Mitral valve replacement with the beating heart technique in a patient with previous bypass graft from ascending to descending aorta due to aortic coarctation

BACKGROUND AND AIM: Conventional mitral valve replacement (MVR) is carried out under cardioplegic arrest with cross-clamping of the ascending aorta during cardiopulmonary bypass. In this case, MVR was performed with on-pump beating heart technique without cross-clamping the aorta because of the diffuse adhesion around the ascending aorta, and tube graft presence between ascending and descending aortas. METHODS: A 47-year-old female patient had aorto-aortic bypass graft from ascending aorta to descending aorta with median sternotomy and left thoracotomy in single stage because of aortic coarctation 2 years ago in our cardiac center. She was admitted to the hospital with palpitation and dyspnea on mild exertion. Transthoracic echocardiography revealed 4th degree mitral insufficiency. RESULTS: MVR was carried out through remedian sternotomy with on-pump beating heart technique without cross-clamping the aorta. CONCLUSIONS: MVR with on-pump beating heart technique offers a safe approach when excessive dissection is required to place cross-clamp on the ascending aorta.     

Beating heart mitral valve replacement in a patient with a previous Bentall operation

Today, mitral valve replacement is performed under cardioplegic arrest with cross-clamping of the ascending aorta. In the case reported here, mitral valve replacement was performed with an on-pump beating heart technique without cross-clamping the aorta because of diffuse adhesion around the tube graft. A 36-year-old man had undergone a Bentall operation (aortic root replacement + coronary reimplantation) via median sternotomy because of type I aortic dissection 4 years previously in our cardiac center. He was admitted to the hospital complaining of palpitation and dyspnea on mild exertion. Transthoracic echocardiography study revealed third-degree mitral insufficiency. Mitral valve replacement was carried out through re-median sternotomy with an on-pump beating heart technique without crossclamping the aorta. On-pump beating heart mitral valve replacement without a cross-clamp offers a safe approach when excessive dissection is required to place a crossclamp on the ascending aorta.     

On-pump beating heart mitral valve surgery without cross-clamping the aorta

BACKGROUND AND AIM: Cardiac reperfusion injury is a well-described complication occurring after ischemia or following cardioplegic arrest. Various strategies have been developed to prevent ischemic reperfusion injury. The aim of this study was to assess the efficacy and applicability of the on-pump beating heart mitral valve surgery without cross-clamping the aorta in order to prevent reperfusion injury. METHODS: The prospective study (between April 2005 and December 2006) included 88 consecutive patients who underwent mitral valve surgery. The operations were carried out on a beating heart using normothermic cardiopulmonary bypass without cross-clamping the aorta, therefore perfusing the heart antegradely through the aortic root. Venting the heart from the aorta and the pulmonary vein provided adequate visualization of the operative field. RESULTS: Seventy-eight patients (88.6%) underwent mitral valve replacement and 10 patients (11.3%) underwent mitral valve repair with this technique. Concomitant surgery was required in 29 patients (32.9%). Twenty-five patients (28.4%) had also undergone previous open heart surgery. Mean cardiopulmonary bypass time was 57.4 +/- 18.4 minutes. Mean duration of ventilation was 12.2 +/- 3.5 hours, mean intensive care unit stay was 1.3 +/- 1.6 days, and mean hospital stay was 6.9 +/- 4.5 days. One-year survival was 96.6% for all causes of mortality. CONCLUSIONS: In this study, we showed that on-pump beating heart operations without cross-clamping is an acceptable surgical choice for mitral valve disease. Complication rates are low and perioperative mortality is lower than that generally reported with conventional technique.     

Redo valve surgery with on-pump beating heart technique

AIM: Reoperations have become of increasing frequency in the last four decades. Redo surgery is more complex than primary surgery and is associated with higher mortality and morbidity. We present our immediate and mid-term results of mitral and aortic prosthetic valve replacement undertaken with beating heart technique. METHODS: The prospective study included 26 consecutive redo valve surgery patients who underwent valve re-replacement. The operation was carried out on a beating heart using normothermic bypass without cross-clamping the aorta for mitral valve surgery and retrograde coronary sinus normothermic noncardioplegic blood perfusion during cross-clamping the aorta for aortic valve procedures. RESULTS: Twenty-six patients (mean age 50+/-15 years) underwent reoperation with beating heart technique. Twenty (76.9%) mitral prosthetic replacements, 4 (15.4%) aortic prosthetic replacements, and 2 (7.7%) double valve replacements were achieved. Fourteen patients (53.8%) were operated for prosthetic valve dysfunction. Eighteen patients (69.2%) were in NYHA class III or IV preoperatively. Mean bypass time was 85+/-30 min. Mean duration of ventilation was 13.6+/-6 h, mean intensive unit stay was 2.8+/-6.4 days, and mean hospital stay was 8.3+/-7.2 days. Two (7.7%) patients required high dose inotropic support and in one patient (3.8%) intra-aortic balloon support was required. Pulmonary complication occurred in 1 patient (3.8%), low cardiac output in 1 patient (3.8%), and re-exploration for bleeding in 2 patients (7.7%). Operative mortality was not observed. CONCLUSION: Normothermic on-pump beating heart valve replacement offers a safe alternative to cardioplegic arrest in high-risk group. Complication rates are low and perioperative mortality is lower than with conventional surgery. Beating heart technique has the advantage of maintaining physiologic condition of the heart throughout the procedure.     

