Transcatheter Mitral Valve Implantation in Failed Transventricular Mitral Valve Repair

An 84-year-old man presented with dyspnea at rest due to severe mitral regurgitation. He first underwent transventricular mitral valve repair with the Harpoon system, which relapsed owing to rupture of neochords. He was definitively treated with transcatheter mitral valve implantation of the Tendyne system 8 months later.

Viability assessment of livers donated after circulatory determination of death during normothermic regional perfusion

BACKGROUND

Abdominal normothermic regional perfusion (A-NRP) allows in-situ reperfusion and recovery of abdominal organs metabolism in donors after circulatory death (DCD). Besides improving liver transplantation outcomes, liver injury and function can be assessed during A-NRP.

METHODS

To refine liver viability assessment during A-NRP, prospectively collected data of controlled DCD donors managed at our Institution between October 2019 and May 2022 were retrospectively analyzed. Baseline characteristics, procedural variables and A-NRP parameters of donors whose liver was successfully transplanted were compared to those of donors whose liver was discarded.

RESULTS

Twenty-seven donors were included and in 20 (74%) the liver was accepted (positive outcome). No differences between study groups were observed concerning baseline characteristics and warm ischemia times (WIT). Initial lactate levels were positively correlated with functional WIT (r2  = 0.4, p = 0.04), whereas transaminase levels were not. Blood flow during A-NRP was comparable, whereas oxygen consumption (VO2 ) was significantly higher in the positive outcome group after 1 h. Time courses of lactate, AST and ALT were significantly different between study groups (p < 0.001). Donors whose liver was accepted showed faster lactate clearance, a difference which was amplified by normalizing lactate clearance to oxygen delivery (DO2 ) and VO2 . Lactate clearance was correlated to transaminase levels and DO2 -normalized lactate clearance was the parameter best discriminating between study groups.

CONCLUSIONS

DO2 -normalized lactate clearance may represent an element of liver viability assessment during A-NRP.

Cytokines Removal During Ex-Vivo Lung Perfusion: Initial Clinical Experience

Ex Vivo Lung Perfusion (EVLP) can be potentially used to manipulate organs and to achieve a proper reconditioning process. During EVLP pro-inflammatory cytokines have been shown to accumulate in perfusate over time and their production is correlated with poor outcomes of the graft. Aim of the present study is to investigate the feasibility and safety of cytokine adsorption during EVLP. From July 2011 to March 2020, 54 EVLP procedures have been carried out, 21 grafts treated with an adsorption system and 33 without. Comparing the grafts perfused during EVLP with or without cytokine adsorption, the use of a filter significantly decreased the levels of IL10 and GCSFat the end of the procedure. Among the 38 transplanted patients, the adsorption group experienced a significant decreased IL6, IL10, MCP1 and GCSF concentrations and deltas compared to the no-adsorption group, with a lower in-hospital mortality (p = 0.03) and 1-year death rate (p = 0.01). This interventional study is the first human experience suggesting the safety and efficacy of a porous polymer beads adsorption device in reducing the level of inflammatory mediators during EVLP. Clinical impact of cytokines reduction during EVLP must be evaluated in further studies.

Three-Dimensional Finger Test: A New Echocardiographic Method to Locate the Best Access Site During NeoChord Procedure

OBJECTIVE

Transventricular beating-heart mitral valve repair (TBMVR) with artificial chordae implantation is a technique to treat mitral valve prolapse. Two-dimensional (2D) echocardiography completed with simultaneous biplane view during surgeon finger pushing on the left ventricular (LV) wall (finger test [FT]) is currently used to localize the desired LV access, on the inferior-lateral wall, between the papillary muscles (PMs). We aimed to compare a new three-dimensional (3D) method with conventional FT in terms of safety and better localization of LV access.

