Artificial chordae in the setting of complex mitral valve repair: early outcomes using the folding leaflet technique.

OBJECTIVES: Neochordal repair is particularly limited in case of large prolapse with absence of a reference point on a nearby segment. Our aim was to overcome these limitations by means of a simple technique: the 'Folding Leaflet'. METHODS: Ninety-six patients underwent this technique between January 2009 and August 2012 from a global mitral valve (MV) repair group of 384 patients. A subgroup of 68 patients with complex lesions, bileaflet, commissural or multisegment prolapse, was selected. These more challenging patients were considered as the study group in order to assess the efficacy of our technique. The neochordae were fixed to the papillary muscle with a simple stitch and then were passed through the free margin of the prolapsing leaflet. Free-edge remodelling was achieved weaving this suture and surpassing the coaptation line. Then, the leaflet was folded and its free margin was temporarily approximated edge-to-edge to the adjacent annulus. This was used as the reference point while the neochordae were tied without the need for adjacent healthy chordae or use of callipers. Complete echocardiographic follow-up was obtained at 6-month intervals. RESULTS: All patients had ≥ 2 prolapsed segments: posterior leaflet (40 patients), anterior leaflet (13 patients) or both leaflets (15 patients). Annuloplasty was routinely used and the mean number of neochordae per patient was 4.1 ± 2.2 (2-13). Mean follow-up was 28 ± 14 months (5-49 months). There was only one in-hospital death. Another patient died by pneumoniae (15th postoperative month). At the first-month follow-up, 51 patients had no mitral regurgitation (MR) and 16 patients had Grade 1 MR. Only 1 patient had more than mild regurgitation at the 6-month follow-up. There was no evidence of Grade 3 or 4 MR in any patient. At the 2-year follow-up, 34 patients remained with no MR or trace MR and 7 patients had Grade 1 MR. CONCLUSIONS: MV repair for complex degenerative MR using this technique of neochordal repair results in excellent early and mid-term outcomes. This technique facilitates the extensive use of neochordae in case of large areas of prolapse.

Impact of increasing degrees of renal impairment on outcomes of coronary artery bypass grafting: the off-pump advantage.

OBJECTIVES: Increasing degrees of renal impairment are associated with higher rates of morbimortality after coronary artery bypass grafting (CABG). This incremental risk has not been well studied in off-pump procedures (OPCAB). We assessed its impact on OPCAB and on-pump CABG (ONCAB). METHODS: A total of 1769 patients undergoing primary CABG (January 1995 through June 2011) had complete data on glomerular filtration rate (eGFR). 930 patients had Stage 2 renal insufficiency, 330 Stage 3, 27 Stage 4 and 465 normal renal function (Stage 1). Seventeen patients with end-stage disease (Stage 5) were excluded. The OPCAB technique was selectively used in 350 high-risk patients. Preoperative variables and postoperative outcomes were compared among eGFR subgroups and between matched and unmatched OPCAB vs ONCAB groups. RESULTS: Stages 3-4 patients were older (P < 0.0001), with higher prevalence of diabetes (36.8, 35.0, 39.7 and 74.1%, P < 0.01, 1-4 eGFR groups) peripheral arteriopathy (6.0, 9.0, 15.8 and 29.6%, P < 0.0001) and lower left ventricular ejection fraction (LVEF) (GFR-LVEF correlation: Pearson: 0.12, P < 0.0001). On-pump GFR groups had increasingly higher in-hospital mortality (1.0, 1.2, 3.5 and 15.4%, P < 0.0001), but no differences were observed in OPCAB (5.5, 4.8, 5.4 and 7.1%, P = 0.97). Similar trends on in-hospital morbidity were observed in ONCAB vs OPCAB groups: low cardiac output (P < 0.01), pneumonia (P < 0.01) and stroke (P < 0.05). GFR only predicted mortality in ONCAB patients (odds ratio (OR): 0.96, 95% CI: 0.94-0.98; P < 0.01). Patients with higher eGFR stages had statistically more reduced long-term survival, and this pattern was similar in the three treatment groups, also including the OPCAB group, who had the lowest survival in patients with eGFR stage 4. CONCLUSIONS: Patients with low GFR (Stages 3-4) undergoing ONCAB were at increased risk of early morbimortality. In contrast, there were no significant differences in operative morbimortality among eGFR groups in OPCAB patients. This 'off-pump advantage' on early outcomes was not observed at the long-term follow-up.

