Double intrathoracic arterial cannulation plus peripheral cannulation for whole-body perfusion in an infant

We report a technique for distal body perfusion in an infant with hypoplastic aortic arch and isthmus stenosis by ultrasound- guided cannulation of the femoral artery using an intra-arterial vascular sheath establishing whole-body perfusion by triple cannulation.

Triple-Arterial Cannulation Approach for Whole-Body Perfusion in Infant Hypoplastic Aortic Arch and Coarctation Repair

Organ and end-organ protection in aortic arch surgery represents a substantial challenge, especially in infants. Selective antegrade cerebral perfusion has been reported to improve organ function during this procedure. Visceral perfusion can be optimized by cannulation of the descending aorta during infant aortic arch surgery, leading to a decrease in end organ damage. However, it is associated with extensive surgical manipulation and subsequent risk of major vessel and potential organ damage. In this report, we describe a technique for distal body perfusion in an infant with hypoplastic aortic arch and isthmus stenosis by ultrasound-guided cannulation of the femoral artery using an intra-arterial vascular sheath establishing whole-body perfusion by triple cannulation.

The zone 2 concept and distal stent graft positioning in TH 2-3 are associated with high rates of secondary aortic interventions in frozen elephant trunk surgery

OBJECTIVES

The goal of this study was to investigate the association between the localization of the distal anastomosis (zone 2/3), the stent graft length (100-160 mm), the position of the distal end of the hybrid prosthesis and the need for secondary aortic intervention (SAI) in acute and chronic thoracic aortic disease after the frozen elephant trunk procedure.

METHODS

From 2009 through 2020, a total of 232 patients (137 men; mean age, 61.7 ± 13.8 years) were treated with the frozen elephant trunk procedure. The main indications were acute aortic dissection type A (n = 106, 46%), chronic aortic dissection type A (n = 52, 22%) and degenerative thoracic aortic aneurysm (n = 74, 32%).

RESULTS

The rate of SAI was significantly higher when we performed a distal anastomosis in zone 2 rather than in zone 3, whereas the rate of SAI was less frequent if the distal positioning of the hybrid prosthesis was below TH 4-5. Combining the zone 2 concept and the short stent graft length (100 mm) was associated with a significantly higher rate of SAIs. Patients with a distal anastomosis in zone 2 were significantly less likely to have a recurrent laryngeal nerve injury (P < 0.001). However, no association between a specific arch zone of a distal anastomosis and the occurrence of spinal cord injury was observed.

CONCLUSIONS

Rates of SAIs are highest in patients who were treated with a distal anastomosis in zone 2 and a short stent graft (100 mm) with the distal end of the hybrid prosthesis at vertebral level TH 2-3.

The reinforced full-root technique for the Ross operation: surgical considerations and operative insights

Background

Surgical treatment of young and middle-aged patients suffering from aortic valve disease remains an unresolved issue due to the limited durability of bioprosthetic heart valve replacements and the valve-related morbidity of patients with mechanical valve substitutes. Theoretically, the "living valve" principle of the Ross operation may represent a potentially viable solution to this dilemma. In this paper, we report on the surgical techniques of the Ross procedure and present long-term post-operative outcomes using the reinforced full-root technique.

Methods

From 1995 to 2020, a total of 832 consecutive patients (mean age, 43.4±13.7 years; 617 males) underwent a Ross operation using the full-root technique. Patients were prospectively monitored with clinical and echocardiographic follow-up. Total follow-up was 9,046 patients-years and was 92% complete. Mean-follow-up was 10.9±6.9 years (range, 0-24.9 years).

Results

Survival at twenty years was 92% (95% CI: 90-94%). Freedom from autograft or right ventricle to pulmonary artery connection reoperation at twenty years was 79% (95% CI: 74-85%). Eighty-nine pulmonary autograft reoperations had to be performed in eighty patients; salvage of the pulmonary autograft could be performed in forty-six of them. Fifty-seven patients required sixty-three reoperations on the right ventricle to pulmonary artery connection. Major cerebral bleeding occurred in one patient and neurological events in seventeen patients, respectively.

