Annular and subvalvular dynamics after extracellular matrix mitral tube graft implantation in pigs

 Open in a separate windowOBJECTIVESEntire mitral valve reconstruction with an extracellular matrix tube graft is a potential candidate to overcome the current limitations of mechanical and bioprosthetic valves. However, clinical data have raised concern with respect to patch failure. The aim of our study was to evaluate the impact of extracellular matrix mitral tube graft implantation on mitral annular and subvalvular regional dynamics in pigs.METHODSA modified tube graft design made of 2-ply extracellular matrix was used (CorMatrix^®; Cardiovascular Inc., Alpharetta, GA, USA). The reconstructions were performed in an acute 80-kg porcine model (N = 8), where each pig acted as its own control. Haemodynamics were assessed with Mikro-Tip pressure catheters and mitral annular and subvalvular geometry and dynamics with sonomicrometry.RESULTSCatheter-based peak left atrial pressure and pressure difference across the mitral and aortic valves in the reconstructions were comparable to the values seen in the native mitral valves. Also comparable were maximum mitral annular area (755 ± 100 mm²), maximum septal-lateral distance (29.7 ± 1.7 mm), maximum commissure–commissure distance (35.0 ± 3.4 mm), end-systolic annular height-to-commissural width ratio (10.2 ± 1.0%) and end-diastolic interpapillary muscle distance (27.7 ± 3.3 mm). Systolic expansion of the mitral annulus was, however, observed after reconstruction.CONCLUSIONSThe reconstructed mitral valves were fully functional without regurgitation, obstruction or stenosis. The reconstructed mitral annular and subvalvular geometry and subvalvular dynamics were found in the same range to those in the native mitral valve. A regional annular ballooning effect occurred that might predispose to patch failure. However, the greatest risk was found at the papillary muscle attachments.     

Early and late results of mitral valve repair with anterior leaflet patch augmentation

OBJECTIVESThe aim of this study was to determine the long-term results of mitral valve (MV) repair with anterior leaflet patch augmentation.Open in a separate windowMETHODSBetween 2012 and 2015, 45 patients underwent MV repair using the anterior leaflet patch augmentation technique at our institution. The mean age of the patients was 65.9 ± 13.0 years (16 males). We reviewed the MV pathology and the surgical techniques used and assessed the early and late results.RESULTSIn terms of MV pathology, 43 patients (95.6%) had pure mitral regurgitation (MR) and 2 patients (4.4%) had mixed mitral stenosis and MR. Rheumatic changes were seen in 18 patients (40.0%). Postoperative echocardiography showed that 95.6% of patients had none to mild MR. During a median follow-up period of 5.5 years (range 0.1–8.3 years), there were 8 late deaths. Nine patients (20%) required reoperation. The mean interval between the initial operation and redo operation was 3.7 ± 3.1 years (range: 0.4–7.8 years). The causes of reoperation included patch dehiscence (n = 4), progression of mitral stenosis (n = 2), band dehiscence (n = 1), patch enlargement (n = 1) and unknown (n = 1). Eight patients underwent MV replacement and 1 underwent repeat MV repair. The freedom from reoperation at 3 and 5 years was 85.7 ± 6.7% and 81.2 ± 7.7%, respectively.CONCLUSIONSAnterior leaflet patch augmentation can provide excellent early results in the majority of the patients even in the presence of rheumatic pathology; however, we observed late reoperation in 20% of patients. Thus, this technique should be used with caution and careful follow-up with serial echocardiography is essential.     

Results of concomitant cryoablation for atrial fibrillation during mitral valve surgery

