUB).

Methods: Two separate prototypes have been built for our purpose: one to be used in SBB mode and the other to be used SUB mode. Forty left atrium samples were taken from the hearts of freshly slaughtered pigs. They were ablated into a simulator ABLABOX, where blood flow, temperature, and contact force were controlled. After being sliced into a cryotome, the samples were digitalized by a flatbed scanner, and the images were analyzed by a computer morphometric software.

Results: Transmural lesions were achieved in 18/20 samples (90%) in SBB, while SUB showed transmurality in 9/20 samples (45%). Overall maximum diameter (D) resulted larger in SUB than in SBB (2.43 ± 0.30 mm, 1.62 ± 0.14 mm, respectively; p < 0.05): Moreover, maximum epicardial and endocardial diameters (D and D, respectively) were wider in SUB group than SBB group (2.28 ± 0.30 mm, 2.26 ± 0.40 and 1.60 ± 0.14 mm, 1.59 ± 0.15 mm, respectively; p < 0.05). We observed the same tendency in lesion depth: The total area and volume (A and V) were broader in SUB group than in SBB one (581.01 ± 65.38 mm/mm, 58.10 ± 6.53 mm/mm and 521.97 ± 73.05 mm/mm, 52.19 ± 7.30 mm/mm. respectively; p < 0.05).

Conclusions: In contrast with the smaller lesion sizes, the biparietal bipolar group showed a higher transmurality rate. These findings may suggest a better drive of the energy flow when compared with SUB lesions.
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http://dx.doi.org/10.1007/s10840-020-00852-5DOI Listing
August 2020

Non-surgical Treatments for Lung Metastases in Patients with Soft Tissue Sarcoma: Stereotactic Body Radiation Therapy (SBRT) and Radiofrequency Ablation (RFA).

Curr Med Imaging 2021 ;17(2):261-275

Cardiovascular Research Institute Maastricht - CARIM, Maastricht University Medical Center, Maastricht, Netherlands.

Background: Radio-frequency ablation (RFA) and Stereotactic Body Radiation Therapy (SBRT) are two emerging therapies for lung metastases.

Introduction: Aliterature review was performed to evaluate the outcomes and complications of these procedures in patients with lung metastases from soft tissue sarcoma (STS).

Methods: After selection, seven studies were included for each treatment encompassing a total of 424 patients: 218 in the SBRT group and 206 in the RFA group.

Results: The mean age ranged from 47.9 to 64 years in the SBRT group and from 48 to 62.7 years in the RFA group. The most common histologic subtype was, in both groups, leiomyosarcoma. In the SBRT group, median overall survival ranged from 25.2 to 69 months and median disease- free interval was from 8.4 to 45 months. Two out of seven studies reported G3 and one G3 toxicity, respectively. In RFA patients, overall survival ranged from 15 to 50 months. The most frequent complication was pneumothorax. Local control showed a high percentage for both procedures.

Conclusion: SBRT is recommended in patients unsuitable to surgery, in synchronous bilateral pulmonary metastases, in case of deep lesions and patients receiving high-risk systemic therapies. RFA is indicated in case of a long disease-free interval, in oligometastatic disease, when only the lung is involved, in small size lesions far from large vessels. Further large randomized studies are necessary to establish whether these treatments may also represent a reliable alternative to surgery.
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http://dx.doi.org/10.2174/1573405616999200819165709DOI Listing
January 2021

Photographic documentation and severity quantification of pectus excavatum through three-dimensional optical surface imaging.

J Vis Commun Med 2020 Oct 14;43(4):190-197. Epub 2020 Aug 14.

Department of Surgery, Division of General Thoracic Surgery, Zuyderland Medical Centre, Heerlen, The Netherlands.

