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Pitoulis F, Pamias-Lopez B, Fraser C, Rao A, Mangino-Blanchard L, Vernick W, Shah R, Kukafka J, Spelde A, Acker M, Szeto W, Ibrahim M. Transaortic TAVR and Mitral Repair Under Deep Hypothermic Circulatory Arrest in a Porcelain Aorta Patient. JACC Case Rep 2024; 29:102144. [PMID: 38223268 PMCID: PMC10784599 DOI: 10.1016/j.jaccas.2023.102144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 09/18/2023] [Accepted: 10/06/2023] [Indexed: 01/16/2024]
Abstract
Vascular and valvular calcifications, commonly seen in renal patients, increase operative mortality and can preclude conventional valvular management. We show a novel approach to treat aortic stenosis and degenerative mitral regurgitation under hypothermic circulatory arrest in a hemodialysis patient with aortic, mitral disease and porcelain aorta with surgical and transcatheter contraindications.
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Affiliation(s)
- Fotios Pitoulis
- University of Pennsylvania Cardiovascular Surgery, Penn Presbyterian Hospital, Philadelphia, Pennsylvania, USA
- Imperial College London, National Heart and Lung Institute, London, United Kingdom
| | - Blanca Pamias-Lopez
- University of Pennsylvania Cardiovascular Surgery, Penn Presbyterian Hospital, Philadelphia, Pennsylvania, USA
- Imperial College London, National Heart and Lung Institute, London, United Kingdom
| | - Charlie Fraser
- University of Pennsylvania Cardiovascular Surgery, Penn Presbyterian Hospital, Philadelphia, Pennsylvania, USA
| | - Akhil Rao
- University of Pennsylvania Cardiovascular Surgery, Penn Presbyterian Hospital, Philadelphia, Pennsylvania, USA
| | - Lisa Mangino-Blanchard
- University of Pennsylvania Cardiovascular Surgery, Penn Presbyterian Hospital, Philadelphia, Pennsylvania, USA
| | - William Vernick
- University of Pennsylvania Cardiovascular Surgery, Penn Presbyterian Hospital, Philadelphia, Pennsylvania, USA
| | - Ronak Shah
- University of Pennsylvania Cardiovascular Surgery, Penn Presbyterian Hospital, Philadelphia, Pennsylvania, USA
| | - Jeremy Kukafka
- University of Pennsylvania Cardiovascular Surgery, Penn Presbyterian Hospital, Philadelphia, Pennsylvania, USA
| | - Audrey Spelde
- University of Pennsylvania Cardiovascular Surgery, Penn Presbyterian Hospital, Philadelphia, Pennsylvania, USA
| | - Michael Acker
- University of Pennsylvania Cardiovascular Surgery, Penn Presbyterian Hospital, Philadelphia, Pennsylvania, USA
| | - Wilson Szeto
- University of Pennsylvania Cardiovascular Surgery, Penn Presbyterian Hospital, Philadelphia, Pennsylvania, USA
| | - Michael Ibrahim
- University of Pennsylvania Cardiovascular Surgery, Penn Presbyterian Hospital, Philadelphia, Pennsylvania, USA
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Ismail I, Wert L, Hanke JS, Dogan G, Chatterjee A, Feldmann C, Cebotari S, Haverich A, Schmitto JD. Mid-term Outcome of the Edge-To-Edge Mitral Valve Repair Via Aortic Outflow Tract in High-Risk Patients. Semin Thorac Cardiovasc Surg 2021; 34:512-516. [PMID: 34089830 DOI: 10.1053/j.semtcvs.2021.05.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 05/21/2021] [Indexed: 11/11/2022]
Abstract
The edge-to-edge mitral valve repair technique, invented by Alfieri and colleagues, introduced valve repair as a treatment option for patients with complex diseases where standard annuloplasty and related repair techniques are insufficient, due to annular calcification and patient frailty. We retrospectively evaluated the results of a transaortic edge-to-edge mitral valve repair (Alfieri stitch) in high-risk patients who were undergoing aortic valve replacement. From February, 2012 to December, 2017, 43 patients underwent transaortic edge-to-edge mitral valve repair with concomitant aortic valve replacement at a single institution. Preoperative and postoperative echocardiograms were compared. Home telephone follow up was conducted and postoperative morbidity was examined, including the need for reoperation, stroke and cardiac arrhythmia. 30-day and long-term survival rates were also determined. Mitral regurgitation (MR) was graded semi-quantitatively as 0 (trace and/or none), mild (1), moderate (2) or moderate to severe (3-4). The patients were 74 ± 7.8 years old. 65% of the patients were male. Mean cardiopulmonary bypass time was 115 ± 37 minutes and mean cross-clamp time was 71 ± 23 minutes. There was a significant improvement in preoperative vs postoperative median MR grade (2 (IQR 2-3) vs 0 (IQR 0-1); P = 0.05). Follow-up transthoracic echocardiograms in 29 patients obtained at a median of 9 months' (range 3 - 19 months') and in 16 patients at a median of 34 months' postoperatively (range 21 - 53 months') showed mild (1 (IQR 1-2)) grade of mitral regurgitation. 30-day survival was 98%. Long term survival at 12 and 24 months' were 88% and 81% respectively. Mitral valve reoperation was conducted in 1 patient (2%), who was suffering of endocarditis. Stroke occurred in 2 patients (7%). Cardiac arrhythmia was observed in 15 patients (35%). 8 patients (19%) suffered from atrial fibrillation and 7 patients (16%) displayed atrioventricular blockage. 10 patients (23%) could be treated conservatively and 5 patients (12%) needed implantation of a pacemaker. Transaortic edge-to-edge mitral valve repair can be safely performed during aortic valve replacement in high-risk patients and improves even long-term MR grade. Postoperative cardiac arrhythmia occurs frequently. 66% of them could be treated successfully by conservative procedures.