Open in a separate window OBJECTIVESConcomitant atrial fibrillation ablation during mitral valve (MV) surgery using radio frequency energy sources has been reported previously with excellent outcomes. However, data regarding the effectiveness of concomitant cryoablation remain limited. This study aimed to assess the efficacy of concomitant cryoablation in patients scheduled for MV surgery.METHODSBetween 2012 and 2020, 242 adult patients who underwent MV surgery and concomitant cryoablation were included. Data on rhythm, medication status and clinical events were assessed at 3, 6 and 12 months, then annually thereafter.RESULTSEarly mortality was 0.4%. The mean follow-up period duration was 43.9 months. The survival rates at 1, 3 and 5 years were 97.3%, 94.3% and 87.7%, respectively. The rates of freedom from atrial arrhythmia paroxysms at 1, 3 and 5 years were 79.0%, 64.0% and 60.5%, respectively. Atrial arrhythmia recurrence was associated with isolated left atrial lesion set (P = 0.038), large right atrial size (P = 0.002), lower surgeon experience (P = 0.003) and atrial fibrillation paroxysms in the early postoperative period (P = 0.002).CONCLUSIONSConcomitant cryoablation during MV surgery is a safe and reproducible technique. The procedure provides acceptable freedom from atrial arrhythmias recurrences during long-term follow-up. The biatrial lesion set has advantages over the left atrium pattern in terms of atrial arrhythmias freedom. Surgeon experience significantly influences atrial fibrillation ablation success. Randomized trials are needed to compare radiofrequency and cryoablation.     

Atrial and ventricular flows across a transcatheter mitral valve

 Open in a separate windowOBJECTIVESThe objective of this study was to evaluate the haemodynamic performance of transcatheter mitral valve replacement (TMVR) Implant with a focus on turbulence and washout adjacent to the ventricular surface of the leaflets. TMVR holds the promise of treating a large spectrum of mitral valve diseases. However, the haemodynamic performance and flow dynamics of such replacements are not fully understood. METHODSA tri-leaflet biopsrosthetic TMVR represented by Caisson implant of size 36A was implanted in the mitral position of a left heart simulator pulse duplicating system under physiological conditions. The 36A implant covers an anterior–posterior range of 26–32 mm and a commissure-to-commissure range of 30–36 mm. Transmitral pressure gradient, effective orifice area and regurgitant fraction were calculated. Particle image velocimetry was performed to evaluate turbulence in 2 perpendicular planes (Reynolds and viscous shear stresses, respectively). Additionally, dye experiments were performed to visualize washout.RESULTSTransmitral pressure gradient was 1.29 ± 0.27 mmHg and effective orifice area was 2.96 ± 0.28 cm². Regurgitant fraction was 14.13 ± 0.08%. Total washout was 4.27 cardiac cycles. Largest viscous shear stress reaches 3.7 Pa and 2.4 Pa in ventricle and atrium, respectively. Reynolds shear stress in the atrial side was <10 Pa. In the ventricular side, the largest Reynolds shear stress reached ∼35 Pa.CONCLUSIONSTMVR leads to favourable haemodynamics with low degree of turbulence combined with fast washout around the leaflets indicating promising potential for freedom from blood damage potential and thrombosis corroborated by initial clinical studies as part of the valves’s Early Feasibility Study.     

Late results after mitral valve replacement with Mosaic bioprosthesis in patients aged 65 years or younger

Open in a separate window OBJECTIVESAlthough in younger patients indications for biological prosthesis implantation in mitral valve replacement remain controversial, recently bioprostheses use increased considerably. We present late results obtained with the Medtronic Mosaic bioprosthesis in patients aged 65 years or younger. METHODSBetween 2007 and 2017, 67 mitral Mosaic bioprostheses were implanted in patients aged 65 years or younger (58.5 ± 6.4 years). Follow-up extended up to 13 years. Survival, freedom from structural valve degeneration, endocarditis, thromboembolic events and reoperation were considered as main clinical end points evaluated at 1, 5 and 10 years.RESULTSThe mean follow-up was 4.7 ± 2.8 years. Overall mortality rate was 12%. At 1, 5 and 10 years, survival was 94 ± 3%, 89 ± 4% and 77 ± 9%, respectively. Freedom from structural valve degeneration was 100%, 94 ± 4% and 71 ± 21%. Freedom from endocarditis was 95 ± 3%, 90 ± 6% and 84 ± 8%. Freedom from thromboembolic events was 94 ± 3%, 90 ± 5% and 90 ± 5%. Freedom from reoperation was 94 ± 3%, 87 ± 5% and 65 ± 19%.CONCLUSIONSMosaic bioprosthesis appears a valid mitral valve substitute even when employed in ≤65-year-old patients.     

