Extended septal myectomy for obstructive hypertrophic cardiomyopathy and its impact on mitral valve function

AIMS

Septal myectomy is the treatment of choice for hypertrophic obstructive cardiomyopathy (HOCM). Around 30-60% of patients with HOCM have a secondary mitral valve regurgitation due to systolic anterior motion (SAM). We report our experience with extended septal myectomy and its impact on the incidence of concomitant mitral valve procedures.

METHODS

This is a retrospective study on 84 patients who underwent SM from January 2008 to February 2022. Surgical procedure was performed according to the concept of 'extended myectomy' described by Messmer in 1994. Follow-up outcomes in terms of survival, hospital admissions for heart failure or MV disease, cardiac reoperations, and pacemaker (PMK) implantation were recorded.

RESULTS

Mean age was 61 ± 15 years. Mitral valve surgery was performed in seven cases (8%); particularly only one patient without degenerative mitral valve disease underwent mitral valve surgery, with a plicature of the posterior leaflet. In-hospital mortality was 5%. Mitral valve regurgitation greater than mild was present in four patients (5%) at discharge. Twelve-year survival was 78 ± 22%. Cumulative incidence of rehospitalization for heart failure and rehospitalization for mitral valve disease was 10 ± 4 and 2.5 ± 2.5%, respectively. PMK implantation was 5% at discharge, with a cumulative incidence of 15 ± 7%. Freedom from cardiac reoperations was 100%.

CONCLUSION

Septal myectomy for HOCM is associated with good outcomes. Although concomitant surgery on the mitral valve to address SAM and associated regurgitation has been advocated, these procedures were needed in our practice only in patients with intrinsic mitral valve disease. Adequate myectomy addresses the underlying pathophysiology in most patients.

Long-term mitral valve repair outcomes and hospital volume: 15 years' analysis of an administrative dataset

BACKGROUND

Procedural volume has been documented as an important contributor to operative outcomes for most complex surgical procedures. Mitral valve repair (MVRep) has been associated with excellent results, and it is increasingly adopted in many cardiac surgical centers. We sought to investigate if procedural volume is associated with better clinical long-term outcomes after MVRep.

METHODS

We analyzed the 10-year outcomes after MVRep by procedural volume for each cardiac surgery center in an Italian Region, Lazio, during the last 15 years, using a regional administrative dataset.

RESULTS

Between 2006 and 2020, 4961 patients were treated in seven cardiac surgery centers for an isolated mitral valve surgery (2677 underwent MVRep). At multivariate analysis, mitral valve replacement (MVR) (vs. MVRep) resulted one of the independent predictors of 30-day mortality [adjusted odds ratio (OR) 3.40; 95% confidence interval (CI) 1.96-5.90; P  < 0.0001]. Notably, a clear association between hospital volume of mitral valve surgery (>40 per year) and high rate of MVRep (>50%) was found. At 10 years, the incidence of mortality and the rate of death and rehospitalization for heart failure after MVRep were significantly lower in high-volume vs. low-volume hospitals.

CONCLUSION

Our data suggest that hospital volume is associated with a high rate of MVRep and long-term benefits in terms of mortality and recurrence of heart failure.

Survival and Recurrence of Endocarditis following Mechanical vs. Biological Aortic Valve Replacement for Endocarditis in Patients Aged 40 to 65 Years: Data from the INFECT-Registry

BACKGROUND

Infective endocarditis (IE) is a serious disease, and in many cases, surgery is necessary. Whether the type of prosthesis implanted for aortic valve replacement (AVR) for IE impacts patient survival is a matter of debate. The aim of the present study is to quantify differences in long-term survival and recurrence of endocarditis AVR for IE according to prosthesis type among patients aged 40 to 65 years.

METHODS

This was an analysis of the INFECT-REGISTRY. Trends in proportion to the use of mechanical prostheses versus biological ones over time were tested by applying the sieve bootstrapped t-test. Confounders were adjusted using the optimal full-matching propensity score. The difference in overall survival was compared using the Cox model, whereas the differences in recurrence of endocarditis were evaluated using the Gray test.

RESULTS

Overall, 4365 patients were diagnosed and operated on for IE from 2000 to 2021. Of these, 549, aged between 40 and 65 years, underwent AVR. A total of 268 (48.8%) received mechanical prostheses, and 281 (51.2%) received biological ones. A significant trend in the reduction of implantation of mechanical vs. biological prostheses was observed during the study period (p < 0.0001). Long-term survival was significantly higher among patients receiving a mechanical prosthesis than those receiving a biological prosthesis (hazard ratio [HR] 0.546, 95% CI: 0.322-0.926, p = 0.025). Mechanical prostheses were associated with significantly less recurrent endocarditis after AVR than biological prostheses (HR 0.268, 95%CI: 0.077-0.933, p = 0.039).

