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Pozzi M, Mariani S, Scanziani M, Passolunghi D, Bruni A, Finazzi A, Lettino M, Foti G, Bellelli G, Marchetto G. The frail patient undergoing cardiac surgery: lessons learned and future perspectives. Front Cardiovasc Med 2023; 10:1295108. [PMID: 38124896 PMCID: PMC10731467 DOI: 10.3389/fcvm.2023.1295108] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 11/27/2023] [Indexed: 12/23/2023] Open
Abstract
Frailty is a geriatric condition characterized by the reduction of the individual's homeostatic reserves. It determines an increased vulnerability to endogenous and exogenous stressors and can lead to poor outcomes. It is an emerging concept in perioperative medicine, since an increasing number of patients undergoing surgical interventions are older and the traditional models of care seem to be inadequate to satisfy these patients' emerging clinical needs. Nowadays, the progressive technical and clinical improvements allow to offer cardiac operations to an older, sicker and frail population. For these reasons, a multidisciplinary team involving cardiac surgeons, clinical cardiologists, anesthesiologists, and geriatricians, is often needed to assess, select and provide tailored care to these high-risk frail patients to optimize clinical outcomes. There is unanimous agreement that frailty assessment may capture the individual's biological decline and the heterogeneity in risk profile for poor health-related outcomes among people of the same age. However, since commonly used preoperative scores for cardiac surgery fail to capture frailty, a specific preoperative assessment with dedicated tools is warranted to correctly recognize, measure and quantify frailty in these patients. On the contrary, pre-operative and post-operative interventions can reduce the risk of complications and support patient recovery promoting surgical resilience. Minimally invasive cardiac procedures aim to reduce surgical trauma and may be associated with better clinical outcome in this specific sub-group of high-risk patients. Among postoperative adverse events, the occurrence of delirium represents a risk factor for several unfavorable outcomes including mortality and subsequent cognitive decline. Its presence should be carefully recognized, triggering an adequate, evidence based, treatment. There is evidence, from several cross-section and longitudinal studies, that frailty and delirium may frequently overlap, with frailty serving both as a predisposing factor and as an outcome of delirium and delirium being a marker of a latent condition of frailty. In conclusion, frail patients are at increased risk to experience poor outcome after cardiac surgery. A multidisciplinary approach aimed to recognize more vulnerable individuals, optimize pre-operative conditions, reduce surgical invasivity and improve post-operative recovery is required to obtain optimal long-term outcome.
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Affiliation(s)
- Matteo Pozzi
- Department of Emergency and Intensive Care, IRCCS San Gerardo dei Tintori Foundation, Monza, Italy
| | - Silvia Mariani
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands
- Division of Cardiac Surgery, IRCCS San Gerardo dei Tintori Foundation, Monza, Italy
| | - Margherita Scanziani
- Department of Emergency and Intensive Care, IRCCS San Gerardo dei Tintori Foundation, Monza, Italy
| | - Davide Passolunghi
- Division of Cardiac Surgery, IRCCS San Gerardo dei Tintori Foundation, Monza, Italy
| | - Adriana Bruni
- Acute Geriatrics Unit, IRCCS San Gerardo dei Tintori Foundation, Monza, Italy
| | - Alberto Finazzi
- Acute Geriatrics Unit, IRCCS San Gerardo dei Tintori Foundation, Monza, Italy
- School of Medicine, University of Milan Bicocca, Monza, Italy
| | - Maddalena Lettino
- Department of Cardiovascular Medicine, IRCCS San Gerardo dei Tintori Foundation, Monza, Italy
| | - Giuseppe Foti
- Department of Emergency and Intensive Care, IRCCS San Gerardo dei Tintori Foundation, Monza, Italy
- School of Medicine, University of Milan Bicocca, Monza, Italy
| | - Giuseppe Bellelli
- Acute Geriatrics Unit, IRCCS San Gerardo dei Tintori Foundation, Monza, Italy
- School of Medicine, University of Milan Bicocca, Monza, Italy
| | - Giovanni Marchetto
- Division of Cardiac Surgery, IRCCS San Gerardo dei Tintori Foundation, Monza, Italy
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Brown A, Jefferson HL, Fatehi Hassanabad A, Noss C, Webb N, Fedak PWM, Kent WDT, Adams C. Echocardiographic and clinical outcomes following beating heart NeoChord DS1000 mitral valve repair: a single centre case series. Front Cardiovasc Med 2023; 10:1160979. [PMID: 37424907 PMCID: PMC10326548 DOI: 10.3389/fcvm.2023.1160979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 06/14/2023] [Indexed: 07/11/2023] Open
Abstract