Aortic valve neocuspidization for aortic regurgitation associated with ventricular septal defect

 Open in a separate windowOBJECTIVESDifferent methods of aortic valve repair have been described in the literature for aortic regurgitation (AR) associated with doubly committed subarterial ventricular septal defects. Our goal was to present our experience with aortic valve reconstruction of a single leaflet using the aortic valve neocuspidization technique in this subset of patients.METHODSIt is a retrospective review of 7 patients with doubly committed subarterial ventricular septal defects with significant (>moderate) AR who underwent the single-leaflet neocuspidization technique of aortic valve reconstruction from January 2016 to January 2019. Data were collected from medical records. All patients had thorough 2-dimensional echocardiographic assessment preoperatively and during the follow-up period. Primary end points were freedom from postoperative AR and freedom from reoperation and all-cause mortality within the follow-up period with secondary end points of freedom from thromboembolism and infective endocarditis.RESULTSOut of 7 patients, 6 were male and 1 was female. There were no perioperative deaths. The mean follow-up period was 2.6 ± 0.8 years. No deaths occurred during the follow-up period. At the latest follow-up examination, only 2 patients showed mild AR and were asymptomatic. There was no documented event of infective endocarditis or thromboembolism during the follow-up period.CONCLUSIONSThe aortic leaflet neocuspidization procedure for the aortic valve is a relatively new concept. Availability of a template makes it an easily reproducible valve repair in paediatric patients with a single-leaflet abnormality. This technique preserves the remaining 2 normal leaflets, thus promoting the growth potential while maintaining near normal aortic root complex dynamics.     

Rheumatic mitral regurgitation: is repair justified by the long-term results?

 Open in a separate windowOBJECTIVESThe best treatment for rheumatic mitral regurgitation is still under debate. Our goal was to assess the long-term results of mitral repair for rheumatic mitral regurgitation performed in 2 referral centres for mitral repair.METHODSPatients who underwent mitral valve repair between 1999 and 2009 were selected. Preoperative and postoperative data were prospectively entered into a dedicated database and retrospectively reviewed. Kaplan–Meier estimates were used to analyse long-term survival. Competing risk analysis was performed by calculating the cumulative incidence function for time to recurrence of mitral regurgitation ≥3+, mitral regurgitation ≥2+, mitral reoperation and the combined end point of repair failure (mitral regurgitation ≥ 3+ and/or mean gradient ≥ 10 mmHg and/or mitral valve REDO) with death as a competing risk.RESULTSA total of 72 patients were included. Mitral calcifications were present in 25 patients (34.7%). Most of the patients (65/72, 90.3%) underwent annuloplasty, and mixes of reparative techniques were used in 21 patients (29.2%). In-hospital mortality was 2.8%. Mean follow-up was 11.6 ± 5.16 (max 19.1 years), 98.6% completed. Survival at 14 years was 70 ± 6.27%. At 14 years, the cumulative incidence function of repair failure was 36.7 ± 6.52%. The presence of severe mitral annulus calcification was an independent predictor of repair failure.CONCLUSIONSMitral repair for rheumatic mitral regurgitation is characterized by a high rate of failure in the long term (14 years), particularly in patients with severe annular calcifications. These results call for a very selective approach when considering a repair strategy in this setting, especially in case of unfavourable anatomical conditions.     

Evolution from mitral annular dysfunction to severe mitral regurgitation in Barlow’s disease

OBJECTIVESBarlow’s disease (BD) is characterized by thick, redundant mitral valve (MV) leaflets, which can lead to prolapse and significant mitral regurgitation (MR). MV annular abnormalities are also commonly observed and increasingly recognized as possible primary pathology, with leaflet thickening being secondary to increased stress on the MV apparatus. To provide more insights into this hypothesis, the evolution of MV abnormalities over time in patients with BD was assessed.Open in a separate windowMETHODSA total of 64 patients (54 ± 12 years, 72% male) with BD who underwent MV surgery and had multiple transthoracic echocardiograms (TTE) before surgery were included. In total, 186 TTE were analysed (median time interval 4.2, interquartile range 2.2–6.5 years) including specific MV characteristics.RESULTSAt baseline, MV leaflet length, thickness, billowing height and annular diameter were larger in patients with BD compared to 59 healthy subjects. Systolic outward motion (curling) of the annulus was observed in 77% and severe mitral annular disjunction (≥5 mm) in 38% of patients with BD. Forty (63%) patients had MR grade I–II and 24 (37%) MR grade III–IV; at baseline, the 2 groups only differed in left atrial volume and in thickness and billowing height of the posterior leaflet, showing comparable MV annular abnormalities and dilatation despite different grades of MR. Over time, MV annulus diameter, leaflet length and billowing height increased significantly along with MR grade.CONCLUSIONSIn patients with BD, MV annulus abnormalities are present at an early stage and precede the development of significant MR, suggesting their substantial role in the pathophysiology of this disease and as an important target for surgical treatment.     