CONCLUSIONS

The present analysis of the INFECT-REGISTRY shows increased survival and reduced recurrence of endocarditis after a mechanical aortic valve prosthesis implant for IE in middle-aged patients.

Aortic Valve Replacement: Understanding Predictors for the Optimal Ministernotomy Approach

INTRODUCTION

The most common minimally invasive approach for aortic valve replacement (AVR) is the partial upper mini-sternotomy. The aim of this study is to understand which preoperative computed tomography (CT) features are predictive of longer operations in terms of cardio-pulmonary bypass timesand cross-clamp times.

METHODS

From 2011 to 2022, we retrospectively selected 246 patients which underwent isolated AVR and had a preoperative ECG-gated CT scan. On these patients, we analysed the baseline anthropometric characteristics and the following CT scan parameters: aortic annular dimensions, valve calcium score, ascending aorta length, ascending aorta inclination and aorta-sternum distance.

RESULTS

We identified augmented body surface area (>1.9 m2), augmented annular diameter (>23 mm), high calcium score (>2500 Agatson score) and increased aorta-sternum distance (>30 mm) as independent predictors of elongated operation times (more than two-fold).

CONCLUSIONS

Identifying the preoperative predictive factors of longer operations can help surgeons select cases suitable for minimally invasive approaches, especially in a teaching context.

Panoramic on Epigenetics in Coronary Artery Disease and the Approach of Personalized Medicine

Epigenetic modifications play a fundamental role in the progression of coronary artery disease (CAD). This panoramic review aims to provide an overview of the current understanding of the epigenetic mechanisms involved in CAD pathogenesis and highlights the potential implications for personalized medicine approaches. Epigenetics is the study of heritable changes that do not influence alterations in the DNA sequence of the genome. It has been shown that epigenetic processes, including DNA/histone methylation, acetylation, and phosphorylation, play an important role. Additionally, miRNAs, lncRNAs, and circRNAs are also involved in epigenetics, regulating gene expression patterns in response to various environmental factors and lifestyle choices. In the context of CAD, epigenetic alterations contribute to the dysregulation of genes involved in inflammation, oxidative stress, lipid metabolism, and vascular function. These epigenetic changes can occur during early developmental stages and persist throughout life, predisposing individuals to an increased risk of CAD. Furthermore, in recent years, the concept of personalized medicine has gained significant attention. Personalized medicine aims to tailor medical interventions based on an individual's unique genetic, epigenetic, environmental, and lifestyle factors. In the context of CAD, understanding the interplay between genetic variants and epigenetic modifications holds promise for the development of more precise diagnostic tools, risk stratification models, and targeted therapies. This review summarizes the current knowledge of epigenetic mechanisms in CAD and discusses the fundamental principles of personalized medicine.

Prognostic role of endocarditis in isolated tricuspid valve surgery. A propensity-weighted study

OBJECTIVES

The role of the underlying etiology in isolated tricuspid valve surgery has not been investigated extensively in current literature. Aim of this study was to analyse outcomes of patients undergoing surgery due to endocarditis compared to other pathologies.

METHODS

The SURTRI study is a multicenter study enrolling adult patients who underwent isolated tricuspid valve surgery (n = 406, 55 ± 16 y.o.; 56% female) at 13 international sites. Propensity weighted analysis was performed to compare groups (IE group n = 107 vs Not-IE group n = 299).

RESULTS

No difference was found regarding the 30-day mortality (Group IE: 2.8% vs Group Not-IE = 6.8%; OR = 0.45) and major adverse events. Weighted cumulative incidence of cardiac death was significantly higher for patients with endocarditis (p = 0.01). The composite endpoint of cardiac death and reoperation at 6 years was reduced in the Group IE (63.2 ± 6.8% vs 78.9 ± 3.1%; p = 0.022). Repair strategy resulted in an increased late survival even in IE cases.

CONCLUSIONS

Data from SURTRI study report acceptable 30-day results but significantly reduced late survival in the setting of endocarditis of the tricuspid valve. Multi-disciplinary approach, repair strategy and earlier treatment may improve outcomes.

3D mitral annulus echocardiography assessment in patients affected by degenerative mitral regurgitation who underwent mitral valve repair with flexible band

BACKGROUND

Degenerative mitral valve (MV) regurgitation (DMR) shows significative mitral annulus (MA) alterations; mitral valve repair (MVR) seeks to restore annular geometry and function, and the current use of flexible band seams to respect most annular mobility reducing parietal stress. Parameters of MV geometry obtained by 3D transesophageal echocardiography (3D-TTE) analysis are crucial for surgical planning and postoperative success. The aim of this study was to assess, by means of a dedicated software, the variations of MA geometry and function in patients affected by DMR compared to controls and after MVR with flexible band.