METHODS

During TBMVR, conventional FT was completed using 3D transesophageal echocardiography by placing the sample box in the bicommissural view of the LV, including the PMs and the apex. The 3D volume was subsequently edited to visualize the LV from above (surgical view) to localize the bulge of the operator's finger pushing on the LV. We asked the first operator, the second operator, and the cardiac surgery fellow, separately, to evaluate the location of their finger pushing, both with the 2D method and the 3D method, to estimate the interoperator concordance.

RESULTS

From 2019 to 2021, 42 TBMVRs were performed without complications related to access using FT completed with the 3D method. Regarding the choice of the right and safe entry site, the operator's agreement was higher using 3D rendering compared with conventional FT (mean agreement 0.59 ± 0.29 for 2D vs 0.83 ± 0.20 for 3D), while full operator agreement was 10 of 42 for 2D and 23 of 42 for 3D (P = 0.004).

CONCLUSIONS

Three-dimensional FT is easy to perform and facilitates surgeons choosing the best access for TBMVR in term of anatomical localization and safety.

Lung Transplantation for Primary Ciliary Dyskinesia and Kartagener Syndrome: A Multicenter Study

Primary ciliary dyskinesia, with or without situs abnormalities, is a rare lung disease that can lead to an irreversible lung damage that may progress to respiratory failure. Lung transplant can be considered in end-stage disease. This study describes the outcomes of the largest lung transplant population for PCD and for PCD with situs abnormalities, also identified as Kartagener's syndrome. Retrospectively collected data of 36 patients who underwent lung transplantation for PCD from 1995 to 2020 with or without SA as part of the European Society of Thoracic Surgeons Lung Transplantation Working Group on rare diseases. Primary outcomes of interest included survival and freedom from chronic lung allograft dysfunction. Secondary outcomes included primary graft dysfunction within 72 h and the rate of rejection ≥A2 within the first year. Among PCD recipients with and without SA, the mean overall and CLAD-free survival were 5.9 and 5.2 years with no significant differences between groups in terms of time to CLAD (HR: 0.92, 95% CI: 0.27-3.14, p = 0.894) or mortality (HR: 0.45, 95% CI: 0.14-1.43, p = 0.178). Postoperative rates of PGD were comparable between groups; rejection grades ≥A2 on first biopsy or within the first year was more common in patients with SA. This study provides a valuable insight on international practices of lung transplantation in patients with PCD. Lung transplantation is an acceptable treatment option in this population.

Is there life on the airway tree? A pilot study of bronchial cell vitality and tissue morphology in the ex vivo lung perfusion (EVLP) era of lung transplantation

BACKGROUND

Ex vivo lung perfusion (EVLP) is a relevant procedure to increase the lung donor pool but could potentially increase the airway tree ischemic injury risk.

METHODS

This study aimed to evaluate the direct effect of EVLP on the airway tree by evaluating bronchial cell vitality and tissue signs of injury on a series of 117 bronchial rings collected from 40 conventional and 19 EVLP-treated lung grafts. Bronchial rings and related scraped bronchial epithelial cells were collected before the EVLP procedure and surgical anastomosis.

RESULTS

The preimplantation interval was significantly increased in the EVLP graft group (p < 0.01). Conventional grafts presented cell viability percentages of 47.07 ± 23.41 and 49.65 ± 21.25 in the first and second grafts which did not differ significantly from the EVLP group (first graft 50.54 ± 25.83 and second graft 50.22 ± 20.90 cell viability percentage). No significant differences in terms of histopathological features (edema, inflammatory infiltrate, and mucosa ulceration) were observed comparing conventional and EVLP samples. A comparison of bronchial cell viability and histopathology of EVLP samples retrieved at different time intervals revealed no significant differences. Accordingly, major bronchial complications after lung transplant were not observed in both groups.

CONCLUSIONS

Based on these data, we observed that EVLP did not significantly impact bronchial cell vitality and airway tissue preservation nor interfere with bronchial anastomosis healing, further supporting it as a safe and useful procedure.