Background The NeoChord DS1000 system implants artificial neochords transapically, through a left mini-thoracotomy to treat degenerative mitral valve regurgitation (MR). Performed without cardiopulmonary bypass, neochord implantation and length adjustment is guided by transesophageal echocardiography. We describe imaging and clinical outcomes for a single center case series using this innovative device platform. Methods In this prospective series, all study patients had degenerative MR and were considered for conventional mitral valve surgery. Moderate to high-risk candidates were screened for NeoChord DS1000 eligibility based on echocardiographic criteria. Study criteria included isolated posterior leaflet prolapse, leaflet-to-annulus index greater than 1.2, and coaptation length index greater than 5 mm. Patients with bileaflet prolapse, mitral annular calcification, and ischemic MR were excluded from our early experience. Results Ten patients underwent the procedure, including 6 males and 4 females, with a mean age of 76 ± 9.5 years. All patients had severe chronic MR and normal left ventricular function. One patient required conversion to an open procedure for failure to deploy neochords with the device transapically. The median number of NeoChord sets was 3 (IQR 2.3-3.8). Immediate post-procedure (POD#0) degree of MR on echocardiography ranged from mild or less, and on postoperative day 1 (POD#1) from moderate or less. Average length of coaptation was 0.85 ± 0.21 cm and average depth of coaptation was 0.72 ± 0.15 cm. At 1-month follow-up echocardiography, MR was graded from trivial to moderate and left ventricular inner diameter dimensions decreased from an average of 5.4 ± 0.4 cm to 4.6 ± 0.3 cm. None of the patients who had successful NeoChord implantation required blood products. There was 1 perioperative stroke with no residual deficits. There were no device-related complications or serious adverse events. The median length of hospital stay was 3 (IQR 2.3-10) days. 30-day and 6-weeks postoperative mortality and readmission rates were 0%. Conclusion We report the first Canadian case series using the NeoChord DS1000 system for off-pump, transapical, beating heart mitral valve repair, through a left mini-thoracotomy. The early surgical outcomes suggest this approach is feasible, safe, and effective in reducing MR. This novel procedure has the advantage of offering a minimally invasive, off-pump option for select patients with high surgical risk.
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Affiliation(s)
- Amy Brown
- Department of Cardiac Sciences, Libin Cardiovascular Institute, University of Calgary, Calgary, AB, Canada
| | - Hallie L. Jefferson
- Department of Cardiac Sciences, Libin Cardiovascular Institute, University of Calgary, Calgary, AB, Canada
| | - Ali Fatehi Hassanabad
- Department of Cardiac Sciences, Libin Cardiovascular Institute, University of Calgary, Calgary, AB, Canada
| | - Christopher Noss
- Department of Anesthesiology, Libin Cardiovascular Institute, University of Calgary, Calgary, AB, Canada
| | - Nicole Webb
- Department of Anesthesiology, Libin Cardiovascular Institute, University of Calgary, Calgary, AB, Canada
| | - Paul W. M. Fedak
- Department of Cardiac Sciences, Libin Cardiovascular Institute, University of Calgary, Calgary, AB, Canada
| | - William D. T. Kent
- Department of Cardiac Sciences, Libin Cardiovascular Institute, University of Calgary, Calgary, AB, Canada
| | - Corey Adams
- Department of Cardiac Sciences, Libin Cardiovascular Institute, University of Calgary, Calgary, AB, Canada
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Shechter A, Lee M, Kaewkes D, Koren O, Skaf S, Chakravarty T, Koseki K, Patel V, Makkar RR, Siegel RJ. Repeat Mitral Transcatheter Edge-to-Edge Repair for Recurrent Significant Mitral Regurgitation. J Am Heart Assoc 2023; 12:e028654. [PMID: 37119061 PMCID: PMC10227228 DOI: 10.1161/jaha.122.028654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 03/30/2023] [Indexed: 04/30/2023]
Abstract
Background There are limited data on repeat mitral transcatheter edge-to-edge repair for recurrent significant mitral regurgitation (MR). Methods and Results We conducted a single-center, retrospective analysis of consecutive patients referred to a second mitral transcatheter edge-to-edge repair after a technically successful first procedure. Clinical, laboratory, and echocardiographic measures were assessed up to 1 year after the intervention. The composite of all-cause death or heart failure (HF) hospitalizations constituted the primary outcome. A total of 52 patients (median age, 81 [interquartile range, 76-87] years, 29 [55.8%] men, 26 [50.0%] with functional MR) met the inclusion criteria. MR recurrences were mostly related to progression of the underlying cardiac pathology. All procedures were technically successful. At 1 year, most patients with available records (n=24; 96.0%) experienced improvement in MR severity or New York Heart Association functional class that was statistically significant but numerically modest. Fourteen (26.9%) patients died or were hospitalized due to HF. These were higher-risk cases with predominantly functional MR who mostly underwent an urgent procedure and exhibited more severe HF indices before the intervention, as well as an attenuated 1-month clinical and echocardiographic response. Overall, 1-year course was comparable to that experienced by patients who underwent only a first transcatheter edge-to-edge repair at our institution (n=902). Tricuspid regurgitation of greater than moderate grade was the only baseline parameter to independently predict the primary outcome. Conclusions Repeat mitral transcatheter edge-to-edge repair is feasible, safe, and clinically effective, especially in non-functional MR patients without concomitant significant tricuspid regurgitation.