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Affiliation(s)
- Issam Ismail
- Department of Cardiothoracic-, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Leonhard Wert
- Department of Cardiothoracic-, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Jasmin Sarah Hanke
- Department of Cardiothoracic-, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Günes Dogan
- Department of Cardiothoracic-, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Anamika Chatterjee
- Department of Cardiothoracic-, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Christina Feldmann
- Department of Cardiothoracic-, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Serghei Cebotari
- Department of Cardiothoracic-, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Axel Haverich
- Department of Cardiothoracic-, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Jan Dieter Schmitto
- Department of Cardiothoracic-, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany.
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Long-term results of the edge-to-edge repair for failed mitral valve repair as a bailout option. Gen Thorac Cardiovasc Surg 2020; 69:32-37. [PMID: 32654090 DOI: 10.1007/s11748-020-01433-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 07/02/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE We evaluate the long-term clinical and echocardiographic outcomes of edge-to-edge (E2E) repair combined with mitral annuloplasty in our institute with degenerative mitral regurgitation (MR) up to 10 years. METHODS Twenty-six consecutive patients undergoing E2E mitral repair after failure of other conventional mitral repair technique. There were 16 (61.5%) male and the mean age was 52.2 ± 10.4 years. Mitral regurgitation was due to anterior leaflet prolapse in 12 (46.2%) patients, bileaflet prolapse in 9 (34.6%), and multiple segment posterior leaflet prolapse in 5 (19.2%). RESULTS There were no perioperative deaths. Follow-up was 100% complete. The mean length of follow-up was 8.7 ± 0.9 years (median 8.4 years, 6.8-10.1 years). Two patients required reoperation of the MV. The freedom from reoperation and ≥ Moderate MR at 10 years was 69.9 ± 11.7%. The freedom from reoperation, ≥ Moderate MR and mitral stenosis (MS) at 10 years was (59.6 ± 10.0) %. The mean transmitral pressure gradient (TMPG) was 6.1 ± 2.5 mmHg, which was significantly elevated compared with preoperative TTE (P = 0.004). The freedom from ≥ Moderate MS at 10 years was 76.9 ± 8.3%. There were no differences between patients with and without MS at follow-up regarding the echocardiographic parameters and clinical status. CONCLUSION There is a slowly progressive elevation of TMPG after E2E mitral repair, while mildly elevated TMPG can be tolerated in most patients. In appropriate patients, the E2E repair combined with annuloplasty provides an effective "bailout" choice.
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Al-Azizi K, Szerlip M. Mitral Stenosis After MitraClip: How to Avoid and How to Treat. Curr Cardiol Rep 2020; 22:50. [PMID: 32500412 DOI: 10.1007/s11886-020-01301-5] [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] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The goal of the paper is to highlight the importance of procedural planning and patient selection when using the MitraClip device in treating severe mitral regurgitation (MR). RECENT FINDINGS Following the recent results of the COAPT trial and FDA approval for functional MR patients, the indications for mitral clip are continuing to expand. Because of this, mitral stenosis from mitral clip can become a problem if the appropriate patients are not selected. Proper valve imaging, utilizing 3D transesophageal echocardiography to identify the pathology, is important to prevent iatrogenic mitral stenosis. In the unfortunate event of severe mitral stenosis as a result of the MitraClip device, surgery is the only treatment.
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Affiliation(s)
- Karim Al-Azizi
- Interventional Cardiology and Structural Heart Disease, The Heart Hospital Baylor Plano, Baylor Scott and White Health, 1100 Allied Dr, Plano, TX, 75093, USA
| | - Molly Szerlip
- Interventional Cardiology and Structural Heart Disease, The Heart Hospital Baylor Plano, Baylor Scott and White Health, 1100 Allied Dr, Plano, TX, 75093, USA.
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Shapeton A. Dynamic Left Ventricular Outflow Obstruction and Systolic Anterior Motion of the Mitral Valve Complicating Surgical Aortic Valve Replacement. J Cardiothorac Vasc Anesth 2018; 33:858-862. [PMID: 29935805 DOI: 10.1053/j.jvca.2018.05.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Alexander Shapeton
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA.