Exposure of the mitral valve by transecting the ascending aorta during aortic and mitral valve replacement

Combined aortic and mitral valve operations are still considered major cardiac surgical procedures. The duration of aortic cross-clamping and cardiopulmonary bypass is longer, which increases morbidity and mortality for these combined, complicated operations. Aortic valve exposure is generally satisfactory, but mitral valve exposure may be difficult and add to the length of the aortic cross-clamping time. We have exposed the mitral valve by transecting the ascending aorta, and retracting both ends apart, to give direct access through the dome of the left atrium in 7 patients. This approach gave good exposure and did not increase the risk of complications. Exposure of the mitral valve through the left atrium using a superior approach, by transecting the ascending aorta, is a good option for patients with multiple cardiac conditions who are undergoing combined aortic and mitral valve operations.     

On pump beating heart mitral valve repair without aortic cross-clamp for low ejection fraction ischemic mitral regurgitation after coronary artery bypass grafting; report of a case

A 59-year-old male with congestive heart failure caused by impaired left ventricular function after coronary artery bypass grafting (CABG) was referred to our hospital, and massive ischemic mitral regurgitation was detected by echocardiography. This patient underwent on-pump beating-heart mitral valve repair without aortic cross-clamp successfully through right thoracotomy. Postoperative echocardiography revealed no mitral regurgitation. The patient recovered uneventfully and was discharged on the 17th postoperative day. At 6th month after the operation, he is well without mitral regurgitation.     

升主动脉粥样硬化患者的冠状动脉旁路移植

目的 总结冠状动脉粥样硬化性心脏病合并升主动脉粥样硬化患者冠状动脉旁路移植手术的特点。方法 22例患者中,13例采用非体外循环、心脏不停跳下冠状动脉旁路移植术(59％);9例采用低温体外循环(41％),其中5例在深低温、低流量并间断停循环条件下不阻断升主动脉行旁路-升主动脉近端吻合。结果 20例康复出院,术后早期死亡2例;并发症有肺部感染、心绞痛、室颤、急性心肌梗死和血胸,无神经系统并发症。结论 减少术中升主动脉操作是防止升主动脉损伤和减少并发症的关键。应用带蒂动脉旁路、旁路远端序贯吻合和近端Y形吻合可避免或减少旁路-升主动脉吻合;低温体外循环加左心室引流时,可不阻断升主动脉行旁路远端吻合;深低温、低流量并间断停循环下行旁路-升主动脉吻合,可避免阻断和部分阻断升主动脉,利于控制并发症。     

Neurocognitive functions after beating heart mitral valve replacement without cross-clamping the aorta

BACKGROUND AND AIM OF THE STUDY: Although neurologic outcome after cardiac surgery is well-established, neurocognitive functions after beating heart mitral valve replacement still needs to be elucidated. The aim of this study was to compare preoperative and postoperative neurocognitive functions in patients who underwent beating heart mitral valve replacement on cardiopulmonary bypass without cross-clamping the aorta. METHODS: The prospective study included 25 consecutive patients who underwent mitral valve replacement. The operations were carried out on a beating heart method using normothermic cardiopulmonary bypass without cross-clamping the aorta. All patients were evaluated preoperatively (E1) and postoperatively (at sixth day [E2] and second month [E3]) for neurocognitive functions. RESULTS: Neurologic deficit was not observed in the postoperative period. Comparison of the neurocognitive test results, between the preoperative and postoperative assessment for both hemispheric cognitive functions, demonstrated that no deterioration occurred. In the three subsets of left hemispheric cognitive function test evaluation, total verbal learning, delayed recall, and recognition, significant improvements were detected at the postoperative second month (E3) compared to the preoperative results (p = 0.005, 0.01, and 0.047, respectively). Immediate recall and retention were significantly improved within the first postoperative week (E2) when compared to the preoperative results (p = 0.05 and 0.05, respectively). CONCLUSIONS: The technique of mitral valve replacement with normothermic cardiopulmonary bypass without cross-clamping of the aorta may be safely used for majority of patients requiring mitral valve replacement without causing deterioration in neurocognitive functions.     