Minimally invasive aortic valve surgery. A safe and useful technique beyond the cosmetic benefits.

INTRODUCTION AND OBJECTIVES: The aim of this study was to compare the in-hospital clinical outcomes of minimally invasive, isolated aortic valve replacement vs median sternotomy. METHODS: Between 2005 and 2012, 615 patients underwent aortic valve replacement at a single institution, 532 by a median sternotomy (E group) and 83 by a J-shaped ministernotomy (M group). RESULTS: No significant differences were found between the E and M groups in terms of age (69.27 [9.31] years vs 69.40 [10.24] years, respectively), logistic EuroSCORE (6.27 [2.91] vs 5.64 [2.17], respectively), size of implanted valve prosthesis (21.94 [2.04] mm vs 21.79 [2.01] mm, respectively), or the incidence of diabetes, hypercholesterolemia, high blood pressure, or chronic obstructive pulmonary disease. Mean cardiopulmonary bypass time was 102.90 (41.68) min for the E group vs 81.37 (25.41) min for the M group (P<.001). Mean cross-clamp time was 77.31 (29.20) min vs 63.45 (17.71) min for the S and M groups, respectively (P<.001). Mortality in the E group was 4.88% (26). There were no deaths in the M group (P<.05). The E group was associated with longer intensive care unit and hospital stays: 4.17 (5.23) days vs 3.22 (2.01) days (P=.045) and 9.58 (7.66) days vs 7.27 (3.83) days (P<.001), respectively. E group patients had more postoperative respiratory complications (42 [8%] vs 1 [1.2%]; P<.05). There were no differences when postoperative hemodynamic, neurologic, and renal complications, systemic infection, and wound infection were analyzed. CONCLUSIONS: In terms of morbidity, mortality, and operative times, outcomes after minimally invasive surgery for aortic valve replacement are at least comparable to those achieved with median sternotomy. The length of the hospital stay was reduced by minimally invasive surgery in our single-institution experience. The retrospective nature of this study warrants further randomized prospective trials to validate our results.

Resultados a corto y mediano plazo del tratamiento de la obstrucción al tracto de salida del ventrículo izquierdo mediante miectomía videoasistida / Video assisted myectomy for relief of left ventricular tract obstruction in patients with Obstructive Hypertrophic Cardiomyopathy

Objetivo: Describir nuestra experiencia y evaluar los resultados a corto y mediano plazo de la miecto-mía videoasistida en el tratamiento de la obstrucción del tracto de salida del ventrículo izquierdo (OTSVI) en pacientes con miocardiopatía hipertrófica. Materiales y métodos: 52 pacientes con edad media de 56,2 (rango 12 - 83) y Euroscore de riesgo de 4,1 +/- 1,92 con diagnóstico de OTSVI fueron intervenidos de manera consecutiva en un mismo centro mediante miectomía videoasistida. Se realizó seguimiento clínico y ecocardiográfico con controles al mes y al año del postoperatorio. Resultados: Entre las patologías asociadas encontramos 11 pacientes con valvulopatía aórtica, 2 con valvulopatía mitral, 3 con cardiopatía isquémica, 1 con aneurisma de aorta ascendente y 1 con foramen oval permeable resueltos en el mismo acto quirúrgico. La mortalidad hospitalaria global fue de 5,8 por ciento (3 pacientes). En el momento de la intervención, 8 (15,4 por ciento) se encontraban en clase funcional II de la NYHA, 42 (80,8 por ciento) en clase III y 2 (3,8 por ciento) en clase IV. El gradiente máximo subaórtico disminuyó de 80,7 mmHg +/- 29,43 en el preoperatorio a 19,0 mmHg +/- 15,57 (p<0,001) en el postoperatorio inmediato, manteniéndose en 14,6 mmHg +/- 8,88 al mes (p<0,001 en relación al preoperatorio) y al año en 13,9 mmHg +/- 7,69 (p<0,001 en relación al preoperatorio). Además, se registró una disminución del grosor del tabique interventricular en diástole de 19,4 mm +/- 3,78 en el preoperatorio a 12,9 mm +/- 2,35 (p<0,001) en el postoperatorio. Todos los pacientes se encontraban en clase funcional I-II al final del seguimiento. Conclusión: Los resultados demuestran que la miectomía videoasistida es un tratamiento seguro para la OTSVI con el que se obtienen resultados favorables a corto y mediano plazo, tanto en parámetros clínicos, como ecocardiográficos.