METHODS

We enrolled 32 patients (cases) with severe DMR who underwent MVR using flexible band; we compare this group with 20 controls. The TEE with 3D MV images acquisition was performed in both groups and then analyzed in postprocessing by using a dedicated software.

RESULTS

There were no anthropometrics differences between cases and controls, both presented normal left ventricular ejection fraction. DMR group showed a significant increase of annulus dimensional parameters (p = .001) and alteration of nonplanarity comparing to controls (p < .05). The annuloplasty with flexible band induces a considerable reduction of MV dimensions comparing to preoperative data and restores physiological mobility and nonplanarity. There were no statistical differences between postoperative DMR and controls data, except for nonplanarity parameters (p ~.05), maybe influenced by hemodynamic settings.

CONCLUSIONS

MVR with annuloplasty using flexible band appears able to reinstate a more physiological anatomic conformation of the MA, without compromising its dynamic properties.

Surgical removal of a bullet in the heart through a trans-mitral approach: a case report

Background

Retained cardiac missiles have been considered bullets, shrapnel, or pellets included in the heart or the pericardial sac. In asymptomatic patients with retained cardiac missiles, the role of surgery is still debated.

Case summary

We describe the case of successful surgical treatment of a retained missile localized within the left ventricle in close proximity of the posterior mitral leaflet. The operation was performed through a transatrial approach, detaching the posterior mitral leaflet. The post-operative course was uneventful. The patient was discharged on the seventh post-operative day. At 30-day follow-up visit, the patient was in good conditions, with normal mitral valve function.

Discussion

The management of retained cardiac missiles should be individualized. If a decision is made to operate, multiple imaging techniques including echocardiography and computed tomography scan are mandatory to precisely locate the bullet.

Surgical Management of Acute Myocardial Infarction Caused by Intramural Anomalous Left Coronary Artery in a Young Female Athlete

In the complex spectrum of coronary anomalies, the origin of the left coronary artery from the right sinus of Valsalva with intramural course could represent a catastrophic life-threatening condition leading to extensive myocardial infarction and sudden cardiac death, especially in young athletes. We report the case of a young female athlete with anomalous left coronary artery from the opposite sinus who survived a major non-ST-elevation myocardial infarction during the eighth kilometer of a running race. It was successfully treated by creating a neo-ostium of the left coronary artery in the left sinus at the point at which the artery left the aortic wall.

Observed versus predicted mortality after isolated tricuspid valve surgery

BACKGROUND

Aim of this study is to analyse the performances of Clinical Risk Score (CRS) and European System for Cardiac Operative Risk Evaluation (EuroSCORE)-II in isolated tricuspid surgery.

METHODS

Three hundred and eighty-three patients (54 ± 16 year; 54% female) were enrolled. Receiver operating characteristic analysis was performed to evaluate the relationship between the true positive fraction of test results and the false-positive fraction for a procedure.

RESULTS

Considering the 30-day mortality the area under the curve was 0.6 (95% confidence interval [CI] 0.50-0.72) for EuroSCORE II and 0.7 (95% CI 0.56-0.84) for CRS-score. The ratio of expected/observed mortality showed underestimation when considering EuroSCORE-II (min. 0.46-max. 0.6). At multivariate analysis, the CRS score (p = .005) was predictor of late cardiac death.

CONCLUSION

We suggest using both scores to obtain a range of expected mortality. CRS to speculate on late survival.

Transcatheter aortic valve implantation in patients with age ≤70 years: experience from two leading structural heart disease centers

BACKGROUND

Transcatheter aortic valve implantation (TAVI) is emerging a an appealing management strategy for patients with severe aortic stenosis at intermediate, high or exceedingly high risk, but its risk-benefit profile in younger patients is less certain. We aimed at exploring the outlook of patients aged 70 years or less and undergoing TAVI at 2 high-volume Italian institituions.

METHODS

We retrospectively collected baseline, imaging, procedural and outcome features of patients with age ≤70 years in whom TAVI was attempted at participating centers between 2012 and 2021. Non-parametric tests and bootstrap resampling were used for inferential purposes.

RESULTS

A total of 39 patients were included, out of >3,000 screened with heart team involvement and >1,500 receiving TAVI. Most common or relevant indications for TAVI were reduced life expectancy (eg cardiogenic shock or severe left ventricular systolic dysfunction), chronic obstructive pulmonary disease, morbid obesity, active or recent extra-cardiac cancer, porcelain aorta, neurologic disability, cirrhosis, or prior surgical aortic valve replacement, as well as extreme cachexia, and Hutchinson-Gilford progeria. At least two contemporary high-risk features were present in most cases. Transapical access was used in 5 (12.8%) cases, and a sheathless approach in 15 (38.5%). A variety of devices were used, including both balloon- and selfexpandable devices. Clinical outcomes were satisfactory, despite the high risk profile, at both shortand mid-term, with no in-hospital death, and 5.1% (95% confidence interval 0-12.8%) mortality at a median follow-up of 15 months (minimum 1; maximum 85). Notably, no case of significant valve deterioration requiring reintervention occurred.