Validation of a Simple, Rapid, and Cost-Effective Method for Acute Rejection Monitoring in Lung Transplant Recipients

Despite advances in immunosuppression therapy, acute rejection remains the leading cause of graft dysfunction in lung transplant recipients. Donor-derived cell-free DNA is increasingly being considered as a valuable biomarker of acute rejection in several solid organ transplants. We present a technically improved molecular method based on digital PCR that targets the mismatch between the recipient and donor at the HLA-DRB1 locus. Blood samples collected sequentially post-transplantation from a cohort of lung recipients were used to obtain proof-of-principle for the validity of the assay, correlating results with transbronchial biopsies and lung capacity tests. The results revealed an increase in dd-cfDNA during the first 2 weeks after transplantation related to ischemia-reperfusion injury (6.36 ± 5.36%, p < 0.0001). In the absence of complications, donor DNA levels stabilized, while increasing again during acute rejection episodes (7.81 ± 12.7%, p < 0.0001). Respiratory tract infections were also involved in the release of dd-cfDNA (9.14 ± 15.59%, p = 0.0004), with a positive correlation with C-reactive protein levels. Overall, the dd-cfDNA percentages were inversely correlated with the lung function values measured by spirometry. These results confirm the value of dd-cfDNA determination during post-transplant follow-up to monitor acute rejection in lung recipients, achieved using a rapid and inexpensive approach based on the HLA mismatch between donor and recipient.

P102 NEW THREE–DIMENSIONAL ECHOCARDIOGRAPHIC PREDICTING PARAMETERS IN TRANS–VENTRICULAR HEART–BEATING MITRAL VALVE REPAIR WITH NEOCHORDAE: A MONOCENTRIC RETROSPECTIVE STUDY

Background

Trans–ventricular off pump mitral valve (MV) repair with neochordae implantation (Neochord procedure) is a minimally invasive surgical technique for correction of degenerative mitral regurgitation (MR) due to prolapse or flail. The aim of this study was to evaluate mid–term results of patients undergoing this procedure and find new three–dimensional pre–operative echocardiographic parameters to predict MR recurrence at follow–up.

Methods

We performed a retrospective analysis of 72 consecutive patients with severe MR due to prolapse or flail who underwent Neochord procedure at our hospital from March 2015 to February 2021. MV pre–operative anatomical parameters were assessed using 2D TEE, 3D TEE and dedicated three–dimensional (3D) post–processing analysis with dedicated software (QLAB, Philips). TTE follow–up and clinical evaluation were performed at 3 months, 6 months, 1 year and then annually.

Results

Twenty–seven patients were female (37.5%), mean age was 77±9 years. The average preoperative EuroSCORE II was 2.2%±1.5%. Twenty–three patients (32%) had an history of paroxysmal or persistent atrial fibrillation. Procedural success at discharge was achieved in sixty–eight patients (94.5%). Mean follow–up was 30±16 months. Three years follow–up was completed by fifty patients. At three years thirteen patients (26%) presented with recurrence of severe MR or underwent new surgical operation. Prevalence of mild or trace MR at three years follow–up visit was 70%. End–systolic annulus area (12.5±2.5 cm2 vs 14.1±2.6 cm2; p = 0.038), end–systolic annulus diameter (13.2±1.2 cm vs 14±1.3 cm; p = 0.042) and indexed left atrial volume (59±17 ml/m2 vs 76±37 ml/m2; p = 0.041) were lower in patients with residual MR less than moderate (MR &lt; 3+/4+). Three–dimensional indexes specifically focused on coaptation reserve and annular disfunction were the best predictors of MR &lt; 3+/4+ at follow–up, in particular diastolic sum of the leaflets/end–systolic annulus area ([AUC] 0.74; p = 0.029) and systo–diastolic annulus area fractional change ([AUC] 0.743; p = 0.035). Furthermore, each of these annular parameters, calculated using dedicated 3D software, were predictive of residual MR, whereas annular 2D dimensions were not (p = 0.347).