Aim: To report a clinical experience and to evaluate early and mid term results of video assisted myec-tomy for relief of left ventricular tract obstruction (LVOTO) in patients with Obstructive Hypertrophic Cardiomyopathy. Methods: 52 patients with Obstructive Car-diomyopathy and a mean age 56.2 years (12 - 83) carrying a Euro score risk of 4.1 +/- (SD 1.92), were consecutively operated on in a single center. Relief of LVOTO was performed with video assisted myec-tomy. Clinical and echocardiographic follow up to 1 year postoperatively was carried out. Results: Apart from the Obstructive Cardiomyo-pathy, 11 patients had aortic valve disease, 2 mitral valve disease, 3 ischemic heart disease, 1 an ascending aortic aneurysm and 1 a patent foramen ovale. All these lesions were surgically repaired in the same surgical act. In hospital mortality was 5.8 percent (3 patients). Pre-operatively 15.4 percent of patients were in NYHA Class II, 80.8 per cent in Class III and 3.8 percent in Class IV. After surgery peak sub aortic gradient decreased from 80.7+/-29.43mmHg to 19.0 +/- 15.57 (p<0.001). Corresponding values were 14.6 +/- 8.88 at 1month and 13.9 +/- 7.69 at 1 year post operatively. Interven-tricular septal thickness in diastole decreased from 19.4 +/- 3.78 mm to 12.9 +/- 2.35 mm after surgery (p<0.001). All patients were Class I or II at the end of follow up. Conclusion: Video assisted myectomy is safe and effective for relief of LVOTO in patients with hypertrophic cardiomyopathy. Good results are maintained one year after surgery.

Factors for development of late significant tricuspid regurgitation after mitral valve replacement: the impact of subvalvular preservation.

OBJECTIVE: Development of late significant tricuspid regurgitation (TR) after successful mitral valve replacement (MVR) is not infrequent. The impact of different aetiologies or diverse surgical procedures has not been adequately investigated. We studied the influence of subvalvular preservation techniques during MVR on the incidence of late TR. METHODS: A total of 801 patients with grade ≤ 2+/4+ preoperative TR underwent MVR without associated tricuspid procedures from January 1994 to August 2008. In 595 patients, only posterior mitral leaflet preservation was performed (group A). In the remaining 206 patients, both anterior and posterior leaflets were retained (group B). Postoperative development of significant TR was defined as a TR increase by more than one grade from preoperative or final TR grade ≥ 3+/4+ at follow-up. RESULTS: The global incidence of postoperative significant TR was 8.6%, with higher incidence in females (9.4% vs 6.7%, p=0.12), rheumatic disease (9.7% vs 6.5%, p=0.07), patients with previous AF (11.8% vs 3.8%, p<0.001) and, especially, in group A (10.8% vs 2.4%, p<0.001). The Maze procedure was protective in patients with AF (the incidence with and without associated Maze was 6.7% vs 13.2%, p=0.04). Preoperative left-atrial diameters were higher in patients with postoperative development of TR (56 ± 9 mm vs 51 ± 12 mm, p=0.01). Group A (p=0.04) and preoperative atrial fibrillation (p=0.001) were significant predictors of late postoperative TR. Late functional TR decreased free survival from chronic heart failure. CONCLUSIONS: Several clinical and operative factors are associated with the development of significant TR after MVR. Although early surgical intervention for TR may be recommended in selected patients, complete subvalvular preservation of the mitral valve and routine surgical ablation of atrial fibrillation can significantly reduce its incidence.

The folding leaflet: a simple method for neochordal repair.

We present a simple technique for facilitating accurate polytetrafluoroethylene chordal height adjustment in surgical repair of myxomatous mitral valve disease. This approach is based on the annulus as the reference level. The artificial chordae are first fixed to the corresponding papillary muscle. Each chordal pair is then attached to the free edge of the prolapsed leaflet, and subsequently, the leaflet edge is also attached to the adjacent annulus by temporary fixing sutures. As a result, the leaflet is gently folded. Finally, the polytetrafluoroethylene suture is knotted during proper apposition of the free edge of the leaflet to the annulus.