CONCLUSIONS

In carefully selected patients with 70 years or less of age and prohibitive risk for surgery or reduced life expectancy, TAVI represents a safe option with a favorable mid-term survival and low rate of adverse events.

Robotic transareolar mitral valve repair

In recent years, the treatment of mitral valve disease with robotic surgery has been increasingly successful, having produced excellent postoperative results and significant cost-savings. However, minimal  experience exists with robotic mitral valve repair using transareolar access. We demonstrate mitral valve repair using the DaVinci Robot Xi through a transareolar approach, showing the technical details of our surgical technique.

Beating vs Arrested Heart Isolated Tricuspid Valve Surgery: Long-term Outcomes

BACKGROUND

Isolated tricuspid valve (TV) surgery is a rare procedure generally considered at high risk of perioperative mortality and poor long-term outcomes. Surgical treatment can be performed with either an arrested heart (AH) or beating heart (BH) technique. Aim of this study is to compare the outcomes of isolated tricuspid surgery with two different approaches.

METHODS

The SUR-TRI study is a multicenter international retrospective study enrolling adult patients who underwent isolated tricuspid valve procedures (n=406, 56±16 years; 56% female) at 13 international sites. AH and BH strategies were performed in 253 and 153 cases, respectively. Propensity score-matched analysis was used to compare groups.

RESULTS

After matching, 129 pairs were obtained and analyzed. The 30-day mortality rate was 6.2 vs 5.0% in the AH and BH groups, respectively (p=0.9). The rates of acute renal failure requiring replacement therapy (3 vs 10%, p=0.02) and stroke (0 vs 1.8%, p=0.08) were numerically higher in the AH group. The 6-year survival rate was 67±6 vs 78±5% in the AH and BH groups, respectively (p=0.18), while freedom from cardiac death was 75±5 vs 84±4% (p=0.21). The six-year composite cardiac endpoint of cardiac death and reoperation rate was 60±9 vs 86±5% (p=0.024) comparing AH-TV replacement and BH-TV repair groups.

CONCLUSIONS

Isolated tricuspid valve surgery performed with a beating heart strategy is a safe option and resulted in a trend of increased long-term survival and freedom from reoperation when compared with the standard arrested heart technique. Patients undergoing beating heart valve repair had the best long-term outcome.

Minimally invasive transatrial repair of posterior left ventricular aneurysm

Left ventricular aneurysms (LVA) are a complication of myocardial infarction, that rarely involve the posterior wall; surgical repair of posterior LVA poses a technical challenge when associated with concomitant mitral regurgitation. We describe a minimally invasive treatment of ischemic MR and concomitant patch exclusion of posterior LVA through a right minithoracotomy. Using a transatrial approach, the aneurysm is closed with a "U" shaped dacron patch, whose base is anchored to the mitral annulus. Two patients were operated by this method with excellent results.

Hutchinson-Gilford Progeria Syndrome and Severe Aortic Stenosis: A New Hope for Treatment

Hutchinson-Gilford progeria syndrome is an autosomal dominant, rare, fatal pediatric segmental premature aging disease. Cardiovascular and cerebrovascular diseases constitute the major cause of morbidity and mortality. Patients with the syndrome and severe aortic valve stenosis have been described in the literature, and for all of them a strategy of conservative management has been followed. We describe the first successful treatment of a 23-year-old Hutchinson-Gilford progeria syndrome patient with severe aortic stenosis who underwent transapical transcatheter aortic valve replacement.

Minimally invasive implantation of a Sapien 3 Ultra Valve in a degenerated tricuspid bioprosthesis

Surgical management of patients affected by structural valve deterioration of bioprostheses in tricuspid valve position represents a challenge. Furthermore, transcatheter valve-in-valve implantation (TVIVI) recently emerged as an interesting option in high-risk surgical patients. When surgery is performed, replacement of the dysfunctional tricuspid bioprosthesis could be a difficult procedure due to the risk of heart rupture during the prosthesis removal. Herein we report the case of a 52-year-old female patient in which a transcatheter TVIVI was successfully performed under direct vision as a bailout strategy due to the impossibility of bioprosthesis removal.

Meta-analysis of results of subvalvular repair for severe ischemic mitral regurgitation

BACKGROUND AND AIM OF THE STUDY

The aim of this meta-analysis was to compare short- and long-term outcomes of patients undergoing mitral annuloplasty (MA) with or without papillary muscle surgery (PMS) for the treatment of ischemic mitral regurgitation (IMR).

METHODS

A systematic review and meta-analysis in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement were performed.