Conclusions

Over a follow-up interval of up to twenty-five years, the Ross operation with the reinforced full-root technique demonstrated excellent survival in young and middle-aged patients. The rate of pulmonary autograft and right ventricular outflow graft reoperations were low in this patient subset. Therefore, the Ross operation with the reinforced full-root technique represents an enduring and valid treatment option in young and middle-aged patients suffering from aortic valve disease.

Clinical Outcomes after Mitral Valve Repair with the Physio II Annuloplasty Ring

BACKGROUND

 Mitral valve (MV) repair with annuloplasty is the standard of care in patients with primary degenerative mitral regurgitation (DMR). Newer generations of annuloplasty rings have been developed with the goals of closer reproduction of native annular geometry and easier implantation. This study investigates the short-term and 5-year clinical outcomes of MV repair with the Carpentier-Edwards (CE) Physio II annuloplasty ring.

METHODS

 This is an observational study including a total of 486 patients who underwent MV repair for DMR using the CE Physio II annuloplasty ring between 2011 and 2016.

RESULTS

 Mean age was 54.8 ± 12.1 years, 364 patients (74.9%) were males, and 84 patients (17.3%) presented with atrial fibrillation. Mean left ventricular ejection fraction was 62.3 ± 7.3%. Mean logistic EuroSCORE was 2.7 ± 2.4%. New York Heart Association functional class III-IV symptoms were present in 134 (27.6%) patients preoperatively. Isolated MV repair was performed via a right-sided mini-thoracotomy in 479 patients (98.6%). Concomitant procedures included ablation for atrial fibrillation in 83 patients (17.1%) and closure of atrial septum defect in 88 patients (18.1%). Median size of implanted annuloplasty rings was 34 mm (interquartile range: 34-38 mm). Mean cardiopulmonary bypass time was 116 ± 34 minutes and mean cross-clamp time was 74 ± 25 minutes. Thirty-day mortality was 0.4%. The Kaplan-Meier 4-year survival was 98.5%. Freedom from MV reoperation was 96.2 and 94.0% at 1 and 4 years.

CONCLUSION

 MV repair with the CE Physio II annuloplasty ring is associated with excellent midterm clinical outcome.

Transcatheter mitral valve repair: review of current techniques

Mitral regurgitation is common and is associated with excess morbidity and mortality. Despite these poor outcomes, only a minority of affected patients undergo mitral surgery, for several reasons, which underlines the substantial unmet need for treatment for this disorder. Transcatheter mitral valve repair interventions have been developed to treat mitral regurgitation in an undertreated patient population. The aim of this status quo review is to provide an overview of currently available transcatheter mitral valve repair techniques, the different approaches and the clinical outcomes reported so far.

Complex cases of acquired pulmonary vein stenosis after radiofrequency ablation: is surgical repair an option?

Aims

Results of catheter based interventional treatment for pulmonary vein stenosis (PVS) following radiofrequency ablation (RFA) for atrial fibrillation remain suboptimal. Surgical repair may represent an alternative therapy, though long-term results have not been thoroughly investigated.

Methods and results

We retrospectively assessed all patients in our centre undergoing surgical repair for radiofrequency-induced PVS. Data regarding surgical technique, clinical outcome, and rate of pulmonary vein (PV) restenosis were collected and analysed. Between 2004 and 2016, the rate for PVS resulting from RFA for atrial fibrillation in our institution was 0.79% (76/9633). During this period, five male patients with multiple PVS (3 ± 1) underwent surgical repair of a total of 13 symptomatic PVS. Surgery was performed in a standard setting under cardiopulmonary bypass. Stenotic veins were incised longitudinally followed by a patch augmentation plasty using either bovine pericard (n = 7) or polytetrafluoroethylene (PTFE) patches (n = 5). Localization of incision was on the anterior side of the PV only (n = 8) or on both the anterior and posterior sides (n = 4). In one PVS lesion, mechanical dilatation was sufficient. Long-term follow-up after 60 ± 69 months revealed an average restenosis rate of 38%. Restenosis was defined as narrowing >70%. All patients reported clinical improvement of symptoms at follow-up.