Conventional photography is commonly used to visually document pectus excavatum and objectively assess chest wall changes over time without repeated exposure to ionising radiation, as in our centre since 2008. However, as conventional photography is labour-intensive and lacks three-dimensional (3D) information that is essential in 3D deformities like pectus excavatum, we developed a novel imaging and processing protocol based on 3D optical surface imaging. The objective of this study was to report our developed protocol to visually document pectus excavatum through 3D imaging. We also investigated the absolute agreement of the 3D image- and conventional photography-derived pectus excavatum depth to investigate whether both techniques could be used interchangeably to measure pectus excavatum depth and assess its evolution. The protocol consisted of three consecutive steps: patient positioning and instructions, data acquisition, and data processing. Three-dimensional imaging through the developed protocol was feasible for all 19 participants. The 3D image- and photography-derived pectus excavatum depth demonstrated good to excellent agreement (intraclass correlation coefficient: 0.97; 95%-confidence interval: 0.88 to 0.99;  < 0.001). In conclusion, 3D imaging through the developed protocol is a feasible and attractive alternative to document the surface geometry of pectus excavatum and can be used interchangeably with conventional photography to determine pectus severity. NCT04185870.
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http://dx.doi.org/10.1080/17453054.2020.1784711DOI Listing
October 2020

One-Stage Versus Sequential Hybrid Radiofrequency Ablation: An In Vitro Evaluation.

Innovations (Phila) 2020 Jul/Aug;15(4):338-345. Epub 2020 Jul 10.

118066 Cardiothoracic Department Maastricht University Hospital, The Netherlands.

Objective: To compare lesion size and depth between a 1-step, a sequential, and a delayed radio-frequency ablation in a hybrid setup.

Methods: Left atrium tissues obtained from fresh porcine hearts were mounted into the ABLABOX simulator. Based on the time differences between the index epicardial (epi) and consequent endocardial (endo) ablation, 3 study groups were compared: a 1-stage (SEQ- 0) group (0-minute delay), an SEQ 1 group (60-minute delay), and an SEQ 2 group (240-minute delay). During the experiment, a constant epicardial (300 gr) and endocardial (30 gr) force were applied. Per group, 20 samples were studied, and the resulting lesion size and depth were quantified with morphometric evaluation.

Results: Overall, no transmural lesion was obtained. Lesions in SEQ 0 had better maximum and minimum diameters ( < 0.001), a larger total area ( < 0.001), and volume ( < 0.001) than SEQ 1 and SEQ 2. There was no statistical difference in morphometric parameters (all, > 0.05) between the delayed procedures (SEQ 1 and SEQ 2).

Conclusions: In our in vitro model, different time sequences of combined epi-endo ablation did not result in transmural lesions. However, simultaneous epi-endo ablation produced broader and deeper lesions. Our findings need to be confirmed by further research.
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http://dx.doi.org/10.1177/1556984520930070DOI Listing
July 2020

Is there a "safe" suction pressure in the venous line of extracorporeal circulation system?

Perfusion 2020 09 4;35(6):521-528. Epub 2020 Jul 4.

Department of Cardiothoracic Surgery, Maastricht University Medical Center, Maastricht, The Netherlands.

Successes of extracorporeal life support increased the use of centrifugal pumps. However, reports of hemolysis call for caution in using these pumps, especially in neonatology and in pediatric intensive care. Cavitation can be a cause of blood damage. The aim of our study was to obtain information about the cavitation conditions and to provide the safest operating range of centrifugal pumps. A series of tests were undertaken to determine the points at which pump performance decreases 3% and gas bubbles start to appear downstream of the pump. Two pumps were tested; pump R with a closed impeller and pump S with a semiopen impeller. The performance tests demonstrated that pump S has an optimal region narrower than pump R and it is shifted to the higher flows. When the pump performance started to decrease, the inlet pressure varies but close to -150 mmHg in the test with low gas content and higher than -100 mmHg in the tests with increased gas content. The same trend was observed at the points of development of massive gas emboli. Importantly, small packages of bubbles downstream of the pump were registered at relatively high inlet pressures. The gaseous cavitation in centrifugal pumps is a phenomenon that appears with decreasing inlet pump pressures. There are a few ways to increase inlet pump pressures: (1) positioning the pump as low as possible in relation to the patient; (2) selecting appropriate sized venous cannulas and their careful positioning; and (3) controlling patient's volume status.
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http://dx.doi.org/10.1177/0267659120936453DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7416326PMC
September 2020

Surgery versus stereotactic radiotherapy for treatment of pulmonary metastases. A systematic review of literature.