Simultaneous transcatheter treatment of ascending aortic aneurysm with aortic and mitral regurgitation: an in vitro study

 Open in a separate windowOBJECTIVESWe sought to explore the efficacy of the endovascular repair of an ascending aortic aneurysm with aortic and mitral regurgitation by 2 novel valved stents.METHODSWe established models of ascending aortic aneurysms combined with aortic and mitral regurgitation in 10 pig hearts, then implanted self-expanding aortic fenestrated and mitral valved stents via the transapical approach. We applied a fluoroscopy-guided in vitro setting to test the approach, then analysed continuous circulating flushing at 37°C. Finally, we determined operating times, echocardiography and changes of coronary flow as well as fenestration alignment with the coronary ostia.RESULTSThis approach resulted in a 100% overall technical success rate, excellent handling properties and precise positioning. The time taken to implant the 2 valved stents was 59 ± 12 min. Flow of the left and right coronary arteries did not significantly decrease after the stents were implanted (330.4 ± 12.06 ml/min vs 289.4 ± 5.29 ml/min, P < 0.001; 376.8 ± 10.5 ml/min vs 350.0 ± 14.5 ml/min; P < 0.001). We found no obvious regurgitation and perivalvular leakage; nor did the gradients of the aortic and mitral valves as well as of the left ventricular outflow tract increase significantly. The final angiographic examination and profile of the coronary opening confirmed the good position of the valved stents, the exclusion of the aneurysm and the patency of both coronary arteries.CONCLUSIONSThese findings indicate the potential for combined transcatheter aortic root and mitral valve replacement in treating aortic root pathologies. In future, in vivo studies are expected to validate this approach and ascertain its durability.     

Minimally invasive mitral valve surgery after failed transcatheter mitral valve repair in an intermediate-risk cohort

Open in a separate window OBJECTIVESAlthough clinical experience with transcatheter mitral valve interventions is rapidly increasing, there is still a lack of evidence regarding surgical treatment options for the management of recurrent mitral regurgitation (MR). This study provides guidance for a minimally invasive surgical approach following failed transcatheter mitral valve repair, which is based on the underlying mitral valve (MV) pathology and the type of intervention.METHODSA total of 46 patients who underwent minimally invasive MV surgery due to recurrent or residual MR after transcatheter edge-to-edge repair or direct interventional annuloplasty between October 2014 and March 2021 were included.RESULTSThe median age of the patients was 78 [interquartile range, 71–82] years and the EuroSCORE II was 4.41 [interquartile range, 2.66–6.55]. At the index procedure, edge-to-edge repair had been performed in 45 (97.8%) patients and direct annuloplasty in 1 patient. All patients with functional MR at the index procedure (n = 36) underwent MV replacement. Of the patients with degenerative MR (n = 10), 5 patients were eligible for MV repair after removal of the MitraClip. The 1-year survival following surgical treatment was 81.3% and 75.0% in patients with functional and degenerative MR, respectively. No residual MR greater than mild during follow-up was observed in patients who underwent MV repair.CONCLUSIONSMinimally invasive surgery following failed transcatheter mitral valve repair is feasible and safe, with promising midterm survival. The surgical management should be tailored to the underlying valve pathology at the index procedure, the extent of damage of the MV leaflets and the type of previous intervention.     