RESULTS

Nine studies met the inclusion criteria. This meta-analysis identified 478 patients: 228 patients underwent MA alone and 250 patients underwent concomitant PMS. Early mortality was similar between two groups (odds ratio [OR] 1.14, 95% confidence interval [CI], 0.51-2.53; P = .75). PMS was associated at follow-up with a higher freedom from cardiac-related events (P = .050); moreover, although both surgical techniques had a positive impact on ventricular remodeling, the PMS group showed a significant higher reduction of left ventricle end-diastolic diameter (OR, 4.89, 95% CI, 2.77-7.01; P < .001) and left ventricle end-systolic diameter values (OR, 4.11, 95% CI, 1.98-6.24; P < .001). Finally, PMS compared with MA alone was associated with a significant reduction of recurrent mitral regurgitation at follow-up (OR, 3.25, 95% CI, 1.60-6.59; P = .001).

CONCLUSIONS

This meta-analysis demonstrated superiority in terms of ventricular remodeling of a combined approach encompassing PMS and MA over MA alone in IMR. Moreover, the association of subvalvular surgery with restrictive MA decreases the incidence of mitral regurgitation recurrence and cardiac-related events at follow-up.

Percutaneous Aortic Valve Closure in Patient With Left Ventricular Assist Device and Dilated Aortic Annulus

Percutaneous transcatheter intervention for aortic regurgitation secondary to implantation of a continuous-flow left ventricular assist device remains challenging, because of the minimal global experience with these procedures. Two treatment options are available: transcatheter aortic valve replacement, which is not always feasible when a dilated aortic annulus is present, and percutaneous aortic valve occlusion. We report a successful percutaneous closure of the aortic valve using an oversized Amplatzer patent foramen ovale multifenestrated device (St Jude Medical, Saint Paul, MN) to treat aortic regurgitation associated with dilated aortic annulus in a patient with a continuous-flow left ventricular assist device.

Influence of Body Mass Index on Outcomes of Patients Undergoing Surgery for Acute Aortic Dissection: A Propensity-Matched Analysis

To determine whether body mass index ≥30 kg/m² affects morbidity and mortality rates in patients undergoing surgery for type A acute aortic dissection, we conducted a retrospective study of 201 patients with type A dissection. Patients were divided into 2 groups according to body mass index (BMI): nonobese (BMI, <30 kg/m²; 158 patients) and obese (BMI, ≥30 kg/m²; 43 patients). Propensity score matching was used to reduce selection bias. The overall mortality rate was 19% (38/201 patients). The perioperative mortality rate was higher in the obese group, both in the overall cohort (33% vs 15%; P=0.01) and in the propensity-matched cohort (32% vs 12%; P=0.039). In the propensity-matched cohort, patients with obesity had higher rates of low cardiac output syndrome (26% vs 6%; P=0.045) and pulmonary complications (32% vs 9%; P=0.033) than those without obesity. The overall 5-year survival rates were 52.5% ± 7.8% in the obese group and 70.3% ± 4.4% in the nonobese group (P=0.036). In the propensity-matched cohort, the 5-year survival rates were 54.3% ± 8.9% in the obese group and 81.6% ± 6.8% in the nonobese group (P=0.018). Patients with obesity (BMI, ≥30 kg/m²) who underwent surgery for type A acute aortic dissection had higher operative mortality rates and an increased risk of low cardiac output syndrome, pulmonary complications, and other postoperative morbidities than did patients without obesity. Additional extensive studies are needed to confirm our findings.

Minimally invasive triple valve surgery: The Rome approach

Although the benefits of minimally invasive cardiac surgery are well recognized, most surgeons have little experience in the treatment of triple valve disease through a minithoracotomy approach. In this video tutorial, we present a case of concomitant aortic valve replacement with mitral and tricuspid valve repair through a lateral minithoracotomy.

A Modified Transatrial Approach for Repair of Postinfarction Ventricular Septal Defect

Ventricular septal defect (VSD) is a life-threatening complication of myocardial infarction. Surgical repair is generally performed through a left/right ventriculotomy. To avoid complications associated with ventriculotomy, a right transatrial approach has been proposed. We describe a modified transatrial approach through the left atrium for basal-inferior VSD. After left atriotomy, mitral valve is detached from the annulus to expose the defect, which is closed with a pericardial patch. Two patients were operated by this method. In both cases venoarterial extracorporeal membrane oxygenation with a ventricular vent was utilized to unload the left ventricle. Echocardiography revealed no residual shunt in both cases.

Minimally Invasive Redo-Aortic Valve Replacement: Reduced Operative Times as Compared to Full Sternotomy

Objectives Increasing experience with minimally invasive cardiac (MIC) aortic valve (AV) replacement makes AV reoperations (rAVR) an appealing alternative to conventional redo surgery. The aim of the study was to compare the perioperative outcome after isolated MIC versus full-sternotomy (FS) rAVR.