Future Sci OA 2020 Apr 15;6(5):FSO471. Epub 2020 Apr 15.

Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands.

It is not clear as to which is the best treatment among surgery and stereotactic radiotherapy (SBRT) for lung oligometastases. A systematic review of literature with selection criteria was conducted on articles on the treatment of pulmonary metastases with surgery or SBRT. Only original articles with a population of patients of more than 50 were selected. After final selection, 61 articles on surgical treatment and 18 on SBRT were included. No difference was encountered in short-term survival between pulmonary metastasectomy and SBRT. In the long-term surgery seems to guarantee better survival rates. Mortality and morbidity after treatment are 0-4.7% and 0-23% for surgery, and 0-2% and 4-31% for SBRT. Surgical metastasectomy remains the treatment of choice for pulmonary oligometastases.
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http://dx.doi.org/10.2144/fsoa-2019-0120DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7273364PMC
April 2020

Optical imaging versus CT and plain radiography to quantify pectus severity: a systematic review and meta-analysis.

J Thorac Dis 2020 Apr;12(4):1475-1487

Department of Surgery, Division of General Thoracic Surgery, Zuyderland Medical Centre, Heerlen, the Netherlands.

Background: Computed tomography (CT) and two-view chest radiographies are the most commonly used imaging techniques to quantify the severity of pectus excavatum (PE) and pectus carinatum (PC). Both modalities expose patients to ionizing radiation that should ideally be avoided, especially in pediatric patients. In an effort to diminish this exposure, three-dimensional (3D) optical surface imaging has recently been proposed as an alternative method. To assess its clinical value as a tool to determine pectus severity we conducted a systematic review in which we assessed all studies that compared 3D scan-based pectus severity measurements with those derived from CT-scans and radiographies.

Methods: Six scientific databases and three registries were searched through April 30th, 2019. Data regarding the correlation between severity measures was extracted and submitted to meta-analysis using the random-effects model and I-test for heterogeneity.

Results: Five observational studies were included, enrolling 75 participants in total. Pooled analysis of participants with PE demonstrated a high positive correlation coefficient of 0.89 [95% confidence interval (CI): 0.81 to 0.93; P<0.001] between the CT-derived Haller index (HI) and its 3D scan equivalent based on external measures. No heterogeneity was detected (I=0.00%; P=0.834).

Conclusions: 3D optical surface scanning is an attractive and promising imaging technique to determine the severity of PE without exposure to ionizing radiation. However, further research is needed to determine novel cut-off values for 3D scans to facilitate clinical decision making and help determine surgical candidacy. No evidence was found that supports nor discards the use of 3D scans to determine PC severity.
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http://dx.doi.org/10.21037/jtd.2020.02.31DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7212142PMC
April 2020

Uniportal video-assisted thoracoscopy is a safe approach in patients with empyema requiring surgery.

J Thorac Dis 2020 Apr;12(4):1460-1466

Department of Surgery, Division of Thoracic Surgery, Zuyderland Medical Center, Heerlen, The Netherlands.

Background: Empyema is a well-known complication of pneumonia, with high morbidity and mortality rates. This warrants direct treatment either with antibiotics and chest tube drainage or surgery. With less invasive surgical approaches such as uniportal video-assisted thoracoscopic surgery (uVATS), surgical intervention gets a more prominent role early on in the treatment of empyema. The aim of this study was to compare uVATS with the complete VATS (cVATS) approach in empyema, with respect to postoperative complications, hospital length of stay and mortality.

Methods: All cases of empyema that were treated surgically in our hospital between 2006 and 2019 were included in a retrospective database. The preferential surgical approach changed from cVATS from 2006 to 2015, towards uVATS from 2016 and on, based on the experience of the surgical team. The database included pre- and postoperative data, as well as peropartive characteristics.