Conclusion

In patients with degenerative MR treated with Neochord procedure, 3D analysis focused on annular measures and coaptation indexes, that included 3D annular dimensions, predicts better MR relapse than conventional 2D parameters.

C40 THREE–DIMENSIONAL FINGER TEST: A NEW ECHOCARDIOGRAPHIC METHOD TO LOCATE THE BEST ACCESS SITE DURING NEOCHORD PROCEDURE

Background

The NeoChord procedure is a trans–ventricular, beating–heart chordal implantation for severe degenerative mitral valve regurgitation due to prolapse or flail leaflet and it is performed using a dedicated device (DS 1000 system, NeoChord, Inc. St. Louis Park, MN). The use of the transesophageal echocardiography (TEE) is crucial to guide the procedure. Bi–dimensional (2D) imaging completed with simultaneous biplane view during surgeon finger pushing on the LV wall (finger test) is currently used to choose the LV access, which is usually on the mid–distal infero–lateral wall (ILW), between the papillary muscles (PMs) at the inferior level of their insertion on LV wall. This simulation helps the operators to evaluate the safe distance to PMs to minimize the risk of damaging the sub–valvular apparatus during the insertion of the device. We aimed to compare a new 3D method with the conventional one in terms of safety and better localization of the desired entry site.

Methods

During the procedure finger test has been performed with conventional 2D imaging and simultaneous biplane method. It has been completed using the real time 3D TEE placing the sample box in the bi–commissural view of the LV including the PMs and the apex. The resulting 3D volume was subsequently edited to visualize the LV from above (surgical view) to localize the bulge of the operator finger pushing on the desired segment of the LV wall. We asked the first operator, the second operator and the cardiac surgery fellow, separately, to evaluate location of their finger pushing, in terms of desired position and safety of access, both with 2D method and the 3D method to estimate the inter–operator concordance.

Results

From March 2019 to September 2021 42 consecutive cases have been performed using finger test completed with 3D method without complications related to the trans–ventricular access. Regarding the choice of the right and safe entry site, the percentage of agreement between operators was higher using LV real time 3D rendering compared to the conventional finger test [82 + 21% Vs 59% + 29%, IC 95%, p: 0,04].

Conclusion

Three–dimensional finger test is easy to perform and decreases inter–operator variability of image interpretation facilitating the surgeons to choose the best entry site in term of anatomical localization and safety.

Surgical left ventricle remodeling to treat functional mitral valve regurgitation

A left ventricular aneurysm complicates an acute myocardial infarction in 4-20% of patients. The loss of the physiological geometry of the ventricle can lead to a dislocation of the papillary muscles with subsequential mitral valve regurgitation. The goal of this case report is to demonstrate that a proper operation to restore the left ventricular anatomy can be a feasible procedure to correct functional mitral regurgitation.

Gastrostomy for infants with severe epidermolysis bullosa simplex in neonatal intensive care

INTRODUCTION

Severe epidermolysis bullosa simplex (EBS sev) is a rare genodermatosis characterized by congenital generalized blistering and mucosal involvement. Increased needs and decreased intake quickly lead to nutritional imbalance. Enteral nutrition support is proposed, but classical nasogastric tubes are not well tolerated in these patients and gastrostomy is preferred.

OBJECTIVE AND METHODS

To report the experience with EBS sev in neonatal units of French reference centers for gastrostomy. In this retrospective multicentric study, we included all patients with EBS sev who had gastrostomy placement before age 9 months during neonatal care hospitalization.

RESULTS

Nine infants (5 males/4 females) with severe skin and mucosal involvement were included. A gastrostomy was decided, at an early age (mean 3.7 months, range 1.4 to 8 months) in infants with mean weight 4426 g (range 3500 to 6000 g). Techniques used were endoscopy with the pull technique for 5 infants and surgery under general anesthesia for 4. Main complications were local but resolved after treatment. All infants gained weight after gastrostomy. The mean withdrawal time (n = 7) for the gastrostomy was 35.8 months (range 10.5 months to 6.5 years). Seven children had persistent oral disorders.