Methods We retrospectively analyzed data of 116 patients from three centers who underwent rAVR by using a FS (n = 70, 60.3%) or a partial upper sternotomy approach (n = 46, 39.7%). Both groups were compared in terms of 30-day mortality by using binary-logistic regression models. Further the EuroSCORE II was used to adjust for preoperative conditions in a multivariable model. Perioperative times and complications were compared between the two groups.

Results There was no statistically significant difference in perioperative mortality between FS (n = 5, 7.1%) and MIC (n = 1, 2.2%) rAVR in the original population (odds ratio [OR] 3.462, 95% confidence interval [CI] 0.391–30,635, p = 0.264) and after adjusting for EuroSCORE II (OR 2.759, 95% CI 0.298–25.567, p = 0.372). Cardiopulmonary bypass- (115.5 minutes vs. 137.5 minutes, p = 0.070) and cross-clamp times (69.0 minutes vs. 81.0 minutes, p = 0.028) were reduced in the MIC group. There was a lower prevalence of postoperative renal failure requiring renal replacement therapy (RRT) in the MIC group 0 and 8.6% (p = 0.041), respectively. No differences were detected between the groups regarding postoperative complications.

Conclusion MIC rAVR is associated with reduced cardiopulmonary and cross-clamp times as well as the need for RRT as compared with FS. MIC-rAVR seems to be a viable option in surgical candidates for AV reoperations.

Implanting neochordae for the repair of mitral valve prolapse using a prosthetic ring with chordal sizing system: a modified technique for myxomatous leaflets

The use of artificial polytetrafluoroethylene (PTFE) chordae has been widely adopted in the setting of mitral valve repair. In this tutorial, we present a modified technique for neochordae placement using a semi-rigid complete ring, with a chordal sizing system. This ring was introduced with the aim of standardizing neo-chordae implantation and we introduce a modification of the implantation technique in the presence of myxomatous leaflets.

Sutureless Perceval Aortic Valve Versus Conventional Stented Bioprostheses: Meta-Analysis of Postoperative and Midterm Results in Isolated Aortic Valve Replacement

Background

Aortic stenosis is the most common valvular disease and has a dismal prognosis without surgical treatment. The aim of this meta‐analysis was to quantitatively assess the comparative effectiveness of the Perceval (LivaNova) valve versus conventional aortic bioprostheses.

Methods and Results

A total of 6 comparative studies were identified, including 639 and 760 patients who underwent, respectively, aortic valve replacement with the Perceval sutureless valve (P group) and with a conventional bioprosthesis (C group). Aortic cross‐clamping and cardiopulmonary bypass duration were significantly lower in the P group. No difference in postoperative mortality was shown for the P and C groups (2.8% versus 2.7%, respectively; odds ratio [OR]: 0.99 [95% confidence interval (CI), 0.52–1.88]; P=0.98). Incidence of postoperative renal failure was lower in the P group compared with the C group (2.7% versus 5.5%; OR: 0.45 [95% CI, 0.25–0.80]; P=0.007). Incidence of stroke (2.3% versus 1.7%; OR: 1.34 [95% CI, 0.56–3.21]; P=0.51) and paravalvular leak (3.1% versus 1.6%; OR: 2.52 [95% CI, 0.60–1.06]; P=0.21) was similar, whereas P group patients received fewer blood transfusions than C group patients (1.16±1.2 versus 2.13±2.2; mean difference: 0.99 [95% CI, −1.22 to −0.75]; P=0.001). The incidence of pacemaker implantation was higher in the P than the C group (7.9% versus 3.1%; OR: 2.45 [95% CI, 1.44–4.17]; P=0.001), whereas hemodynamic Perceval performance was better (transvalvular gradient 23.42±1.73 versus 22.8±1.86; mean difference: 0.90 [95% CI, 0.62–1.18]; P=0.001), even during follow‐up (10.98±5.7 versus 13.06±6.2; mean difference: −2.08 [95% CI, −3.96 to −0.21]; P=0.030). We found no difference in 1‐year mortality.

Conclusions

The Perceval bioprosthesis improves the postoperative course compared with conventional bioprostheses and is an option for high‐risk patients.

Mitral Valve Repair with a Semi-Rigid C-Band Annuloplasty Ring in Ischemic Mitral Regurgitation: Still a Viable Surgical Option?

BACKGROUND

Ischemic mitral valve regurgitation (IMR) develops in approximately 10% of patients after myocardial infarction. Surgical management of IMR is controversial, as many series have failed to demonstrate the superiority of mitral valve repair (MVRep) over mitral valve replacement (MVR) in IMR. Moreover, in the setting of MVRep, the choice of ring type is the subject of much debate. The study aim was to evaluate the results of MVRep in IMR with the use of a semi-rigid incomplete C-ring.