Results: One hundred and thirty-seven patients were treated with cVATS and 49 with uVATS. Apart from a slightly reduced kidney function in the uVATS group (57.3±6.3 . 71.4±17.2 mL/min/1.73 m, P≤0.001), there were no significant baseline differences in patient characteristics. The duration of uVATS was comparable to cVATS (70±17 . 56±23 min, P=0.240), and with low per- and postoperative complications. The postoperative hospital stay was equal in both groups (19±13 . 20±15 days, P=0.320). There were no statistically significant differences in postoperative complications or death.

Conclusions: Uniportal VATS is a feasible and safe technique for the use in patients with empyema requiring surgery. Even if decortication in stage III empyema is required this can be performed by uniportal VATS.
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http://dx.doi.org/10.21037/jtd.2020.02.29DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7212173PMC
April 2020

Clinical and Radiologic Features Together Better Predict Lung Nodule Malignancy in Patients with Soft-Tissue Sarcoma.

J Clin Med 2020 Apr 23;9(4). Epub 2020 Apr 23.

Cardiovascular Research Institute Maastricht-CARIM, Maastricht University Medical Center, 6229 ER Maastricht, The Netherlands.

We test the hypothesis that a model including clinical and computed tomography (CT) features may allow discrimination between benign and malignant lung nodules in patients with soft-tissue sarcoma (STS). Seventy-one patients with STS undergoing their first lung metastasectomy were examined. The performance of multiple logistic regression models including CT features alone, clinical features alone, and combined features, was tested to evaluate the best model in discriminating malignant from benign nodules. The likelihood of malignancy increased by more than 11, 2, 6 and 7 fold, respectively, when histological synovial sarcoma sub-type was associated with the following CT nodule features: size ≥ 5.6 mm, well defined margins, increased size from baseline CT, and new onset at preoperative CT. Likewise, in the case of grade III primary tumor, the odds ratio (OR) increased by more than 17 times when the diameter of pulmonary nodules (PNs) was >5.6 mm, more than 13 times with well-defined margins, more than 7 times with PNs increased from baseline CT, and more than 20 times when there were new-onset nodules. Finally, when CT nodule was ≥5.6 in size, it had well-defined margins, it increased in size from baseline CT, and when new onset nodules at preoperative CT were concomitant to residual primary tumor R2, the risk of malignancy increased by more than 10, 6, 25 and 28 times, respectively. The combination of clinical and CT features has the highest predictive value for detecting the malignancy of pulmonary nodules in patients with soft tissue sarcoma, allowing early detection of nodule malignancy and treatment options.
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http://dx.doi.org/10.3390/jcm9041209DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7230600PMC
April 2020

Epicardial Fibrosis Explains Increased Endo-Epicardial Dissociation and Epicardial Breakthroughs in Human Atrial Fibrillation.

Front Physiol 2020 21;11:68. Epub 2020 Feb 21.

Department of Physiology, Maastricht University, Maastricht, Netherlands.

Background: Atrial fibrillation (AF) is accompanied by progressive epicardial fibrosis, dissociation of electrical activity between the epicardial layer and the endocardial bundle network, and transmural conduction (breakthroughs). However, causal relationships between these phenomena have not been demonstrated yet. Our goal was to test the hypothesis that epicardial fibrosis suffices to increase endo-epicardial dissociation (EED) and breakthroughs (BT) during AF.

Methods: We simulated the effect of fibrosis in the epicardial layer on EED and BT in a detailed, high-resolution, three-dimensional model of the human atria with realistic electrophysiology. The model results were compared with simultaneous endo-epicardial mapping in human atria. The model geometry, specifically built for this study, was based on MR images and histo-anatomical studies. Clinical data were obtained in four patients with longstanding persistent AF (persAF) and three patients without a history of AF.