Conclusion

Even in the era of wide circumferential lesions, PVS still occurs. While surgical PV patch plasty represents a valuable treatment option, restenosis remains an issue during follow-up. Nevertheless, surgical repair achieves highly acceptable long-term results for RFA-acquired PVS. Hence, it should be routinely discussed as a therapeutic option in cases with multiple PVS.

Annuloplasty ring dehiscence after mitral valve repair: incidence, localization and reoperation

OBJECTIVES

Mitral valve (MV) annuloplasty ring dehiscence with subsequent recurrent mitral regurgitation represents an unusual but challenging clinical problem. Incidence, localization and outcomes for this complication have not been well defined.

METHODS

From 1996 to 2016, a total of 3478 patients underwent isolated MV repair with ring annuloplasty at the Leipzig Heart Centre. Of these patients, 57 (1.6%) underwent reoperation due to annuloplasty ring dehiscence. Echocardiographic data, operative and early postoperative characteristics as well as short- and long-term survival rates after MV reoperation were analysed.

RESULTS

Occurrences of ring dehiscence were acute (<30 days), early (≤1 year) and late (>1 year) in 44%, 33% and 23% of patients, respectively. Localization of annuloplasty ring dehiscence was found most frequently in the P3 segment (68%), followed by the P2 (51%) and the P1 segments (47%). The 30-day mortality rate and 1- and 5-year survival rates after MV reoperation were 2%, 89% and 74%, respectively. During reoperation, MV replacement was performed in 38 (67%) and MV re-repair in 19 (33%) patients.

CONCLUSIONS

Annuloplasty ring dehiscence is clinically less common, localized more frequently on the posterior annulus and occurs mostly acutely or early after MV repair. MV reoperation can be performed safely in such patients.

Isolated Mitral Valve Repair in Patients with Reduced Left Ventricular Ejection Fraction

Purpose: This study aims to analyze the clinical outcomes after isolated mitral valve (MV) repair in patients with reduced left ventricular ejection fraction (LVEF <50%) with focus on perioperative characteristics, survival, and freedom from reoperations.

Methods: Between 1997 and 2015, 557 patients with reduced LVEF (age: 62.8 ± 11.7 years, male: 320) underwent MV repair for symptomatic mitral regurgitation (MR). Etiologies were dilated non-ischemic cardiomyopathy and ischemic cardiomyopathy in 487 (87.4%) and 70 (12.6%) patients, respectively; these were classified into three different subgroups: LVEF 40%–49% (group 1), 30%–39% (group 2), and <30% (group 3).

Results: Overall, 294, 145, and 118 patients had an LVEF of 40%–49%, 30%–39%, and <30%, respectively. Logistic EuroSCORE was significantly higher (P <0.001) as the LVEF worsened. The survival analysis for groups 1–3, respectively, revealed the following: 30-day mortality: 1.4%, 3.4%, and 7.6% (P <0.001); 1-year survival: 93.9%, 89.4%, and 82% (P <0.001); 5-year survival: 81.2%, 75.2%, and 58% (P <0.001).

Conclusion: MV repair in patients with impaired LVEF could be performed safely with good clinical short- and mid-term outcome. Nevertheless, reduced preoperative LVEF correlates with worse perioperative and long-term survival.

Changes in dynamic mitral valve geometry during percutaneous edge-edge mitral valve repair with the MitraClip system

BACKGROUND

The aim of this study was to quantify the acute dynamic changes of mitral valve (MV) geometry throughout the cardiac cycle-during percutaneous MV repair with the MitraClip system by 3-dimensional transesophageal echocardiography (3D TEE).

METHODS

The MV was imaged throughout the cardiac cycle (CC) before and after the MitraClip procedure using 3D TEE in 28 patients (mean age, 77 ± 8 years) with functional mitral regurgitation (FMR). Dynamic changes in the MV annulus geometry and anatomical MV orifice area (AMVOA) were quantified using a novel semi-automated software.