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Morimoto Y, Sugimoto T. Alfieri stitch for temporary severe functional mitral regurgitation after aortic valve replacement. Surg Case Rep 2018; 4:4. [PMID: 29313150 PMCID: PMC5758482 DOI: 10.1186/s40792-017-0410-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2017] [Accepted: 12/21/2017] [Indexed: 11/22/2022] Open
Abstract
The outcome in functional mitral regurgitation after aortic valve replacement is unclear. A frail 82-year-old woman with severe aortic valve regurgitation and mild to moderate functional mitral valve regurgitation (NYHA functional class III) was referred to our clinic. In consideration of her frail condition, aortic valve replacement without mitral surgery was performed. She had hemodynamic instability and difficulty to wean off cardiopulmonary bypass caused by severe functional mitral valve regurgitation with left ventricular dilatation. A central Alfieri edge-to-edge stitch was placed between the anatomical middle of the two leaflets of the mitral valve after reinstitution of cardiopulmonary bypass. This eliminated the mitral regurgitation, which enabled successful separation from cardiopulmonary bypass.
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Affiliation(s)
- Yoshihisa Morimoto
- Department of Cardiovascular Surgery, Ako City Hospital, 1090 Nakahiro, Ako, Hyogo, 678-0232, Japan.
| | - Takaki Sugimoto
- Department of Cardiovascular Surgery, Awaji Medical Center, Hyogo, Japan
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Akiyama K, Itatani K, Naito Y, Kinoshita M, Shimizu M, Hamaoka S, Yasumoto H, Kato H, Nakajima Y, Numata S, Yaku H, Sawa T. Vector Flow Mapping and Impaired Left Ventricular Flow After the Alfieri Stitch. J Cardiothorac Vasc Anesth 2017; 31:211-214. [PMID: 28277247 DOI: 10.1053/j.jvca.2016.07.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2016] [Indexed: 11/11/2022]
Affiliation(s)
- Koichi Akiyama
- Departments of Anesthesiology, Kyoto Prefectural University of Medicine, Kyoto, Japan.
| | - Keiichi Itatani
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yoshifumi Naito
- Departments of Anesthesiology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Mao Kinoshita
- Departments of Anesthesiology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masaru Shimizu
- Departments of Anesthesiology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Saeko Hamaoka
- Departments of Anesthesiology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hiroaki Yasumoto
- Departments of Anesthesiology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hideya Kato
- Departments of Anesthesiology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yasufumi Nakajima
- Department of Anesthesiology, Kansai Medical University, Hirakata, Japan
| | - Satoshi Numata
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hitoshi Yaku
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Teiji Sawa
- Departments of Anesthesiology, Kyoto Prefectural University of Medicine, Kyoto, Japan
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Biancari F, Schifano P, Pighi M, Vasques F, Juvonen T, Vinco G. Pooled estimates of immediate and late outcome of mitral valve surgery in octogenarians: a meta-analysis and meta-regression. J Cardiothorac Vasc Anesth 2013; 27:213-9. [PMID: 23507013 DOI: 10.1053/j.jvca.2012.11.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2012] [Indexed: 12/26/2022]
Abstract
OBJECTIVE The authors evaluated the outcome of patients≥80 years undergoing mitral valve (MV) surgery. DESIGN Systematic review of the literature and meta-analysis. SETTING None. PARTICIPANTS None. INTERVENTIONS None. MAIN RESULTS Twenty-four studies reporting on 5,572 patients ≥80 years of age who underwent MV surgery were included in this analysis. Pooled proportion of operative mortality was 15.0% (95% confidence interval [CI] 11.9-18.1), stroke was 3.9% (95% CI 2.6-5.2), and dialysis was 2.7% (95% CI 0.5-4.9). Early date of study (p = 0.014), increased age (p = 0.006), MV replacement (p = 0.008), procedure other than isolated MV surgery (p = 0.010), MV surgery associated with coronary artery surgery (p = 0.029), aortic cross-clamping time (p<0.001), and cardiopulmonary bypass time (p<0.001) were associated significantly with increased operative mortality. MV repair had lower operative mortality compared with MV replacement (7.3% v 14.2%, relative risk 0.573, 95% CI 0.342-0.962). Random-effects metaregression showed that prolonged aortic cross-clamping time (p = 0.005) was the only determinant of increased operative mortality, even when adjusted (p<0.001) for date of study (p = 0.004). Operative mortality was significantly higher in studies reporting a mean cross-clamp time >90 minutes (17.0% v 7.4%, p<0.001). Survival rates at 1, 3, and 5 years were 76.1%, 67.7%, and 56.5%, respectively. CONCLUSIONS MV surgery in patients ≥80 years of age is associated with operative mortality, which has decreased significantly during recent years. Prolonged aortic cross-clamp time is a major determinant of operative mortality. MV repair may achieve better results than MV replacement in the very elderly. Five-year survival of these patients is good and justifies surgical treatment of MV diseases in octogenarians.
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Affiliation(s)
- Fausto Biancari
- Department of Surgery, Oulu University Hospital, Oulu, Finland.
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