Benefits of robotically-assisted surgery for complex mitral valve repair

OBJECTIVESTo determine whether robotic mitral valve repair can be applied to more complex lesions compared with minimally invasive direct mitral valve repair through a right thoracotomy. Open in a separate windowMETHODSWe enrolled 335 patients over a 9-year period; 95% of the robotic surgeries were performed after experience performing direct mitral valve repair.RESULTSThe mean age in the robotic versus thoracotomy repair groups was 61 ± 14 vs 55 ± 11 years, respectively (P < 0.001); 97% vs 100% of the patients, respectively, had degenerative aetiologies. Repair complexity was simple in 106 (63%) vs 140 (84%), complex in 34 (20%) vs 20 (12%) and most complex in 29 (17%) vs 6 (4%) patients undergoing robotic versus thoracotomy repair, respectively. The average complexity score with robotic repair was significantly higher versus thoracotomy repair (P < 0.001). The robotic group underwent more chordal replacement using polytetrafluoroethylene and less resections. All patients underwent ring annuloplasty. Cross-clamp time did not differ between the groups, and no strokes or deaths occurred. More patients undergoing robotic repair underwent concomitant procedures versus the thoracotomy group (30% vs 14%, respectively; P < 0.001). The overall repair rate was 100%, with no early mortality or strokes in either group. Postoperative mean residual mitral regurgitation was 0.3 in both groups, and the mean pressure gradient through the mitral valve was 2.4 vs 2.7 mmHg (robotic versus thoracotomy repair, respectively; P = 0.031).CONCLUSIONSRobotic surgery can be applied to repair more complex mitral lesions, with excellent early outcomes.     

Mini-thoracotomy and full-sternotomy approach for reoperative mitral valve surgery after a previous sternotomy

 Open in a separate windowOBJECTIVESRight mini-thoracotomy approach may enhance the visualization of mitral valve (MV) visualization during redo MV surgery, thereby minimizing the risk of reoperative median sternotomy. We described the clinical outcomes of redo MV surgery by mini-thoracotomy and full-sternotomy approach.METHODSOf 730 consecutive adult patients who underwent redo MV surgery between 2002 and 2018 at our institution, we identified 380 patients (age: 56.0 [14.8] years) after excluding those who underwent concomitant aortic valve or coronary artery surgeries.RESULTSThe clinical outcomes in patients who underwent mini-thoracotomy (MINI group; n = 168) and full-sternotomy (STERN group; n = 218) were described. The early and overall mortality in the MINI group was 4.3% (7/162) and 17.3% (28/162), with the rates of early major complications as follows: low cardiac output syndrome, 5.6% (9/162); early stroke, 6.8% (11/162); new-onset dialysis, 6.2% (10/162); prolonged ventilation, 15.4% (25/162); and postoperative bleeding requiring exploration, 7.4% (12/162). In the STERN group, the early mortality was 11.0% (24/218), whereas the risk of low cardiac output syndrome, early stroke, new-onset dialysis, prolonged ventilation, and postoperative bleeding was 12.4% (27/218), 14.2% (31/218), 17.0% (37/218), 33.0% (72/218), and 10.1% (22/218), respectively. The duration of intensive care unit and hospital stay was 2.0 [range 1.0, 3.0] and 8.0 [6.0, 13.0], respectively, in the MINI group and 3.0 [2.0, 7.0] and 14.0 [8.0, 29.0], respectively, in the STERN group.CONCLUSIONSMini-thoracotomy may be a viable alternative to conventional sternotomy for redo MV surgery.     

Endovascular aortic arch repair with a pre-cannulated double-fenestrated physician-modified stent graft: a benchtop experiment

 Open in a separate windowOBJECTIVESThe critical step in total endovascular aortic arch repair is to ensure alignment of fenestrations with, and thus maintenance of flow to, supra-aortic trunks. This experimental study evaluates the feasibility and accuracy of a double-fenestrated physician-modified endovascular graft [single common large fenestration for the brachiocephalic trunk and left common carotid artery and a distal small fenestration for left subclavian artery (LSA) with a preloaded guidewire for the LSA] for total endovascular aortic arch repair.METHODSEight fresh human cadaveric thoracic aortas were harvested. Thoracic endografts with a physician-modified double fenestration were deployed for total endovascular aortic arch repair in a bench test model. A guidewire was preloaded through the distal fenestration for the LSA. All experiments were undertaken in a hybrid room under fluoroscopic guidance with subsequent angioscopy and open evaluation for assessment.RESULTSMean aortic diameter in zone 0 was 31.3 ± 3.33 mm. Mean duration for stent graft modification was 20.1 ± 5.8 min. Mean duration of the procedure was 24 ± 8.6 min. The Medtronic Valiant Captivia stent graft was used in 6 and the Cook Alpha Zenith thoracic stent graft in 2 cases. LSA catheterization was technically successful with supra-aortic trunk patency in 100% of cases.CONCLUSIONSThe use of a double-fenestrated stent graft with a preloaded guidewire appears to be a useful technical addition to facilitate easy and correct alignment of stent graft fenestrations with supra-aortic trunk origins.     