CONCLUSIONS

Gastrostomy in infants with EBS sev can be necessary in neonatal intensive care units. Both surgical and endoscopic pull techniques seem efficient, with good tolerance.

HLA-DRB1 mismatch-based identification of donor-derived cell free DNA (dd-cfDNA) as a marker of rejection in heart transplant recipients: A single-institution pilot study

BACKGROUND

Donor-derived cell-free DNA (dd-cfDNA) is considered a reliable marker of organ damage with potential applications in the follow-up of transplant recipients.

METHODS

In this work we present an assay based on the donor-recipient HLA-mismatch (human leukocyte antigen) at the HLA-DRB1 locus to monitor rejection by quantifying the percentage of dd-cfDNA using a droplet digital PCR (polymerase chain reaction) technique. A panel of probes targeting the HLA-DRB1 locus and covering >85% genetic variability was validated and used to assess dd-cfDNA levels in a prospective cohort of 19 adult heart transplant recipients (mean age 50.9±14.8 years). The assay was carried out on a total of 232 liquid biopsies collected at the same time as endomyocardial biopsy (EMB) during routine post-transplant follow-up.

RESULTS

Results show a significant increase of dd-cfDNA related to ischemia-reperfusion injury (2.22±2.09%) and to acute cellular rejection (1.71±3.10%) compared to stable conditions (0.43±1.04%, p < 0.0001). On the contrary, no increase was observed during infections or vascular complications, underlining the potential role of this biomarker for rejection monitoring. With a cut-off of 0.11%, the test showed 70.8% specificity (95% CI, 58.17% - 81.40%) and 64.2% sensitivity (95% CI, 49.80% - 76.86%) in discriminating acute rejection from no rejection.

CONCLUSIONS

These data demonstrate that this HLA mismatch-based droplet digital PCR method is effective for monitoring rejection in heart transplant recipients. Compared to next generation sequencing approaches, it is far more flexible, less expensive and provides faster results.

Nonresponse to Acute Vasodilator Challenge and Prognosis in Heart Failure With Pulmonary Hypertension

BACKGROUND

An acute vasodilator challenge is recommended in patients with heart failure and pulmonary hypertension during heart transplant evaluation. The aim of the study was to assess which hemodynamic parameters are associated with nonresponsiveness to the challenge.

METHODS AND RESULTS

This study is a retrospective analysis of 402 patients with heart failure with pulmonary hypertension who underwent right heart catheterization and a pulmonary vasodilator challenge. Among the 140 who fulfilled the transplant guidelines eligibility criteria for the vasodilator challenge, 38 were responders and 102 nonresponders. At multivariable analysis, a diastolic blood pressure of <70 mm Hg, pulmonary vascular resistance of >5 Woods units, and pulmonary artery compliance of <1.2 mL/mm Hg were independently associated with poor response to vasodilator challenge (all P < .001). The presence of any 2 of these 3 conditions was associated with a 90% probability of being a nonresponder. The covariate-adjusted hemodynamic predictors of death in the entire population were a low baseline systolic blood pressure (P = .0017) and a low baseline right ventricular stroke work index (P = .0395).

CONCLUSIONS

In patients with heart failure and pulmonary hypertension, low pulmonary arterial compliance, high pulmonary vascular resistance, and low diastolic blood pressure predict the nonresponsiveness to acute vasodilator challenge whilst a poor right ventricular function predicts a dismal prognosis.