RESULTS

Percutaneous MV repair decreased anterior-posterior diameter by up to 9% (at 50% of CC; from 34.5 to 31.9 mm; p < 0.001) throughout the CC and increased the diastolic lateral-medial diameter by up to 7% (at 60% of the CC; from 39.7 to 42.3 mm; p < 0.001), whereas the annular circumference and area were not significantly affected. Annulus sphericity index was reduced up to 13% (at 50% of the CC; from 0.89 to 0.78, p < 0.001). The AMVOA also decreased during systole, the maximum decrease being from 0.6 to 0.2 mm² (at 0% of CC; p = 0.007), and during diastole the maximum decrease being from 4.6 to 1.6 cm² (at 50% of CC; p < 0.001).

CONCLUSIONS

Percutaneous MV repair reduces the MR by an improved coaptation of MV leaflets joint with a simultaneous indirect reduction of anterior-posterior diameter. Further, the MitraClip procedure leads to a reduction of AMVOA of more than 60% during diastole.

Acute Effect of Mitral Valve Repair on Mitral Valve Geometry

BACKGROUND

 The aim of this study was to quantify acute mitral valve (MV) geometry dynamic changes throughout the cardiac cycle using three-dimensional transesophageal echocardiography (3D TEE) in patients undergoing surgical MV repair (MVR) with ring annuloplasty and optional neochord implantation.

METHODS

 Twenty-nine patients (63 ± 10 years) with severe primary mitral regurgitation underwent surgical MVR using ring annuloplasty with or without neochord implantation. We recorded 3D TEE data throughout the cardiac cycle before and after MVR. Dynamic changes (4D) in the MV annulus geometry and anatomical MV orifice area (AMVOA) were measured using a novel semiautomated software (Auto Valve, Siemens Healthcare).

RESULTS

 MVR significantly reduces the anteroposterior diameter by up to 38% at end-systole (36.8-22.7 mm; p < 0.001) and the lateromedial diameter by up to 31% (42.7-30.3 mm; p < 0.001). Moreover, the annular circumference was reduced by up to 31% at end-systole (129.6-87.6 mm, p < 0.001), and the annular area was significantly decreased by up to 52% (12.8-5.7 cm²; p < 0.001). Finally, the AMVOA experienced the largest change, decreasing from 1.1 to 0.2 cm² during systole (at midsystole; p < 0.001) and from 4.1 to 3.2 cm² (p < 0.001) during diastole.

CONCLUSIONS

 MVR reduces the annular dimension and the AMVOA, contributing to mitral competency, but the use of annuloplasty rings reduces annular contractility after the procedure. Surgeons can use 4D imaging technology to assess MV function dynamically, detecting the acute morphological changes of the mitral annulus and leaflets before and after the procedure.

Advances in Mitral Valve Surgery

Mitral valve (MV) insufficiency, classified as primary and secondary mitral regurgitation (MR), is a common cause of morbidity and mortality. In industrialized countries, degenerative forms are the predominant cause of MR; however, an increasing number of patients present with secondary MR (Iung et al. EHJ 24:1231-1243, 2003). During the last decades, MV surgery experienced substantial advancements. Alain Carpentier pioneered the field of reconstructive valve surgery in the beginning of the 1970s and, since then, a plethora of innovations have led to today's landscape of MV surgery. Modern MV repair techniques including minimally invasive approaches represent the gold standard for primary MR with reconstruction rates of > 97% in high-volume reference centers (Castillo et al. JTCS 144(2):308-312, 2012). Although there is a clear strategy for treatment of primary MR with established high-quality results, the optimal course for treatment of secondary MR remains controversial. Results for a variety of MV repair techniques for secondary MR have been uniformly disappointing and there has been a recent resurgence in interest for MV replacement surgery. Innovations in equipment and imaging have led to the development of new techniques for patients with MV disease. High-risk patients who are poor candidates for surgery have been the focus for most of these techniques, usually within the construct of a multidisciplinary heart team. Efforts have been predominantly focused on less invasive strategies, usually transcatheter technologies, in these high-risk patients. This article aims to give an overview about current surgical treatment options for primary and for secondary MR with special focus on new surgical and transcatheter developments.