METHODS

Between January 2006 and May 2014, a total of 105 patients (79 males, 26 females; mean age 69 ± 8 years) underwent surgical MVRep using a semi-rigid incomplete ring (median size 30 mm) during coronary artery bypass grafting (CABG) to treat IMR. The patients' mean logistic EuroSCORE was 14 ± 12, and the preoperative left ventricular ejection fraction was 43 ± 11%. The mean duration of follow up was 48 ± 31 months, and was 100% complete.

RESULTS

In-hospital mortality was 6.6% (n = 7). The main predictor of in-hospital mortality was cardiopulmonary bypass time (p <0.05). Echocardiography performed at discharge showed moderate mitral regurgitation (MR) in only one patient, and significant reductions in left ventricular end-diastolic diameter (p <0.0001) and MR grade (p <0.0001). After seven years, freedom from all-cause death was 73 ± 9%, while freedoms from recurrence of MR grade ≥2 and NYHA class >II were 95 ± 3% and 89 ± 4%, respectively. Freedom from reintervention was 100%.

CONCLUSIONS

Despite the adverse prognosis of IMR, the present study demonstrated the effectiveness and durability of mitral valve repair with the use of a semi-rigid ring, as a concomitant procedure to CABG, showing good results in terms of recurrence of MR and event-free survival at mid-term follow up.

Mitral valve repair using a prosthetic ring with chordal sizing system: a modified technique in the presence of myxomatous leaflets

A semi-rigid complete ring including a chordal sizing system has been introduced with the aim of standardizing neochordae implantation. Instructions for use of this ring suggest to pass the neochordae through the free margin of mitral leaflets. We introduce a modification of this technique in the presence of myxomatous leaflets.

Long-Term Results of Aortic Root Surgery in Marfan Syndrome Patients: A Single-Center Experience

BACKGROUND AND AIM OF THE STUDY

The study aim was to compare long-term results of Marfan syndrome (MFS) patients affected by aortic root disease undergoing aortic root replacement with the Bentall or David operation.

METHODS

Since 1994, a total of 59 patients has been followed at the authors' Marfan Center, having undergone either a Bentall operation (Bentall group, n = 30) or a David operation (David group, n = 29).

RESULTS

No operative mortality was recorded. After 20 years (mean follow up 97 ± 82 months; range 1 to 369 months) no prosthesis-related major bleeding or thromboembolic events had been observed; the 20-year survival was 94 ± 6% in the Bentall group, and 100% in the David group (p = 0.32). Freedom from reintervention for aortic valve dysfunction was 100% in the Bentall group, and 75 ± 13% in the David group (p = 0.04). This inter-group difference became relevant after the first eight-year period of follow-up, and was mainly associated with a particular familiar genetic phenotype involving three out of four reoperated patients. Freedom from all-cause death, myocardial infarction, stroke, prosthetic valve-related complications, and reintervention on any aortic segment was 69 ± 12% in the Bentall group, and 67 ± 14% in the David group (p = 0.33).

CONCLUSIONS

The Bentall and David operations are both associated with satisfactory long-term results in MFS patients. The low rate of valve prosthesis-related complications suggested that the Bentall operation would continue to be a standard surgical treatment. The reimplantation technique, adopted for less-dilated aortas, provides satisfactory freedom from reoperation. Careful attention should be paid to the reimplantation technique in patients affected by a serious familiar genetic phenotype.

Perceval S Valve Solution for Degenerated Freestyle Root in the Presence of Chronic Aortic Dissection

Aortic root replacement with porcine xenograft is a valuable treatment option in acute aortic dissection, but conduits are often prone to degeneration. Reoperation is still associated with high operative mortality, and it usually requires root removal and repetition of the Bentall procedure, or a less radical option limited to valve replacement. We describe two cases of Freestyle root degeneration in patients with chronic aortic dissection, in whom we performed a valve-in-valve procedure with the Perceval S prosthesis (Sorin Group, Saluggia, Italy).

Mitral valve repair and aortic valve replacement with sutureless prosthesis implantation through a right minithoracotomy

Little experience exists in minimally invasive treatment of double-valve disease. In this report, we present a minimally invasive approach for mitral and aortic valve disease through a minithoracotomy in the 3rd intercostal space with a sutureless aortic prosthesis implantation.

Mitral valve repair and aortic valve replacement with sutureless prosthesis implantation through a right minithoracotomy

Little experience exists in minimally invasive treatment of double-valve disease. In this report, we present a minimally invasive approach for mitral and aortic valve disease through a minithoracotomy in the 3rd intercostal space with a sutureless aortic prosthesis implantation.