Noncalcific Mechanisms of Bioprosthetic Structural Valve Degeneration

Bioprosthetic heart valves (BHVs) largely circumvent the need for long‐term anticoagulation compared with mechanical valves but are increasingly susceptible to deterioration and reduced durability with reoperation rates of ≈10% and 30% at 10 and 15 years, respectively. Structural valve degeneration is a common, unpreventable, and untreatable consequence of BHV implantation and is frequently characterized by leaflet calcification. However, 25% of BHV reoperations attributed to structural valve degeneration occur with minimal leaflet mineralization. This review discusses the noncalcific mechanisms of BHV structural valve degeneration, highlighting the putative roles and pathophysiological relationships between protein infiltration, glycation, oxidative and mechanical stress, and inflammation and the structural consequences for surgical and transcatheter BHVs.

COVID-19 in Heart Transplant Recipients: A Multicenter Analysis of the Northern Italian Outbreak

OBJECTIVES

The aim of this study was to assess the clinical course and outcomes of all heart transplant recipients affected by coronavirus disease-2019 (COVID-19) who were followed at the leading heart transplant centers of Northern Italy.

BACKGROUND

The worldwide severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) pandemic has created unprecedented challenges for public health, demanding exceptional efforts for the successful management and treatment of affected patients. Heart transplant patients represent a unique cohort of chronically immunosuppressed subjects in which SARS-CoV-2 may stimulate an unpredictable clinical course of infection.

METHODS

Since February 2020, we enrolled all 47 cases (79% male) in a first cohort of patients, with a mean age of 61.8 ± 14.5 years, who tested positive for SARS-CoV-2, out of 2,676 heart transplant recipients alive before the onset of the COVID-19 pandemic at 7 heart transplant centers in Northern Italy.

RESULTS

To date, 38 patients required hospitalization while 9 remained self-home quarantined and 14 died. Compared to the general population, prevalence (18 vs. 7 cases per 1,000) and related case fatality rate (29.7% vs. 15.4%) in heart transplant recipients were doubled. Univariable analysis showed older age (p = 0.002), diabetes mellitus (p = 0.040), extracardiac arteriopathy (p = 0.040), previous PCI (p = 0.040), CAV score (p = 0.039), lower GFR (p = 0.004), and higher NYHA functional classes (p = 0.023) were all significantly associated with in-hospital mortality. During the follow-up two patients died and a third patient has prolonged viral-shedding alternating positive and negative swabs. Since July 1st, 2020, we had 6 new patients who tested positive for SARS-CoV-2, 5 patients asymptomatic were self-quarantined, while 1 is still hospitalized for pneumonia. A standard therapy was maintained for all, except for the hospitalized patient.

CONCLUSIONS

The prevalence and mortality of SARS-CoV-2 should spur clinicians to immediately refer heart transplant recipients suspected as having SARS-CoV2 infection to centers specializing in the care of this vulnerable population.

Insidious postoperative Aspergillus niger graft aortitis

Fungal endocarditis/aortitis is an uncommon yet emerging entity accounting for 2% to 4% of all cases of infective endocarditis and continues to be associated with a poor prognosis. We present the first case of polyethylene-terephthalate (PETE) graft aortitis caused by A. niger, a rare fungal agent. Early diagnosis with frequent transoesophageal echocardiography (TEE) and a prompt surgical intervention coupled with optimal antifungal therapy are still the only option to reduce the exceedingly high mortality and morbidity.

P1412 A new light to improve the view of the anatomical details during micro-invasive trans-ventricular repair of degenerative prolapse of mitral valve

BACKGROUND

Mitral valve repair is the preferred surgical treatment for severe mitral regurgitation due to degenerative leaflet prolapse. Within the growing era of transcatheter treatments for valvular heart disease, an innovative micro-invasive trans-ventricular beating-heart procedure was developed. Three-dimensional (3D) transoesophageal echocardiographic guidance is crucial to assist the operator in instrument navigation and chords positioning. 3D ultrasound technology is constantly evolving and a special light, that can be mobilized within the 3D images, has recently been invented. This light allows to illuminate the structures from different points of view and increase the definition of the anatomical details.