Six-month outcome after transcatheter edge-to-edge repair of severe tricuspid regurgitation in patients with heart failure

AIMS

Severe tricuspid regurgitation (TR) is common in patients with right-sided heart failure (HF) and causes substantial morbidity and mortality. Treatment options beyond medical therapy are limited for high-risk patients. Transcatheter edge-to-edge tricuspid valve (TV) repair showed procedural safety and short-term efficacy. Impact on mid-term outcome is unclear. This dual-centre observational study evaluates the mid-term safety, efficacy and clinical outcome after edge-to-edge TV repair for severe TR in patients with HF.

METHODS AND RESULTS

Overall, 50 patients with right-sided HF and severe TR were treated with the transcatheter edge-to-edge repair technique; 14 patients were treated for isolated TR and 36 patients for combined mitral regurgitation (MR) and TR. At 6-month follow-up (available for 98% of patients), a persistent reduction of at least one echocardiographic TR grade was achieved in 90% of patients and New York Heart Association class improved in 79% of patients. The 6-minute walk distance increased by 44% (+84 m, P < 0.001), the median N-terminal pro-B-type natriuretic peptide decreased by 30% (from 3625 to 2526 pg/mL, P = 0.002), and the quality of life score improved by 16% (decrease of 6 points in the Minnesota Living with Heart Failure Questionnaire score, P = 0.056). The improvements were comparable in patients undergoing isolated TR or combined MR and TR treatment. During follow-up, 8 patients died, 14 were hospitalized for worsening of HF, 2 underwent TV surgery, and 2 received a second TV clip procedure.

CONCLUSIONS

Transcatheter edge-to-edge TV repair for severe TR is safe and effective in reducing TR. It appears to be associated with improved clinical outcome in the majority of patients.

Transapical Mitral Valve Implantation for Native Mitral Valve Stenosis Using a Balloon-Expandable Prosthesis

BACKGROUND

Transcatheter mitral valve implantation (TMVI) is still in its infancy and is mainly limited to valve-in-valve or valve-in-ring implantations. We present the early experience with TMVI for severe calcified native MV stenosis.

METHODS

Between January 2014 and June 2015, 6 of 11 patients screened (mean age, 77.4 ± 6.3 years; 66% men) with severe native mitral valve (MV) stenosis (mean gradient [Pmean], 11.1 ± 2.1 mm Hg; mean effective orifice area [EOA], 0.9 ± 0.12 cm²) underwent transcatheter MV replacement at our institution as a bailout procedure. Conventional surgical procedures were denied in all patients because of severe annular calcification and extensive comorbidities (mean logistic EuroScore, 31.4% ± 8.3%). The Edwards SAPIEN 3 (29 mm) (Edwards Lifesciences, Irvine, CA) was used in all cases. Procedural access was transapical in 5 cases and concomitant to aortic valve replacement through the left atrium through a sternotomy in 1 case.

RESULTS

Initial implantation was successful in 100% of the cases. Because of early migration, 1 patient needed a valve-in-valve procedure. Postoperative echocardiography showed no residual mitral regurgitation in 4 cases (66%) and mild regurgitation in 2 cases (34%). Mean gradients were reduced to 4.2 ± 0.6 mm Hg (mean EOA, 2.8 ± 0.4 cm²⁾. No patient had a stroke during hospitalization, and 30-day mortality was seen in 1 patient (17%) resulting from pneumonia.

CONCLUSIONS

TMV implantation using the SAPIEN 3 aortic prosthesis in patients with heavy annular calcification is feasible and represents a reasonable bailout option for inoperable patients. However, several limitations need to be considered in this special patient population.

Minimally Invasive Mitral Valve Surgery for Mitral Valve Infective Endocarditis

Background The feasibility of minimally invasive mitral valve (MV) surgery in infective endocarditis (IE) has not been reported in detail. We assessed the safety, efficacy, and durability of the minimally invasive approach through a right anterolateral minithoracotomy for surgical treatment of MV IE.

Methods A review of the Leipzig Heart Center database revealed 92 eligible patients operated on between 2002 and 2013. All patients had undergone minimally invasive surgery for IE. The indication for surgery was isolated IE of the MV in all patients. Baseline and intraoperative data, as well as clinical outcomes and short-term follow-up were analyzed retrospectively.