Balloon-expanding transcatheter aortic valve implantation for degenerated Mitroflow bioprostheses: clinical and echocardiographic long-term outcomes

Open in a separate window OBJECTIVESThis study aims to analyse the risks associated with valve-in-valve procedures for treating structural valve deterioration in Mitroflow bioprostheses, as well as to determine the impact of the original Mitroflow size on the patients’ long-term outcomes.METHODSBetween January 2012 and September 2019, 21 patients (61.9% males; mean age 82.4 ± 5.4 years) were treated for Mitroflow deterioration with valve-in-valve procedures (12 transapical and 9 transfemoral).RESULTSMean EuroSCORE I and EuroSCORE II were 28.2% ± 13.6% and 10.5% ± 6.1%, respectively. Six patients presented an indexed aortic root diameter <14 mm/m² and 7 patients a diameter of sinus of Valsalva <30 mm. Implanted transcatheter valve sizes were 20 mm in 6 cases, 23 mm in 14 cases and 26 mm in 1 patient. A Valve Academic Research Consortium-2 complication occurred in 23.8% of cases, including 3 coronary occlusions. In-hospital mortality was 9.5%. The 20 mm transcatheter valves presented significantly higher postoperative peak and mean aortic gradients than other sizes (54.1 ± 11.3 mmHg vs 29.9 ± 9.6 mmHg, P = 0.003; and 29.3 ± 7.7 mmHg vs 17.4 ± 5.9 mmHg, P = 0.015, respectively). There were 12 cases of patient–prosthesis mismatch (57.1%) and 3 cases (14.3%) of severe patient–prosthesis mismatch. Cumulative survival was 85.7% ± 7.6% at 1 year, 74.3% ± 10% at 2 years and 37.1% ± 14.1% at 5 years.CONCLUSIONSValve-in-valve procedures with balloon-expandable transcatheter valves associate a high risk of coronary occlusion in patients with indexed aortic root diameter <14 mm/m² and low coronary ostia <12 mm. Valve-in valve procedures with 20 mm balloon-expandable transcatheter valves in ≤21 mm Mitroflow bioprosthesis leave significant residual transvalvular gradients that might obscure patients’ long-term outcomes.     

Minimal invasive temporary percutaneous right ventricular circulatory support after left ventricular assist device implantation

 Open in a separate windowOBJECTIVESCardiogenic shock is a life-threatening situation with high mortality rates. Mechanical unloading of the left ventricle may be achieved via left ventricular assist device (LVAD) implantation. Postoperative right ventricular (RV) failure, however, has very limited therapeutic options and is associated with increased postoperative mortality. In this paper, we describe a percutaneous right heart bypass for temporary postoperative RV support.METHODSWe retrospectively examined all patients receiving percutaneous RV mechanical support after LVAD implantation. All patients receiving trans-jugular mechanical right heart bypass during or after LVAD implantation in our tertiary medical centre between November 2014 and December 2019 were examined retrospectively. The venous draining cannula was placed in the femoral vein; the pulmonary cannula was placed in the pulmonary artery using fluoroscopy.RESULTSIn total, 14 patients received RV support using the trans-jugular technique. Mean age was 48.4 ± 14.9 years. Nine patients were treated with mechanical circulatory support before LVAD implantation. Biventricular support was done in 7 patients. All patients were treated with an Heartware HVAD . Mean postoperative intensive care unit stay was 46.3 ± 32.4 days. Mean right heart bypass support time was 10.6 ± 4.3 days. Twelve patients (86%) could be bridged to RV recovery, RV assist device implantation or heart transplantation.CONCLUSIONSPercutaneous RV mechanical support is feasible, safe and shows acceptable outcome. Early implantation of RV support may contribute to successful outcome after LVAD implantation.     