PURPOSE

To show the advantages of this new 3D image analysis technology, described above, through a sequence of intra-procedural images of a mitral valve repair by trans-ventricular polytetrafluoroethylene (ePTFE) chords implantation.

METHODS

The procedure is performed using a device that is introduced through a posterolateral ventriculotomy and it is advanced towards the mitral valve under real-time 3D transoesophageal guidance. The prolapsing segment, in this case central part of posterior leaflet (Fig. 1 A, B and C), is grasped with the jaw of the instrument (J in Fig. 1D), then the chords are implanted, tensioned and secured outside the ventricle. Figure 1A shows the pre-operative image of posterior leaflet prolapse with flail (P2 segment) and the light illuminates the valve from above. The broken chords (arrow in Fig. 1A) can be recognized with high definition. The light can also be placed on the valve plane (Fig. 1B) or below (Fig. 1C). When illumination occurs from the left ventricular side, the coaptation loss due to the P2 flail is highlighted (arrow in Fig. 1C). After placement, tensioning and securing the chords outside the ventricle, the prolapse disappears and the correct coaptation is re-established (Fig. 1E). The coaptation deficit is no longer visible, even with the light placed below the valve and it is possible to see the light coming out of the aortic valve (Ao), opened in systole, with mitral valve closed (Fig. 1F).

RESULTS

At the end of the procedure the residual mitral regurgitation was trivial and no loss of coaptation can be evidenced even with the light placed in the left ventricle (Fig. 1F).

CONCLUSIONS

This new light allows to improve the anatomical definition of 3D echocardiographic images, allows better visualization of the coaptation defects and can be used as a further verification of the result especially in cases of micro-invasive mitral repair.

Abstract P1412 Figure 1

P951 Intraprocedural echocardiographic technique to locate the insertion points of artificial chordae during transventricular beating heart mitral valve repair: ultrasound ""starry sky""

BACKGROUND

Mitral valve repair is the preferred surgical treatment for severe mitral regurgitation due to degenerative leaflet prolapse. Within the growing era of transcatheter treatments for valvular heart disease, an innovative micro-invasive trans-ventricular beating-heart procedure was developed. Three-dimensional transoesophageal echocardiographic guidance is crucial to assist the operator in instrument navigation and chords positioning. Indeed, it is important an equidistant chords placement on the leaflet to ensure a uniform force distribution on the prolapsing segment and to avoid damaging of the previously inserted chords.

PURPOSE

To propose an intraoperative three-dimensional echocardiographic technique that allows operators to see the exact location of the polytetrafluoroethylene (ePTFE) chords used for the mitral repair.

METHODS

The procedure is performed using a device that is introduced through a posterolateral ventriculotomy and it is advanced towards the mitral valve under real-time 3D transoesophageal guidance. The prolapsing segments are grasped with the jaw of the instrument and the chords are implanted to achieve the proper distribution of forces and then tensioned and secured outside the ventricle.

The proposed technique exploits the greater echogenicity of the artificial chord loop compared to native chords and leaflets. By lowering of the gains, remaining in the three-dimensional mitral valve surgical view, the signals of the native structures are attenuated, the underlying ventricular cavity appears black and the insertion points are visible as an intense signal on the virtual free edge of the leaflet treated.

Figure 1 shows the intraoperative sequence of images of a case performed at our centre. The images were acquired using real time single beat three-dimensional reconstruction. Figure 1A shows the surgical view of the native valve with prolapse of the P2-P3 scallops. Image 1B reveals the prolapsing leaflet grasping and device location. After gain lowering, it’s possible to see the intense signal of the positioned artificial chord (Figure 1C). It can also be noted how this position matches with the position of the device at the time of grasping. Image 1D shows the partial disappearance of the prolapse during the tensioning test after the positioning of a second chord in a more medial position. Figure 1E shows the correct position of the ePTFE chords. We can notice the second chord placed in a medial position from the first one. This view, with dark ventricular chamber and intense signals of chordae loops, looks like a "STARRY SKY".