Concurrent single stage repair of coarctation of aorta and associated cardiac pathology in adult patients

Background Thoracic aortic coarctation and associated intracradiac pathology including a concomitant valvular lesion or coronary artery disease is an uncommon combination in adult patients. The simultaneous operative management of both lesion is preferred to avoid a second redo surgery and the risks associated with it. Methods We describe a simultaneous operative management of six adult patients with coarctation of aorta and associated cardiac lesion. All six patients had heterotopic bypass (Dacron tube implanted between the ascending and descending aorta) to repair the coarctation and concomitant repair of the cardiac lesion. The associated procedures were aortic valve replacement in 3 patients, coronary artery bypass grafting in 2 patients and mitral valve replacement in 1 patient. Results There were no operative deaths and all patients are doing well on follow up with patent coarctation of aorta bypass graft at a mean follow up of 18 months. No graft related complications occurred, and there were no instance of stroke or paraplegia. All patients had an uneventful post operative course and are on routine out patient follow up. Conclusion A median sternotomy for repairing adult coarctation of aorta with concomitant cardiac lesion can be performed safely and readily managed as an excellent single stage approach.     

Excision of a left atrial myxoma in the presence of a calcified ascending aorta: a surgical challenge

Atrial myxomas are rare tumors that require surgical excision. However, in the presence of a severely calcified ascending aorta, such excision becomes rather challenging and difficult. Here we report a case of a left atrial myxoma in a 64-year-old woman with an extensively calcified aorta that was successfully excised using cardiopulmonary bypass beating-heart technique without the need for cardioplegic cardiac arrest and aortic cross-clamping. The use of this technique proved useful with no increased risk incurred to the patient.     

Beating mitral valve replacement for a patient with porcelain aorta

Beating mitral valve replacement was performed for mitral valve stenosis in a patient with a porcelain aorta after aortic valve replacement. The 77-year-old patient had developed heart failure several times. A chest computed tomographic scan revealed severe calcification on the ascending aorta and aortic arch. A cardiopulmonary bypass was established by bicaval drainage and aortic return after epiaortic echographic evaluation of the ascending aorta. The mitral valve was successfully replaced under a beating heart.     

Beating Heart Video-Assisted Mitral Valve Surgery: A Useful Technique for High-Risk Patients

Abstract   Background: Beating-heart valve surgery through a sternotomy has been used as an excellent myocardial protection strategy in high risk patients. Minimally invasive approaches have reduced the trauma and enhanced the recovery of patients undergoing heart surgery. We hypothesized that high-risk patients undergoing mitral valve surgery will benefit from a combination of these two approaches. Methods: A 52-year-old male with dilated cardiomyopathy and left ventricular function of 15% was referred for surgery because of congestive heart failure. Results: Using a 4-cm right minithoracotomy and femoral cannulation for cardiopulmonary bypass, successful beating-heart video-assisted mitral valve repair was performed. The adequacy of myocardial protection was confirmed by absence of ischemic electrophysiologic changes. The patient was discharged home on the 6^th postoperative day. Conclusion: Beating-heart strategy can be combined with a minimally invasive approach in patients with severely reduced ventricular function, who require mitral valve surgery.     

Cerebral perfusion using the tissue oxygenation index in mitral valve repair in a patient with porcelain aorta and aortic regurgitation.

We report successful mitral valve repair in a patient with porcelain aorta, complicated by aortic regurgitation, severe cerebrovascular disease, and multiple cerebral infarctions. The patient was a 77-year-old male who had congestive heart failure as a result of severe mitral regurgitation. Mitral valve repair was performed without aortic cross-clamping, using moderate hypothermic cardiopulmonary bypass. Aortic regurgitation was likely to worsen upon retracting the atrial septum to expose the mitral valve, complicating the operative procedure. We therefore controlled the regurgitation by lowering the blood temperature and using systemic perfusion flow. During systemic low-flow perfusion, we used near-infrared spectroscopy (NIRS) and the bispectral index to prevent cerebral hypoperfusion. The tissue oxygenation index value derived from NIRS was maintained above 55% during the procedure. The repair was performed safely with no difficulty. The postoperative course was satisfactory, with no neurological complications; echocardiography revealed no mitral regurgitation. The use of NIRS is valuable in preventing neurological complications in mitral valve operations complicated by porcelain aorta and aortic regurgitation.     