Mitral valve replacement in rheumatic patients: effects of chordal preservation.

BACKGROUND: Subvalvular preservation is beneficial in patients undergoing mitral valve replacement, especially in degenerative mitral regurgitation. Its feasibility and benefit is less evident in rheumatic disease. Our aim was to study the impact of preservation techniques in rheumatic patients and determine risk factors for mortality. METHODS: Five hundred sixty-six rheumatic patients undergoing mitral valve replacement between 1996 and 2006 have been included. One hundred fifty-six patients had complete excision of the subvalvular apparatus (group 1), 248 had preservation of the posterior leaflet (group 2), and 162 had total chordal preservation (group 3). Echocardiography was performed preoperatively, at discharge, at 1 year, and at late follow-up. RESULTS: Reduction of ventricular volume was greater in groups 2 and 3, especially if previous mitral regurgitation or mixed disease were present. In mitral stenosis, valve resection caused postoperative increase of volume. Ventricular ejection and pulmonary hypertension had better outcome with valve preservation. Valve resection was associated with late mortality (hazard ratio, 2.64; p < 0.05), and complete chordal preservation was protective (hazard ratio, 0.31; p = 0.13). Actuarial survival (130 months) was better in group 3: 77.18% +/- 0.04%, 85.38% +/- 0.03%, and 93.22% +/- 0.02%, respectively (p < 0.01 group 1 versus group 3). Group 1 exhibited more low cardiac output syndrome (p < 0.01) and more patients in New York Heart Association functional class III and IV at last follow-up: 17.8% versus 3.9% and 2.0% (p < 0.001). CONCLUSIONS: Complete chordal preservation is possible in a large percentage of rheumatic patients. Greater decrease of ventricular volume is obtained for mitral regurgitation. In mitral stenosis, subvalvular preservation may avoid postoperative ventricular dilatation. Consequently, ventricular ejection, pulmonary hypertension, and clinical outcomes may improve with time.

Intraoperative cryoablation of atrial fibrillation with the old-fashioned cryode tips: a simple, effective, and inexpensive method.

Nowadays atrial fibrillation is usually treated simultaneously with cardiac procedures, and new cryo-systems have been developed for performing easier and faster intraoperative ablation. However, the old cryode designs can still be useful in surgical practice and represent a more cost-effective method. In this article we present a technique using old-fashioned cryodes for intraoperative treatment of atrial fibrillation and comment on its advantages and limitations.

Prosthesis - patient mismatch with latest generation supra-annular prostheses. The beginning of the end?

Most studies about prosthesis-patient mismatch (PPM) were conducted before the introduction of new high-performance prostheses. Nowadays, PPM could become unfrequent. Our aim was to study the impact of new prostheses on PPM in comparison with previous experience. Prosthetic Indexed Effective Orifice Area (EOAi) was estimated in two historical cohorts. Group A: 339 patients undergoing AVR from Mar 94-Nov 01. Group B: 404 operated on during the last three years when latest generation prostheses were implanted. Incidence, determinants of PPM and clinical results were studied. Moderate PPM (EOAi

Posterior transposition of anterior leaflet for complete chordal preservation.

A method of complete chordal preservation based on posterior transposition of anterior leaflet is presented. The anterior leaflet and chordae are completely detached from the annulus and reimplanted as a large patch under the posterior leaflet. The excess tissue without chordae is excised and the remnant with all the chordae is plicated by sutures used to implant the prosthesis. The posterior leaflet is left intact. The technique is safe and reproducible and no complications related with the procedure have been observed at mid-term follow-up. These results have led to a wider application of total chordal preservation during mitral valve replacement.

[Trends in coronary artery bypass surgery: changes in the profile of the surgical patient]. / Tendencias en cirugía coronaria: cambios en el perfil del paciente quirúrgico.