RESULTS

This technique allows to locate the correct insertion points of the artificial chords during the procedure.

CONCLUSIONS

This is a simple technique to guide operators during trans-ventricular beating heart mitral valve repair with ePTFE chords.

Abstract P951 Figure 1

Use of a photo-realism 3D rendering technique to enhance echocardiographic visualization of the anatomical details during beating-heart mitral valve repair

The NeoChord procedure is an innovative microinvasive, transventricular, beating-heart chordal replacement technique for patients with severe degenerative mitral valve regurgitation resulting from prolapsed or flail leaflets. Use of three-dimensional (3D) transoesophageal echocardiographic imaging is crucial to the physician operator for device navigation during the procedure and to assess the functional results of the repair at the end of the procedure. Photo-realistic, 3D rendering techniques have been recently developed for medical use. Philips TrueVue (Philips Healthcare, Eindhoven, NL) is a photo-realism technique that employs the use of a virtual light source that simulates the interaction of light on 3-dimensional surfaces. Use of photo-realism techniques, in conjunction with 3D echocardiography, improves the visualization of morphological characteristics of the mitral valve before, during, and after beating-heart mitral valve repair procedures.

"The Starry Sky." A new intraprocedural three-dimensional echocardiographic technique

The NeoChord procedure is a micro-invasive, trans-ventricular, beating-heart chordal replacement technique for patients with severe degenerative mitral valve regurgitation resulting from prolapsed or flail leaflets. Three dimensional transoesophageal echocardiographic guidance is crucial to assist the operator during the procedure. Equidistant placement of neochordae along the free edge of the prolapsing leaflet segment is important to ensure uniform stress distribution and to avoid damaging any of the previously placed neochordae. Lowering the image gain associated with the three-dimensional surgical view of the mitral valve allows for signal attenuation of the native structures delineating the precise placement location of the neochordae.

Extracorporeal membrane oxygenation after lung transplantation: risk factors and outcomes analysis

Background

Lung transplantation is the treatment of choice for end-stage pulmonary disease in selected patients. However, severe primary graft dysfunction is a significant complication of transplant and requires the implantation of an extracorporeal support. The aim of the study is to evaluate the impact of extracorporeal membrane oxygenation (ECMO) after transplant in our center.

Methods

From January 2008 till June 2018, 195 consecutive unselected patients receiving a lung transplant were considered. Mean age was 49±15 years. Main indications for transplant were idiopathic pulmonary fibrosis in 72 patients, chronic obstructive pulmonary disease in 60 patients, and cystic fibrosis in 40 patients. Prior to transplant, 18 patients were on mechanical ventilation and 14 were on ECMO.

Results

Twenty-five patients required venous-venous ECMO after transplant. Vascular disease as cause of transplant [relative risk (RR) 7.8, 95% CI: 1.5-41, P=0.02], donor age (RR 1.6, 95% CI: 1.03-2.3, P=0.03) and need for cardiopulmonary by-pass during transplant (RR 3.1, 95% CI: 1.02-9, P=0.04) were associated with ECMO implantation. Patients requiring post-transplant ECMO received more transfusions (P<0.01), had a longer mechanical ventilation (P<0.01) and ICU stay (P<0.01) and had a higher hospital mortality (P<0.01). Post-transplant ECMO significantly influenced one- and five-year survival [hazard ratio (HR) 5.5, 95% CI: 3-10, P<0.001 and HR 3.5, 95% CI: 2-6, P<0.001, respectively]. However, conditional survival after t months is similar for patients with or without post-transplant ECMO.

Conclusions

In our experience, although ECMO is a reliable and effective strategy to support pulmonary function, severe graft dysfunction after lung transplantation still has a significant impact on early and late results.