In-hospital outcomes of patients undergoing concomitant aortic and mitral valve replacement in Germany

 Open in a separate windowOBJECTIVESTo evaluate in-hospital outcomes of concomitant mitral valve replacement (MVR) in patients undergoing conventional aortic valve replacement due to aortic stenosis in a nationwide cohort.METHODSAdministrative data from all patients with aortic stenosis undergoing conventional aortic and concomitant MVR (reason for MVR not specified) between 2017 and 2018 in Germany were analysed.RESULTSA total of 2597 patients with a preoperative logistic EuroScore of 9.81 (standard deviation: 8.56) were identified. In-hospital mortality was 6.8%. An in-hospital stroke occurred in 3.4%, acute kidney injury in 16.3%, prolonged mechanical ventilation of more than 48 h in 16.3%, postoperative delirium in 15.8% and postoperative pacemaker implantation in 7.6% of the patients. Mean hospital stay was 16.5 (standard deviation: 12.1) days. Age [odds ratio (OR): 1.03; P = 0.019], New York Heart Association class III or IV (OR: 1.63; P = 0.012), previous cardiac surgery (OR: 2.85, P = 0.002), peripheral vascular disease (OR: 2.01, P = 0.031), pulmonary hypertension (OR: 1.63, P = 0.042) and impaired renal function (glomerular filtration rate <15, OR: 3.58, P = 0.001; glomerular filtration rate <30, OR: 2.51, P = 0.037) were identified as independent predictors for in-hospital mortality.CONCLUSIONSIn this nationwide analysis, concomitant aortic and MVR was associated with acceptable in-hospital mortality, morbidity and length of in-hospital stay. The regression analyses may help to identify high-risk patients and further optimize treatment strategies.     

Can surgical repair for pectus excavatum contribute to lung growth?

 Open in a separate windowOBJECTIVESThis study investigates whether the surgical correction of chest deformity is associated with the growth of the lung parenchyma after surgery for pectus excavatum.METHODSTen patients with pectus excavatum who were treated by the Nuss procedure were examined. The preoperative and postoperative computed tomography (2.5 ± 1.2 years after surgery) scans were performed, and the Haller index, lung volume and lung density were analyzed using a three-dimensional image analysis system (SYNAPSE VINCENT, Fujifilm, Japan). The radiological lung weight was calculated as follows: lung volume (ml) × lung density (g/ml).RESULTSThe average age of the 10 patients (men 8; women 2) was 13.8 years (range: 6–26 years). The Haller index was significantly improved from the preoperative value of 5.18 ± 2.20 to the postoperative value of 3.68 ± 1.38 (P = 0.0025). Both the lung volume and weight had significantly increased by 107.1 ± 19.6% and 121.6 ± 11.3%, respectively, after surgery.CONCLUSIONSA significant increase in the weight of the lung after surgical correction suggests that the growth of the lung parenchyma is associated with the correction of chest deformity in younger patients with pectus excavatum.     

Usability,performance and safety of a new device for degenerative mitral regurgitation: in vivo chronic evaluation

Open in a separate window OBJECTIVESThis study aimed to evaluate the usability, performance and safety of an innovative mitral valve device in the chronic setting characterized by an intraventricular bridge, which enables artificial chordae anchoring and/or direct posterior leaflet fixation.METHODSTen female sheep were employed and underwent device implantation. Any interference of the device with leaflet motion, ease of device use, correct chordae length estimation and implantation were evaluated. Post-procedural valve competence and device performance were verified by periodic postoperative echocardiograms and laboratory examinations. Following euthanasia, gross anatomy and histology evaluation of the hearts and valves were performed to detect tissue abnormalities and inflammation reaction related to the device.RESULTSThe procedure was successfully completed in all 10 sheep. Lengths of the 2 chordae implanted were 23 (21.5–24) mm and 23 (22.5–24) mm. The time required to suture both pairs of the artificial chordae was 2.7 ± 0.7 min. At the 3-month follow-up, left ventricular function was normal. The transvalvular peak pressure gradient was 9 (7.5–10) and the mean gradient was 4 (3.5–4) mmHg. Upon necropsy and histological evaluation, no damage to left ventricle wall, valve leaflets, chordae and papillary muscles and absence of thrombus formation and inflammatory reaction were observed. Radiological images showed neither fracture of the device nor calcifications. Laboratory tests showed no signs of haemolysis.CONCLUSIONSIn vivo late tests confirmed the ease of correct chordal length estimation prior to implantation, short operative time and usability in flailed anterior leaflet repair. The absence of negative impact of the device on mitral leaflets motion, function and structure and successful repair might suggest that the device would be useful in complex degenerative mitral disease.     