Results The patients' mean age was 60.9 ±  15.3 years, the logistic EuroSCORE II was 19.6 ± 19.1%, and 64.1% (59) were male. MV repair was feasible in 23.9% (22/92) of patients. Repair techniques included annuloplasty ring implantation, anterior mitral leaflet resection, posterior mitral leaflet resection, and implantation of neochordae. MV replacement was performed in 69 patients (75%), a mitral annulus patch in 1 patient, and concomitant tricuspid valve surgery for tricuspid regurgitation in 5 patients. Bacteriological analysis showed staphylococcus infection in 45.5%, streptococcus in 36.4%, enterococcus in 13.6%, and others in 4.5%. The 30-day-mortality rate was 9.8% (9 patients). The 1-year follow-up showed a 1-year survival rate of 77.7 ± 4.4% and freedom from reoperation within 1 year due to reendocarditis of 93.3 ± 2.1%.

Conclusions The minimally invasive approach is suitable for the treatment of IE of the MV. It is a good technique in IE in selected patients.

Preoperative Predictors and Outcome of Triple Valve Surgery in 487 Consecutive Patients

Background Triple valve surgery (TVS) is associated with an elevated risk for operative mortality and thus remains a surgical challenge. We report our experience and results of TVS procedures, especially with respect to identification of preoperative risk factors, to improve patient selection. Methods Between December 1994 and January 2013, 487 consecutive patients (240 male, 247 female) underwent TVS at the Heart Center Leipzig, University of Leipzig. The data were prospectively collected and retrospectively analyzed. Univariate and multivariable regression analyses were performed to identify risk factors. Results The 30-day mortality was 16.1% and the long-term survival at 1 year and 5 years was 71.8% and 54.6%, respectively. Multivariable logistic regression analysis identified previous myocardial infarction to be the only significant predictor for early mortality. Age, New York Heart Association functional class IV, previous myocardial infarction, dialysis, and liver dysfunction were identified as preoperative predictors for late mortality. Furthermore, an increase of operative risk, given for each year, was observed during the study period. In contrast, 30-day mortality decreased during the observation time. Conclusion TVS is associated with a high surgical risk. Long-term survival is decreased, but acceptable for these high-risk patients. The series demonstrates that increasing surgical risk, age, and comorbidities are the future challenges in TVS.

Incidence, characteristics and functional implications of cerebral embolic lesions after the MitraClip procedure

AIMS

This study aimed to assess the incidence and impact of cerebral embolic events after the MitraClip procedure.

METHODS AND RESULTS

Twenty-seven high-risk patients (logistic EuroSCORE I 25±15%) underwent the MitraClip procedure and cerebral diffusion-weighted magnetic resonance imaging (MRI) in median two days before and three days after the procedure. On the same day, neurocognitive function was assessed using the Montreal Cognitive Assessment (MoCA) questionnaire and thorough clinical examination. Comparison of pre- and post-interventional MRI showed that 23 of 27 patients (85.7%) had newly acquired microembolic lesions with in median three (interquartile range 1-9) new lesions per patient. Of these, three patients (11.1%) had lesions with diameter >5 mm. Patients with >3 new cerebral embolic lesions (n=13, 48%) had a lower post-interventional MoCA score in comparison to patients with ≤3 embolic lesions (23.6±3.6 vs. 20.3±4.5; p=0.046) in univariate analysis. Multivariate stepwise regression analysis identified device time as an independent predictor of the number of post-procedural new lesions (p=0.003) and, for reduced post-interventional MoCA score, a low MoCA score at baseline (p<0.001).

CONCLUSIONS

The MitraClip procedure results in new ischaemic cerebral lesions in the vast majority of patients. Preliminary data suggest that these lesions are clinically without significant impact on global cognitive function. ClinicalTrials.gov: NCT01288976.

Transcatheter mitral valve repair: where are we?

Mitral valve regurgitation is the second most common form of valve pathology after aortic stenosis needing surgery. While open surgical repair is still the gold standard, innovative interventional approaches have emerged as an alternative treatment option for high-risk patients. While only a few of these new techniques have been approved for the clinical setting, many others are currently under development or in pre-clinical testing. This editorial will attempt to summarize all current transcatheter-based innovations targeting the mitral valve and explore their potential for the future.