Valve surgery in octogenarians with a "porcelain" aorta and aortic insufficiency

We report the technique of balloon occlusion of the ascending aorta in two patients requiring valve operations. In the first patient, it provided a rapid solution to unexpected and potentially catastrophic severe aortic insufficiency (AI) with the initiation of cardiopulmonary bypass in a patient who required aortic valve replacement using deep hypothermic circulatory arrest due to a "porcelain" aorta. In the second patient, it allowed for a routine mitral valve repair to be performed by providing aortic occlusion in the setting of AI and avoiding the devastating consequences of cross-clamping a "porcelain" aorta.     

On-pump beating heart versus hypothermic arrested heart valve replacement surgery

BACKGROUND: Comparison of neurological parameters in patients undergoing prosthetic heart valve replacement with two operating techniques-either cardioplegic arrest of the heart under hypothermic cardiopulmonary bypass (CPB) or the heart beating on normothermic bypass, with or without cross-clamping the aorta, without cardioplegic arrest. methods: Fifty valvular surgery patients were randomly assigned into three groups. Sixteen patients underwent beating heart valve replacement with normothermic bypass without cross-clamping the aorta, 17 patients underwent the same procedure with cross-clamping the aorta and retrograde coronary sinus perfusion, and the remaining 17 patients had conventional surgery with hypothermic bypass and cardioplegic arrest. RESULTS: Two-channel electroencephalography (EEG) was recorded to assess changes in cerebral cortical synaptic activity and 95% spectral edge frequency values were recorded continuously. Bispectral monitoring was used to measure the depth of anesthesia. Blood flow rates in middle cerebral artery (MCA) were measured by transcranial Doppler (TCD). Reduction in spectral edge frequency (>50%) or bispectral index (BIS) (<20) or transcranial Doppler flow velocity (>50%) was detected in four patients in Group 1, five patients in Group 2, and three patients in Group 3. BIS or EEG values never reached zero, which indicates isoelectric silence during surgery. Gross neurological examinations were normal in all patients postoperatively. CONCLUSION: There is no difference regarding neurological monitoring results between on-pump beating heart and hypothermic arrested heart valve replacement surgery. Also no significant difference was encountered among the groups regarding the clinical outcomes.     

Surgical treatment of valvular and supravalvular aortic stenosis in homozygous familial hypercholesterolemia

A 61-year-old male with homozygous familial hypercholesterolemia presented with dyspnea and syncope. He had been treated with low-density lipoprotein apheresis for 26 years. Echocardiography and computed tomography showed severe valvular and supravalvular aortic stenosis. Computed tomography and cardiac catheterization revealed a severely calcified narrowed aortic root and an occlusion in the proximal right coronary artery. During surgery, the ascending aorta was replaced under deep hypothermic circulatory arrest without aortic cross-clamping. After that, the aortic root from the annulus to the sino-tubular junction was enlarged with a two-ply bovine pericardial patch. An aortic valve replacement with a 17 mm mechanical valve and coronary artery bypass grafting to the right coronary artery were performed. The patient recovered from the surgery without any cerebrovascular complications.     

Port-Access cardiac surgery using endovascular cardiopulmonary bypass: theory, practice, and results

BACKGROUND: Reduction of surgical trauma is the aim of minimally invasive cardiac surgery. This can be achieved by reducing the size of the incision or by eliminating or changing the cardiopulmonary bypass system. However, certain cardiac surgical procedures, such as valvular surgery and complex multivessel coronary artery surgery, are not feasible without the use of cardiopulmonary bypass. Therefore endovascular cardiopulmonary bypass may allow reduction of surgical trauma for these patients. METHODS: Since its first application in April 1995, more than 1100 procedures have been performed worldwide using the EndoCPB endovascular cardiopulmonary bypass system. The authors' experience consists of 60 Port-Access coronary artery bypass grafting procedures, 34 Port-Access mitral valve procedures (18 replacements, 16 repairs), 5 atrial septal defect closures, and 3 atrial myxoma removals. RESULTS: The patient survival rate was 99%, the incidence of perioperative stroke was 1%, and the incidence of aortic dissection was 1%. In the Port-Access mitral valve and atrial septal defect patients, the survival rate was 100% with no peri- or postoperative complications. Peri- and postoperative transesophageal echocardiography revealed no perivalvular leak or remaining mitral insufficiency after valve repair. CONCLUSIONS: The EndoCPB endovascular cardiopulmonary bypass system allows the application of true Port-Access minimally invasive cardiac surgery in procedures that require the use of cardiopulmonary bypass and cardioplegic arrest. Sternotomy and its potential complications can be avoided, and the surgical procedures can be performed safely on an empty, arrested heart with adequate myocardial protection.     