Results: The AF cycle length (AFCL), conduction velocity (CV), and EED were comparable in the mapping studies and the simulations. EED increased from 24.1 ± 3.4 to 56.58 ± 6.2% ( < 0.05), and number of BTs per cycle from 0.89 ± 0.55 to 6.74 ± 2.11% ( < 0.05), in different degrees of fibrosis in the epicardial layer. In both mapping data and simulations, EED correlated with prevalence of BTs. Fibrosis also increased the number of fibrillation waves per cycle in the model.

Conclusion: A realistic 3D computer model of AF in which epicardial fibrosis was increased, in the absence of other pathological changes, showed increases in EED and epicardial BT comparable to those in longstanding persAF. Thus, epicardial fibrosis can explain both phenomena.
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http://dx.doi.org/10.3389/fphys.2020.00068DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7047215PMC
February 2020

Evaluating the diagnostic accuracy of maximal aortic diameter, length and volume for prediction of aortic dissection.

Heart 2020 Jun 8;106(12):892-897. Epub 2020 Mar 8.

Department of Cardiothoracic Surgery, Maastricht University Medical Center, Maastricht, Limburg, The Netherlands.

Objective: Management of thoracic aortic aneurysms (TAAs) comprises regular diameter follow-up until the indication criterion for prophylactic surgery is reached. However, this approach is unable to predict the majority of acute type A aortic dissections (ATAADs). The current study aims to evaluate the diagnostic accuracy of ascending aortic diameter, length and volume for occurrence of ATAAD.

Methods: This two-centre observational cohort study retrospectively screened 477 consecutive patients who presented with ATAAD between 2009 and 2018. Of those, 25 (5.2%) underwent CT angiography (CTA) within 2 years before dissection onset. Aortic diameter, length and volume of these patients ('pre-ATAAD') were compared with those of TAA controls (n=75). Receiver operating curve analysis was performed to evaluate the predictive accuracy of the three different measurements.

Results: 96% of patients with pre-ATAAD did not meet the surgical diameter threshold of 55 mm before dissection onset. Maximal aortic diameters (45 (40-49) mm vs 46 (44-49) mm, p=0.075) and volume (126 (95-157) cm vs 124 (102-136) cm, p=0.909) were comparable between patients with pre-ATAAD and TAA controls. Conversely, ascending aortic length (84±9 mm vs 90±16 mm, p=0.031) was significantly larger in patients with pre-ATAAD. All three parameters had an area under the curve of >0.800. At the 55 mm cut-off point, the maximal diameter yielded a positive predictive value (PPV) of 20%. While maintaining same specificity levels, measurements of aortic volume and length showed superior diagnostic accuracy (PPV 55% and 70%, respectively).

Conclusion: Measurements of aortic volume and length have superior diagnostic accuracy compared with the maximal diameter and could improve the timely identification of patients at risk for ATAAD.
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http://dx.doi.org/10.1136/heartjnl-2019-316251DOI Listing
June 2020

The EACTS simulation-based training course for endoscopic mitral valve repair: an air-pilot training concept in action.

Interact Cardiovasc Thorac Surg 2020 05;30(5):691-698

Department of Cardiothoracic Surgery, Maastricht University Medical Center, Maastricht, Netherlands.

Objectives: We have developed a high-fidelity minimally invasive mitral valve surgery (MIMVS) simulator that provides a platform to train skills in an objective and reproducible manner, which has been incorporated in the European Association for Cardiothoracic Surgery (EACTS) endoscopic mitral valve repair course. The aim of the study is to provide data on the application of simulation-based training in MIMVS using an air-pilot training concept.

Methods: The 2-day EACTS endoscopic mitral training course design was based on backwards chaining, pre- and post-assessment, performance feedback, hands-on training on MIMVS, theoretical content and follow-up. One hundred two participants who completed the full programme throughout 2016-2018 in the EACTS endoscopic mitral training courses were enrolled in the current study.