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Affiliation(s)
- Alon Shechter
- Department of CardiologySmidt Heart Institute, Cedars‐Sinai Medical CenterLos AngelesCAUSA
- Department of CardiologyRabin Medical CenterPetach TikvaIsrael
- Faculty of MedicineTel Aviv UniversityTel AvivIsrael
| | - Mirae Lee
- Department of CardiologySmidt Heart Institute, Cedars‐Sinai Medical CenterLos AngelesCAUSA
- Division of Cardiology, Department of MedicineSamsung Changwon HospitalChangwonRepublic of Korea
| | - Danon Kaewkes
- Department of CardiologySmidt Heart Institute, Cedars‐Sinai Medical CenterLos AngelesCAUSA
- Department of Medicine, Faculty of MedicineKhon Kaen UniversityThailand
| | - Ofir Koren
- Department of CardiologySmidt Heart Institute, Cedars‐Sinai Medical CenterLos AngelesCAUSA
- Rappaport Faculty of MedicineTechnion Israel Institute of TechnologyHaifaIsrael
| | - Sabah Skaf
- Department of CardiologySmidt Heart Institute, Cedars‐Sinai Medical CenterLos AngelesCAUSA
| | - Tarun Chakravarty
- Department of CardiologySmidt Heart Institute, Cedars‐Sinai Medical CenterLos AngelesCAUSA
| | - Keita Koseki
- Department of CardiologySmidt Heart Institute, Cedars‐Sinai Medical CenterLos AngelesCAUSA
- Department of Cardiovascular MedicineThe University of TokyoTokyoJapan
| | - Vivek Patel
- Department of CardiologySmidt Heart Institute, Cedars‐Sinai Medical CenterLos AngelesCAUSA
| | - Raj R. Makkar
- Department of CardiologySmidt Heart Institute, Cedars‐Sinai Medical CenterLos AngelesCAUSA
| | - Robert J. Siegel
- Department of CardiologySmidt Heart Institute, Cedars‐Sinai Medical CenterLos AngelesCAUSA
- David Geffen School of MedicineUniversity of California Los AngelesLos AngelesCAUSA
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Tomšič A, Klautz RJM, Borger MA, Palmen M. Microinvasive mitral valve surgery: Current status and status quo. Front Cardiovasc Med 2023; 10:1094969. [PMID: 37180783 PMCID: PMC10169618 DOI: 10.3389/fcvm.2023.1094969] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 04/11/2023] [Indexed: 05/16/2023] Open
Abstract
Surgical mitral valve repair, performed either through median sternotomy or minimal invasive approach, presents the gold standard treatment for degenerative mitral valve disease. In dedicated centres, high repair and low complication rates have been established with excellent valve repair durability. Recently, new techniques have been introduced, that allow mitral valve repair to be performed through small surgical incisions and while avoiding cardio-pulmonary bypass. These new techniques, however, conceptually differ significantly when compared to surgical repair and it remains questionable whether they are capable of reproducing the results of surgical treatment.