INTRODUCTION AND OBJECTIVES: In the last few years, the percentage of high-risk patients proceeding to coronary artery bypass surgery has increased. The most common risk factors are older age and the presence of comorbid complaints. We carried out a retrospective study to confirm this new risk profile and to evaluate its impact on surgical results. PATIENTS AND METHOD: We analyzed the changing risk profile of 1360 patients who underwent coronary artery bypass surgery in our hospital between 1993 and 2001, divided into three historical cohorts: 1993-1996, 1997-1999 and 2000-2001. The main factors associated with morbidity and mortality were analyzed by logistic regression analysis. The introduction of new operative techniques, such as off-pump surgery and arterial grafting, was also evaluated. RESULTS: The patients' risk profile worsened over time: patients were older, comorbid complaints were more common, and ventricular function was poorer. EuroSCORE figures reflected this trend: estimated mortality in the three historical cohorts was 2.0%, 4.0% and 4.2%, respectively (P<.001). However, risk-adjusted mortality, at 3.7%, 2.7% and 1.5%, respectively, decreased (P<.05), and combined overall morbidity and mortality remained stable, at 16.7%, 16.4% and 13.8%, respectively, (P<.39). There was a non-significant tendency for arterial grafting and off-pump surgery to reduce in-hospital morbidity and mortality. CONCLUSIONS: The risk profile of patients undergoing surgery has worsened as their mean age has increased and as comorbid complaints have become more prevalent. However, there has been no simultaneous increase in risk-adjusted mortality. The potential benefits of new surgical advances such as off-pump surgery and multiple arterial grafting must be corroborated by future studies.

[Ablation of permanent atrial fibrillation in cardiac surgery. Short-term and mid-term results]. / Ablación de la fibrilación auricular permanente en la cirugía cardíaca. Resultados a corto y medio plazo.

INTRODUCTION: Surgical ablation of atrial fibrillation is currently a simple procedure that can be done during cardiac surgery in most patients. A number of different energy sources now available allow to easily create ablation lines in the atria. We describe our experience during the previous three years. PATIENTS AND METHOD: In 93 patients with cardiac problems treated with surgery and permanent atrial fibrillation (longer than 3 months), surgical ablation of the arrhythmia was done at the same time. Mean duration of the atrial fibrillation was 6 years (range 0.3 to 24 years). Mean (SD) preoperative size of the atrium as measured echocardiographically was 51.7 (8.8) mm (range 35 to 77 mm). RESULTS: Five patients died in the hospital (5.3% in-hospital mortality). After a mean follow-up of 10 months, 83.8% of the patients had recovered and maintained sinus rhythm, and 16.1% of the patients remained in atrial fibrillation. A permanent pacemaker was implanted in 3 of these patients. Among the 82 patients followed for more than 6 months, the prevalence of sinus rhythm was 84.1%. Echocardiographically documented contractility in both atria was observed in 50% of the patients. Major complications related to the ablation procedure occurred in 3.5% of the patients, and consisted of a perivalvular leak 2 months after surgery, a circumflex artery spasm, and an atrio-esophageal fistula. CONCLUSIONS: Surgical ablation of permanent atrial fibrillation is a simple procedure associated with low morbidity and mortality, and with recovery of sinus rhythm in most patients. The main problem with the procedure is the incidence of early postoperative arrhythmias.

Arterial graft extension with radial artery: a method of total arterial revascularization.

A method of total arterial revascularization is presented. This technique is based on the extension of a semi-skeletonized right internal thoracic artery graft with an entire radial artery in an end to end fashion. A complete arterial revascularization is achieved with a bilateral in situ internal thoracic artery strategy preserving the left internal thoracic artery to the left anterior descending artery bypass as an isolated graft. In our experience, this pattern of revascularization has been especially important in patients with atheromatous disease of the ascending aorta, a difficult situation in which a 'no-touch technique' is mandatory.

[Anatomic atrial remodeling after mitral valve surgery in permanent atrial fibrillation]. / Remodelado anatómico auricular tras la cirugía de la valvulopatía mitral con fibrilación auricular permanente.