Total Arch versus Hemiarch Replacement for Type A Acute Aortic Dissection: A Single-Center Experience

We retrospectively evaluated early and intermediate outcomes of aortic arch surgery in patients with type A acute aortic dissection (AAD), investigating the effect of arch surgery extension on postoperative results. From January 2006 through July 2013, 201 patients with type A AAD underwent urgent corrective surgery at our institution. Of the 92 patients chosen for this study, 59 underwent hemiarch replacement (hemiarch group), and 33 underwent total arch replacement (total arch group) in conjunction with ascending aorta replacement. The operative mortality rate was 22%. Total arch replacement was associated with a 33% risk of operative death, versus 15% for hemiarch (P=0.044). Multivariable analysis found these independent predictors of operative death: age (odds ratio [OR]=1.13/yr; 95% confidence interval [CI], 1.04-1.23; P=0.002), body mass index >30 kg/m² (OR=9.9; 95% CI, 1.28-19; P=0.028), postoperative low cardiac output (OR=10.6; 95% CI, 1.18-25; P=0.035), and total arch replacement (OR=8.8; 95% CI, 1.39-15; P=0.021) The mean overall 5-year survival rate was 59.3% ± 5.5%, and mean 5-year freedom from distal reintervention was 95.4% ± 3.2% (P=NS). In type A AAD, aortic arch surgery is still associated with high operative mortality rates; hemiarch replacement can be performed more safely than total arch replacement. Rates of distal aortic reoperation were not different between the 2 surgical strategies.

Valve Replacement with a Sutureless Aortic Prosthesis in a Patient with Concomitant Mitral Valve Disease and Severe Aortic Root Calcification

Aortic valve replacement with concomitant mitral valve surgery in the presence of severe aortic root calcification is technically difficult, with long cardiopulmonary bypass and aortic cross-clamp times. We performed sutureless aortic valve replacement and mitral valve annuloplasty in a 68-year-old man who had severe aortic stenosis and moderate-to-severe mitral regurgitation. Intraoperatively, we found severe calcification of the aortic root. We approached the aortic valve through a transverse aortotomy, performed in a higher position than usual, and we replaced the valve with a Sorin Perceval S sutureless prosthesis. In addition, we performed mitral annuloplasty with use of an open rigid ring. The aortic cross-clamp time was 63 minutes, and the cardiopulmonary bypass time was 83 minutes. No paravalvular leakage of the aortic prosthesis was detected 30 days postoperatively. Our case shows that the Perceval S sutureless bioprosthesis can be safely implanted in patients with aortic root calcification, even when mitral valve disease needs surgical correction.

Early and long-term outcomes of minimally invasive mitral valve surgery through right minithoracotomy: a 10-year experience in 1604 patients

Background

To report early and long-term outcomes of patients undergoing minimally invasive mitral valve surgery (MIMVS) through right mini-thoracotomy (RT) over a 10-year period.

Methods

From September 2003 to December 2013, a total of 1604 consecutive patients underwent MIMVS through RT.

Results

The mean age was 63 ± 13 years, 770 (48 %) patients were female and 218 (13.6 %) had previous cardiac operations. The most predominant pathology was degenerative disease (70 %), followed by functional mitral valve regurgitation (12 %), rheumatic disease (9.4 %), endocarditis (5 %) and prosthetic dysfunction (3.2 %). Mitral valve repair was performed in 1137 (71 %) patients and 476 (29 %) had mitral valve replacement. Direct aortic cannulation was achieved in 1325 (83 %) patients. Among patients with degenerative disease candidate for repair (n = 958), rate of mitral valve repair was 95 %. Repair techniques included annuloplasty (95 %), leafleat resection (63 %), neochordae implantation (16 %) and sliding plasty (11 %). Concomitant procedures included tricuspid valve repair (14.6 %), atrial fibrillation ablation (9.5 %) and atrial septal defect closure (3.2 %). Overall in-hospital mortality was 1.1 %. Thirty-four patients (2.1 %) had conversion to sternotomy. Incidence of stroke was 2 %. Overall survival at 10 years was 88 ± 2 %. Freedom from reoperation at 10 years was 94 ± 2 % for repair and 80 ± 6 % for replacement. Freedom from recurrent mitral regurgitation >3+ at 10 years was 90 ± 3 %.

Conclusions

Minimally invasive mitral valve surgery is a safe and reproducible approach associated with low mortality and morbidity, high rate of mitral valve repair and excellent late results.

Initial Experience with Sutureless Sorin Perceval S Aortic Prosthesis for the Treatment of Prosthetic Valve Endocarditis

BACKGROUND

The objective of this study is to evaluate results of the initial experience with sutureless Perceval S for active prosthetic valve endocarditis (PVE).

MATERIALS AND METHODS

From October 2012 to April 2014, f: ve patients underwent surgery for aortic PVE with Perceval S bioprosthesis.

RESULTS

There was one in-hospital death (20%). Echocardiography performed at discharge showed excellent hemodynamic performance of Perceval S bioprosthesis.

CONCLUSION

Aortic valve replacement with Perceval S sutureless valve in patients with PVE is a feasible and safe procedure, associated with low in-hospital mortality and good hemodynamic performance of the prosthesis.