Results: Of the 102 participants, 83 (83.3%) participants were staff/attending surgeons, 12 (11.8%) participants had finished residency and 5 (4.9%) participants were residents. Theoretical pre- and post-assessment showed that participants scored significantly higher on post-assessment (median score 58% vs 67%, P < 0.001). Pre- and post-assessment of skills on MIMVS showed that participants could work with long-shafted instruments more accurately (suture accuracy 43% vs 99%, P < 0.001) and faster (87 vs 42 s, P < 0.001). Follow-up, based on course evaluation and a survey, had a response rate of 55% (57 participants). Of all surveyed participants, 33.3% (n = 19) had started an endoscopic mitral programme successfully, while 66.7% (n = 38) did not yet start.

Conclusions: The MIMVS is a valuable tool for the development and assessment of endoscopic mitral repair skills. This EACTS course provides surgeons with theoretical knowledge and necessary skills to start an endoscopic mitral valve programme successfully.
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http://dx.doi.org/10.1093/icvts/ivz323DOI Listing
May 2020

VATS-US1: Thoracoscopic ultrasonography for the identification of nodules during lung metastasectomy.

Future Oncol 2020 Feb 9;16(5):85-89. Epub 2020 Jan 9.

Cardiothoracic Department, Maastricht University Hospital, Maastricht, The Netherlands.

Open thoracotomy during pulmonary metastasectomy allows lung palpation and may discover unexpected further nodules. We assess the validity of intraoperative lung ultrasonography via thoracoscopy in identifying lung nodules. A first surgeon will perform an ultrasonographic investigation on the deflated lung by thoracoscopy. A second surgeon will then perform a manual exploration of the organ by thoracotomy. Data on number and localization of nodules will be matched and compared with final histology report. Sensitivity and specificity will be assessed. Concordance will be assessed with Cohen K test. Calculated sample size is 89 patients. This study might have an important role in shifting the surgical practice towards a less invasive approach, with consequent benefits for the patient. Protocol is registered on clinicaltrials.gov. Protocol registration number: NCT03864874.
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http://dx.doi.org/10.2217/fon-2019-0608DOI Listing
February 2020

Left Atrial Appendage Management with the Watchman Device during Hybrid Ablation of Atrial Fibrillation.

J Interv Cardiol 2019 26;2019:4525084. Epub 2019 Jun 26.

Department of Cardiology, Maastricht University Medical Center, Maastricht, Netherlands.

Background: In the recent ESC/EACTS guidelines, left atrial appendage (LAA) occlusion or exclusion in patients undergoing (thoracoscopic) atrial fibrillation (AF) ablation surgery is recommended. The Watchman device (WD, Boston Scientific, Minnesota) has proved to reduce the risk of thromboembolic events by closing of the LAA, yet no data exist on WD implantation during surgical AF ablation. The objective is to determine if WD implantation is safe and feasible in a hybrid AF ablation setting (i.e., combination of thoracoscopic epicardial surgical and endocardial catheter ablation) and could become subject of further testing to serve as a bail-out in cases in which surgical LAA occlusion methods cannot be applied, due to, for example, severe adhesions.

Methods: In this prospective, single center, pilot study, 10 consecutive patients undergoing a hybrid ablation qualifying for LAA exclusion (CHADS-VASc ≥ 1) were included. At the end of the hybrid ablation, the LAA was occluded endocardially using the WD. The feasibility endpoint was successful implantation. The safety endpoint concerned major complications.

Results: One patient was excluded and replaced because the LAA was insufficiently visible on transesophageal echocardiography. In 10/11 patients, device delivery was successful (mean time: 35 minutes). No major complications occurred. Transesophageal echocardiography after 6 weeks and 6 months showed successful occlusion of the LAA without significant peridevice flow.

Conclusion: Implantation of the WD seems to be feasible and safe in the setting of hybrid AF ablation and could be an alternative to epicardial occlusion in surgical AF ablation procedures. Larger studies are required to confirm these findings. This trial is registered with NCT02471131.
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http://dx.doi.org/10.1155/2019/4525084DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6739757PMC
March 2020