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Affiliation(s)
- Anton Tomšič
- Department of Cardiothoracic Surgery, Leiden University Medical Centre, Leiden, Netherlands
| | - Robert J. M. Klautz
- Department of Cardiothoracic Surgery, Leiden University Medical Centre, Leiden, Netherlands
| | - Michael A. Borger
- Leipzig Heart Center, University Clinic for Cardiac Surgery, Leipzig, Germany
| | - Meindert Palmen
- Department of Cardiothoracic Surgery, Leiden University Medical Centre, Leiden, Netherlands
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Mastro F, Angelini A, D'Onofrio A, Gerosa G. A journey from resect to respect to restore: aiming at optimal physiological surgical mitral valve repair. J Cardiovasc Med (Hagerstown) 2023; 24:1-11. [PMID: 36484280 DOI: 10.2459/jcm.0000000000001390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The concept of 'repairing' a degenerated mitral valve in order to restore the native competence means achieving the best physiological result coupled with the least invasive approach: this represents an interesting challenge for cardiac surgeons. The evolution of cardiac surgery through the years has involved techniques and technologies in every field of interest. From 'resect', to 'respect', to 'restore': the micro-invasive approach based on Neochord implant implies a transapical beating heart surgery which is based on the concept of implanting artificial chordae, preserving the physiological dynamics of the mitral annulus and avoiding the disadvantages of cardiopulmonary bypass and cardioplegic arrest of the heart.
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Affiliation(s)
- Florinda Mastro
- Cardiac Surgery Unit, Cardio-Thoracic-Vascular Sciences and Public Health Department, Padova University Hospital, Padova
| | - Annalisa Angelini
- Cardiovascular Pathology, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Augusto D'Onofrio
- Cardiac Surgery Unit, Cardio-Thoracic-Vascular Sciences and Public Health Department, Padova University Hospital, Padova
| | - Gino Gerosa
- Cardiac Surgery Unit, Cardio-Thoracic-Vascular Sciences and Public Health Department, Padova University Hospital, Padova
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Zhong Z, Xu H, Song W, Liu S. Re-repair vs. Replacement for Failed Mitral Valve Repair: A Systemic Review and Meta-Analysis. Front Cardiovasc Med 2022; 9:868980. [PMID: 35774370 PMCID: PMC9237322 DOI: 10.3389/fcvm.2022.868980] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 05/12/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveThe objective of this study was to compare outcomes of re-repair with those of mitral valve replacement (MVR) for failed initial mitral valve repair (MVr).MethodsWe searched the Pubmed, Embase, and Cochrane Library databases for studies that compared mitral valve re-repair with MVR for the treatment of failed initial MVr. Data were extracted by two independent investigators and subjected to a meta-analysis. Odds ratio (OR), risk ratio (RR), hazard ratio (HR), ratio difference (RD), mean difference (MD), and 95% confidence interval (CI) were calculated with the Mantel-Haenszel and inverse-variance methods for mode of repair failure, perioperative outcomes, and follow-up outcomes.ResultsEight retrospective cohort studies were included, with a total of 938 patients, and mean/median follow-up ranged from 1.8 to 8.9 years. Pooled incidence of technical failure was 41% (RD: 0.41; 95% CI: 0.32 to 0.5; P = 0.00; I2 = 86%; 6 studies, 846 patients). Pooled mitral valve re-repair rate was 36% (RD: 0.36; 95% CI: 0.26–0.46; P = 0; I2 = 91%; 8 studies, 938 patients). Pooled data showed significantly lower perioperative mortality (RR: 0.22; 95% CI: 07 to 0.66; I2 = 0%; P = 0.008; 6 studies, 824 patients) and significantly lower long-term mortality (HR:0.42; 95% CI: 0.3 to 0.58; I2 = 0%; P = 0; 7 studies, 903 patients) in the re-repair group compared with MVR.ConclusionsMitral valve re-repair was associated with better immediate and sustained outcomes for failed MVr and should be recommended if technically feasible.
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Thourani KV, Mandadi PR, Thourani VH. Commentary: Re-Fixing the Broken Mitral Valve Using Beating Heart Technologies. Semin Thorac Cardiovasc Surg 2020; 33:45-46. [PMID: 32846227 DOI: 10.1053/j.semtcvs.2020.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 08/17/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Keegan V Thourani
- Department of Cardiovascular Surgery, Marcus Valve Center, Piedmont Heart Institute, Atlanta, Georgia
| | - Pavan R Mandadi
- Department of Cardiovascular Surgery, Marcus Valve Center, Piedmont Heart Institute, Atlanta, Georgia
| | - Vinod H Thourani
- Department of Cardiovascular Surgery, Marcus Valve Center, Piedmont Heart Institute, Atlanta, Georgia.
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Miceli A. Commentary: A New Approach for Repeat Mitral Valve Repair. Semin Thorac Cardiovasc Surg 2020; 33:47-48. [PMID: 32841715 DOI: 10.1053/j.semtcvs.2020.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 08/17/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Antonio Miceli
- Minimally Invasive Cardiac Department, Istituto Clinico Sant'Ambrogio, Milano, Italy.
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