Aortic valve construction using new nitinol templates and pericardial tissue.

The use of pericardial tissue has been widely adopted in a range of cardiac surgery procedures involving the reconstruction of heart valves. Its use in aortic valve construction has been discussed in recent years by Ozaki et al. A key parameter in the optimal functioning of a fabricated valve is the sizing of the new cusps. This video tutorial demonstrates aortic valve construction using newly designed templates and forceps to facilitate sizing and enhance the symmetrical coaptation of the new cusps.

Aortic valve construction using pericardial tissue: short-term single-centre outcomes.

OBJECTIVES: Aortic valve construction using pericardial tissue has been known since the late 1960s. The procedure was re-introduced by Ozaki in 2010 and is currently used to treat specific aortic valve diseases. The exact sizing of the neo-cusps and the insertion of the commissures remain the keys to success when performing this procedure. We evaluated our experience using modified custom-made templates. METHODS: In this prospective single-centre study, we evaluated 52 consecutive patients who underwent aortic valve construction between September 2015 and March 2017 using either autologous (16 patients, 30.8%) or tissue-engineered pericardium (36 patients, 69.2%). Most patients (34, 65.4%) presented with aortic stenosis or endocarditis (5, 9.6%). Twenty patients had bicuspid and 5 had unicuspid valves. A modified sizing technique with specially designed templates was used. The primary end point was early death; the secondary end points were major adverse cardiac and cerebrovascular events, freedom from reoperation and overall mortality rate. Echocardiographic follow-up was performed intraoperatively and at 12-month intervals. RESULTS: The mean age was 60 ± 14 years; 63.5% were men; and 34 (65.4%) patients had combined procedures. The mean cross-clamp time was 99 ± 17 min. Early outcomes included 1 stroke, 2 patients needing short-term dialysis and 1 death. During follow-up (mean 11.2 ± 4.8 months), trace aortic regurgitation was observed in 4 patients; the mean pressure gradient was 6.8 ± 2.9 mmHg. Three patients died later (of non-cardiac reasons), and 5 patients needed reoperation due to endocarditis. CONCLUSIONS: Aortic valve construction using pericardial tissue could be an alternative in middle-age patients presenting with aortic valve disease in whom valve repair was not possible. The newly designed templates allow exact sizing of the neo-cusps and optimal commissure implantation; however, long-term follow-up in a larger cohort is warranted to assess the durability of the neo-valves.

Endoscopy in aortic valve repair: does it worth it?

BACKGROUND: Aortic valve repair (AVR) is a technically challenging procedure. Usually, the repaired valve is checked after weaning from cardiopulmonary bypass (CPB). We aimed to evaluate intraoperative and clinical outcomes of AVR patients in whom intraoperative aortic root endoscopy was applied. METHODS: The present study was a retrospective single-center study. An autoclavable video-scope was used to evaluate aortic valve. During endoscopy, crystalloid cardioplegia was administered to pressurize the aortic root. Primary endpoints were: need for Re-CPB after weaning from bypass and early postoperative aortic valve regurgitation. Secondary endpoints included: 30-day mortality and freedom from aortic regurgitation/reoperation during follow-up. RESULTS: A total of 66 consecutive patients who underwent AVR (05/2014-03/2017) were evaluated. Patients mean age was 53.5±14.5 years and 74.2% were male. Seventy-three percent of the patients were in New York Heart Association (NYHA) functional class III/IV. The main underlying aortic valve pathology was aortic valve regurgitation in 83.3%, 9.1% aortic stenosis and combination of both in 7.6%. A tricuspid or bicuspid aortic valve was observed in 48.5% and 43.9%, respectively, whereas 7.6% showed a functional unicuspid aortic valve. Intraoperative results revealed endoscopy as a helpful tool, where second time cross-clamp was avoided in most (58, 87.9%) of patients. Thirty-day mortality was 3.0%. During follow-up (28±10 months), 2 patients required re-operation due to recurrent aortic valve regurgitation. CONCLUSIONS: The present analysis showed, that intraoperative aortic valve endoscopy is a helpful tool to evaluate AVR before weaning from bypass. This easy-to-use tool gives real-time information about the intraoperative result and might provide additional guidance to achieve optimal results after AVR.

Safety and Efficiency of Percutaneous Dilatational Tracheostomy With Direct Bronchoscopic Guidance for Thoracic Transplant Recipients.

BACKGROUND: Percutaneous dilatational tracheostomy (PDT) is the standard airway access in critically ill patients who require prolonged mechanical ventilation. However, the literature lacks reports about the effectiveness and safety of this procedure in thoracic organ transplant recipients, who have increased risks of bleeding and infection. METHODS: We retrospectively reviewed the records of subjects who underwent thoracic organ transplantation at our institution between January 2004 and March 2011 followed by PDT (using the Ciaglia Blue Rhino technique with direct bronchoscopic guidance). RESULTS: From a total of 312 thoracic transplant recipients, we identified 93 (29.8%) subjects with PDT. Of these, 79 had undergone double lung transplant, 11 had undergone heart transplant, 2 had undergone combined heart-lung transplant, and 1 had undergone combined heart-kidney transplant. Mean age was 49.5 ± 11.2 y, and 58% of subjects were female. The mean time from intubation to PDT was 3.7 ± 3.4 d, and mean time from transplant to PDT was 12.6 ± 28.3 d. Thirty-two subjects (34.4%) underwent PDT after re-intubation. Thirty-nine subjects were receiving renal replacement therapy (41.9%), and 28 had a coagulopathy (30.1%). Moderate but not significant bleeding was observed in 3 subjects. There were no major complications during PDT procedures. Forty-five subjects (48.4%) could be weaned successfully from the ventilator and the tracheostoma could be removed. Forty-eight subjects (51.6%) died due to sepsis, multi-organ failure, or transplant failure. No procedure-related deaths were noted. There were no significant late complications. Among the 45 who survived their stay in the ICU, the functional and cosmetic outcomes of PDT were excellent. CONCLUSIONS: PDT can be safely performed on patients with acute respiratory failure after thoracic organ transplantation. Therefore, we recommend the use of this technique for prolonged airway management in these patients.