Stroke after cardiac surgery: a risk factor analysis of 16,184 consecutive adult patients

BACKGROUND: Stroke remains a devastating complication after cardiac surgical procedures despite advances in perioperative monitoring and management. The purpose of this study was to determine the predictors of stroke in a large, contemporary cardiac surgery population. METHODS: Prospective data on 16,184 consecutive patients undergoing cardiac surgery (coronary artery bypass grafting [CABG], n = 8,917; beating heart CABG, n = 1,842; aortic valve surgery, n = 1,830; mitral valve surgery, n = 708; double or triple valve surgery, n = 381; CABG and valve surgery, n = 2,506) between April 1996 and August 2001 were subjected to univariate and multivariate analysis. Stroke was defined as any new permanent (manifest stroke) or temporary neurologic deficit or deterioration (transient ischemic attack or prolonged reversible ischemic neurologic deficit) and was confirmed by computed tomography or magnetic resonance imaging whenever possible. RESULTS: Overall incidence of stroke was 4.6% and varied between surgical procedures (CABG 3.8%; beating-heart CABG 1.9%; aortic valve surgery 4.8%; mitral valve surgery 8.8%; double or triple valve surgery 9.7%; CABG and valve surgery 7.4%). Of 63 patient-specific and treatment variables, 54 were found to have a significant univariate association with postoperative stroke. Multivariable analysis revealed 10 variables that were independent predictors of stroke: history of cerebrovascular disease, peripheral vascular disease, diabetes, hypertension, previous cardiac surgery, preoperative infection, urgent operation, CPB time more than 2 hours, need for intraoperative hemofiltration, and high transfusion requirement. Beating heart CABG was associated with a lower incidence of stroke in this multivariable analysis. CONCLUSIONS: Identification of predictors for stroke is important for understanding the pathogenesis of this devastating complication as well as for developing preventative strategies. Although retrospective analyses can be subject to selection bias we believe beating heart CABG is associated with a lower incidence of stroke and may therefore improve patient outcomes.     

Accessory mitral valve associated with aortic regurgitation in an elderly patient: report of a case

We encountered a 75-year-old man who complained of exertional dyspnea. An echocardiographic examination showed aortic regurgitation and a tumor in the left ventricular outflow tract. Under complete extracorporeal circulation, we surgically made an incision of the ascending aorta with a slight thickening of the aortic valve and an enlarged annulus. After excising the aortic valve, an examination of the subvalvular region revealed mitral valve-like tissue extending from the annular region of the right coronary cusp to the ventricular septum, while the chordae tendinae was attached to the septum. This issue was excised, and the aortic valve was replaced with a 27-mm SJM valve. The postoperative course was uneventful, and the patient was discharged in good condition on postoperative day 30. An accessory mitral valve is extremely rare. Since this indication for surgical treatment is associated with congenital heart disease or a left ventricular outflow tract obstruction, most patients are young. Our patient had no associated cardiac anomalies and no pressure gradient attributable to a left ventricular outflow tract obstruction. This accessory mitral valve was discovered during aortic valve replacement surgery. To our knowledge, our patient is the oldest reported with an accessory mitral valve to have undergone a surgical resection.     

Posterior pericardial ascending-to-descending aortic bypass through median sternotomy

Abstract   Background and Aim: Adult patients with complex forms of descending aortic disease remain a surgical challenge and have a high risk of postoperative mortality and morbidity. Surgical management may be complicated when there is an associated cardiac defect, necessitating repair, or a hostile anatomy exists. We present our experience with extra-anatomic bypass through posterior pericardial route at the same stage with intracardiac/ascending aortic aneurysm repair. Methods: Patients that underwent one-stage surgery with posterior pericardial bypass between ascending and descending aorta during 2003-2007 were reviewed. Data from early and mid-term follow-up, including mortality, perioperative blood loss, graft-related complications, patency, and persistant hypertension, were noted. Results: Six male patients with a mean age of 20.8 ± 0.7 years were operated for coarctation of the aorta associated with additional pathologies (three cases of ascending aortic aneurysm—one with associated aortic valve insufficiency, one case of isolated aortic valve regurgitation, two cases of mitral valve regurgitation). No early or mid-term mortality was observed during follow-up of a mean of 21.6 ± 10.0 months. No late graft-related complications or reoperations were observed with patent grafts. Systolic blood pressure decreased after surgery by an average of 43 mmHg. Conclusions: Coarctation of the aorta with concomitant cardiac lesions can be repaired simultaneously through sternotomy and posterior pericardial approach, when patients present in adulthood, to minimize morbidity and mortality.