Extensive calcification of the mitral valve annulus in transcatheter aortic valve implants

 Open in a separate windowOBJECTIVESThis study sought to report the calcification pattern of the mitral valve annulus and its implications for procedural and safety outcomes in transcatheter aortic valve implantation.METHODSBetween November 2018 and September 2019, a total of 305 patients had transcatheter aortic valve implants at our institution. The extent of calcification of the mitral valve annulus was analysed, and the impact on safety outcomes was evaluated.RESULTSThe prevalence of mitral annular calcification (MAC) was 43%. Calcification of the mitral valve annulus was either less than or at least one-third of the posterior annulus (34% and 32%), the whole posterior annulus (28%) or the extension to the attachment of the anterior leaflets (7%). Severe circumferential MAC revealed moderate paravalvular leaks in 5/8 (63%) patients and was associated with right branch bundle block [odds ratio (OR) 2.01 (0.39–3.06); P = 0.098] and low cardiac output [OR 3.12 (1.39–7.04); P = 0.033]. Subannular calcification at the anterolateral trigonum represented a risk factor for left ventricular outflow tract injury [OR 3.54 (1.38–8.27); P = 0.001] in balloon-expandable valves, associated with relevant rhythm disorders [OR 2.26 (1.17–5.65); P = 0.014] and female gender (7/8, 88%). The 30-day all-cause mortality in circumferential MAC reaching into the anterior annulus (grade IV) compared to patients with less MAC (grade I–III) was 13% vs 2% with a mean valve size of 24.6 vs 25.7 mm.CONCLUSIONSExtensive MAC was associated with moderate paravalvular leaks, with implications for the prosthesis size and survival in transcatheter aortic valve implants. In severe MAC, we recommend implanting oversized self-expandable prostheses, the goal being to reduce the risk of right branch bundle block and paravalvular leaks.Subj collection122, 125     

Modified Nuss procedure with a novel steel bar in patients with pectus excavatum post-congenital heart surgery

 Open in a separate windowOBJECTIVESPectus excavatum (PE) can be secondary in patients who underwent sternotomy for cardiac surgery. Retrosternal adhesions increase the complexity and risk of traditional Nuss repair. Thus, we summarized the outcomes of our modified Nuss procedure using a newly designed bar.METHODSA retrospective analysis was performed on 35 patients who underwent modified PE repair after open heart surgery from January 2011 to July 2019. The surgery was performed using a novel bar with no need for intraoperative reshaping and rotation, assisted by thoracoscopy and subxiphoid incision when necessary.RESULTSThere were 19 males and 16 females with a median age of 5.3 years (interquartile range, 4.1–10.9) at PE repair. All patients underwent the modified procedure uneventfully with no death. The median operating time was 70 min. Twenty-nine (82.9%) patients required subxiphoid incision assistance. There was 1 case (2.8%) with unexpected sternotomy due to intraoperative bleeding. The median length of postoperative hospital stay was 4 days. During the median 3.5 years of follow-up, no bar dislocation was found and 30 (85.7%) patients had their bars removed with no recurrence recorded. After PE repair, the Haller index improved significantly (2.6 ± 0.4 vs 4.9 ± 1.3, P < 0.05) and further decreased till the time of bar removal (2.5 ± 0.4 vs 2.6 ± 0.4, P < 0.05). All patients were satisfied with the cosmetic outcome.CONCLUSIONSThe novel bar can be placed and removed easily with a low rate of adverse events. This modified Nuss procedure seems to be a safe, effective and convenient approach for the management of PE after cardiac surgery.