BACKGROUND: Mitral valve pathology is frequently associated with atrial dilation and fibrillation. Mitral surgery allows immediate surgical atrial remodeling, and in those cases in which sinus rhythm is achieved, it is followed by late remodeling. The aim of this study was to investigate the process of postoperative atrial remodeling in patients with permanent atrial fibrillation who undergo mitral surgery. PATIENTS AND METHOD: In a prospective randomized trial, 50 patients with permanent atrial fibrillation and dilated left atrium, repaired surgically, were divided into two groups: group I, 25 patients with left atrial reduction and mitral surgery, and group II, 25 patients with isolated valve surgery. The characteristics of both groups were considered homogeneous in the preoperative assessment. RESULTS: After a mean follow-up of 31 months, 46% of the patients in group I versus 18% in group II regained sinus rhythm (p = 0.06). Atrial remodeling with shrinkage occurred in patients who recovered sinus rhythm, with larger changes in group II (-10.8% left atrial volume reduction in group I compared to -21.5% in group II; p < 0.05). The atrium became enlarged again in patients whose atrial fibrillation did not remit (+16.8% left atrial volume increase in group I versus +8.4% in group II; p < 0.05). CONCLUSIONS: Mitral surgery produces a postoperative decrease in atrial volume, especially when reduction techniques are used. Late left atrial remodeling was influenced by the type of atrial rhythm and postoperative surgical volume.

[Aortic valve replacement in patients over 70 years old: determinants of early death]. / Recambio valvular aórtico en pacientes mayores de 70 años: determinantes de mortalidad temprana.

INTRODUCTION AND OBJECTIVES: There is controversy regarding the risk factors associated with early death in geriatric patients undergoing aortic valve replacement. We analyzed the risks in these patients and established an accurate model for predicting in-hospital mortality. PATIENTS AND METHOD: Univariate and multivariate analyses were made of the risk factors associated with early death in a group of 129 patients older than 70 years who underwent aortic valve replacement (May 1994-June 2001). The variables obtained by multivariate logistic regression were combined to produce an equation for the prediction of early death. The equation was tested using a receiver operating characteristic curve. RESULTS: Univariate analysis identified four factors related to early death: NYHA III-IV (p < 0.0001), ejection fraction < 40% (p < 0.05), aortic regurgitation (p < 0.05) and high left ventricular mass index (p < 0.05). Multivariate analysis revealed three independent risk factors: NYHA III-IV (p < 0.01), aortic regurgitation (p < 0.05), and small body surface area (p < 0.05). A lower mortality was observed in patients with a larger body surface area (0% for > 1.90 m2, 20% for < 1.40 m2). The estimated mortality with the predictive model was 7.06%, which was similar to the observed mortality of 7.80% (area under the ROC curve 0.87) and better than estimates obtained with the EuroSCORE (6.5%; area under the ROC curve 0.56). CONCLUSIONS: Risk factors associated with early death after aortic valve replacement in geriatric patients include functional status, aortic regurgitation, and small body surface area. Our model based on these factors accurately predicted operative mortality in our patients. Gender, prosthesis size, and pump time were not identified as risk factors.

[Advantages of off-pump coronary bypass surgery in high-risk patients]. / Ventajas de la revascularización miocárdica sin circulación extracorpórea en pacientes de riesgo.

INTRODUCTION AND OBJECTIVES: Myocardial revascularization without cardiopulmonary bypass has been shown to reduce operative morbi-mortality. We report our recent experience with this novel technique in order to evaluate its theoretical advantages in comparison with conventional surgery. PATIENTS AND METHODS: This retrospective analysis included 547 consecutive patients undergoing isolated myocardial revascularization from December 1997 through November 2000. One hundred twenty-one off-pump patients were compared to 426 undergoing cardiopulmonary bypass. Logistic regression analysis was performed to find predictors of mortality, transfusion, postoperative atrial fibrillation and length of hospital stay. RESULTS: Off-pump patients were at greater risk: they were older, with a lower ejection fraction and a higher prevalence of unstable angina, heart failure and associated comorbidity. Off-pump surgery reduced transfusions (1 1 vs 1,9 2 blood units; p < 0.0001) and postoperative hospital stays (8.9 5 vs 11,3 7 days; p < 0.001). The off-pump group showed a trend toward reduced morbidity but the technique did not decrease hospital mortality. Cardiopulmonary bypass was an independent predictor of blood transfusion and longer hospital stay. Short-term follow-up revealed no significant differences in recurring angina or patency rates. CONCLUSIONS: Off-pump coronary bypass surgery is a good option in high-risk patients because it reduces the incidence of perioperative transfusion and the length of hospitalization. Furthermore, it showed a trend toward reduced morbidity. Mortality was not significantly higher in spite of the higher risk of the patients. Long-term longitudinal follow-up is mandatory to assess the true effectiveness of this technique.