RotaFlow and CentriMag extracorporeal membrane oxygenation support systems as treatment strategies for refractory cardiogenic shock.

BACKGROUND: RotaFlow and Levitronix CentriMag veno-arterial extracorporeal membrane oxygenation (ECMO) support systems have been investigated as treatment for refractory cardiogenic shock (CS). METHODS: Between 2004 and 2012, 119 consecutive adult patients were supported on RotaFlow (n = 104) or CentriMag (n = 15) ECMO at our institution (79 men; age 57.3 ± 12.5 years, range:19-78 years). Indications for support were: failure to wean from cardiopulmonary bypass in the setting of postcardiotomy (n = 47) and primary graft failure (n = 26); post-acute myocardial infarction CS (n = 11); acute myocarditis (n = 3); and CS on chronic heart failure (n = 32). RESULTS: A central ECMO setting was established in 64 (53.7%) patients while peripherally in 55 (46.2%). Overall mean support time was 10.9 ± 8.7 days (range:1-43 days). Forty-two (35.2%) patients died on ECMO. Overall success rate, in terms of survival on ECMO (n = 77), weaning from mechanical support (n = 51; 42.8%) and bridge to heart transplantation (n = 26; 21.8%), was 64.7%. Sixty-eight (57.1%) patients were successfully discharged. Stepwise logistic regression identified blood lactate level and CK-MB relative index at 72 h after ECMO initiation, and number of packed red blood cells (PRBCs) transfused on ECMO as significant predictors of mortality (p = 0.011, odds ratio [OR] = 2.48; 95% confidence interval [CI] = 1.11-3.12; p = 0.012, OR = 2.81, 95% CI = 1.02-2.53; and p = 0.012, OR = 1.94; 95% CI = 1.02-5.21; respectively). Central ECMO population had a higher rate of continuous veno-venous hemofiltration (CVVH) need and bleeding events when compared with the peripheral setting. CONCLUSIONS: Patients with a poor hemodynamic status may benefit by rapid insertion of veno-arterial ECMO. The blood lactate level, CK-MB relative index and PRBCs transfused should be strictly monitored during ECMO support.

Intravascular lithotripsy (IVL) enabled the percutaneous closure of a severely calcified paravalvular leak regurgitation following implantation of a self-expandable transcatheter aortic valve: a case report.

Background: Closure of paravalvular leak (PVL) regurgitation after self-expandable (SE) transcatheter aortic valve implantation (TAVI) may be more challenging than after balloon-expandable (BE) valve implantation. Case summary: An 85-year-old woman suffering from long-standing atrial fibrillation and severe symptomatic aortic stenosis underwent SE TAVI (26 mm Evolut™ R®, Medtronic Inc., MN, USA). A total of eighteen months after TAVI she was admitted for congestive heart failure and two-dimensional (2D) transesophageal echocardiography (TEE) color Doppler showed moderate-severe PVL regurgitation due to a long and heavily calcified leak located below the left coronary sinus. The patient was deemed to be at prohibitive surgical risk and a catheter-based PVL closure procedure was planned. A first attempt to cross the PVL from the femoral artery was unsuccessful due to an inappropriate angle between the catheter and the entry site of this hard-to-approach calcified leak. A Terumo hydrophilic guidewire 0.35 inch-260 cm from the right radial artery was then successfully advanced across the leak to the left ventricle (LV); however, of most of the catheters used, only a Glidecath 4-Fr could cross the leak over the hydrophilic wire. The hydrophilic guidewire was replaced with a stiffer guidewire that, after creating a loop in the LV, was advanced across the self-expandable valve into the descending aorta where it was snared and externalized through the left femoral artery, thus creating an arterio-arterial (AA) loop. A 6-Fr Multipurpose guiding catheter was advanced over the exchange wire and the leak was crossed with an additional 0.0014 coronary guidewire (PILOT, Abbott Vascular), predilated with two non-compliant balloon dilatation catheters, and finally, the PVL was engaged with a 3.0 mm × 12 mm Shockwave balloon (Shockwave Medical Inc, Santa Clara, California, USA). Intravascular lithotripsy (IVL) application to this highly calcified leak and the increased support provided by the stiff guidewire finally allowed the progression of the 6-Fr dedicated delivery sheath (ODS III) into the LV. A 5 mm square twist (ST) device (PLD, Occlutech, Helsingborg, Sweden) was successfully deployed within the leak and the final echocardiographic and angiographic control confirmed the effective PVL closure. Discussion: In patients at high surgical risk with moderate to severe regurgitation after SE TAVI due to a hard-to-approach calcified long tract, an extra AA support loop is mandatory during percutaneous PVL closure. Furthermore, IVL application greatly facilitates the progression of the delivery sheath and occluder which is key to a successful procedure.

Multiplane two-dimensional versus real time three-dimensional transesophageal echocardiography in ischemic mitral regurgitation.

OBJECTIVES: Intraoperative three-dimensional (3D) transesophageal echocardiography (TEE) has been suggested to be a valuable technique for the evaluation of the mechanisms of ischemic mitral regurgitation (IMR). Studies comparing multiplane two-dimensional (2D) with 3D TEE reconstruction of the mitral valve using the new mitral valve quantification (MVQ) software are lacking. We undertook a prospective comparison between multiplane 2D and 3D TEE for the assessment of IMR. METHODS: We evaluated echocardiographically 45 patients with IMR who underwent mitral valve surgery in our institution. 2D and 3D TEE examinations followed by a 3D offline assessment of the mitral valve apparatus were performed in all patients. Offline analysis of mitral valve apparatus was conducted with QLAB-MVQ. RESULTS: 3D TEE image acquisitions were performed in a short period of time and were feasible in all patients. Real time 3D TEE imaging was superior to 2D in identifying specific mitral scallops (A1, A3, P1, P3) and commissures. When compared with 2D TEE, 3D offline reconstruction of the mitral valve allows an accurate quantification of the shape and diameters of the mitral annulus. Both approaches provide almost similar values for the tenting area and the coaptation depth. The 3D approach gave the advantage of direct calculation of the leaflets angles, tenting volume, and surface of the leaflets. The interpapillary muscles distance at the level of the papillary muscle head was greater in 2D than in 3D. CONCLUSIONS: 3D TEE imaging provides valuable and complementary information to multiplane 2D TEE for the assessment of patients with IMR.

Mid-term results of bicuspid aortic valve repair guided by morphology and function assessment.

OBJECTIVES: Bicuspid aortic valve (BAV) is frequently associated with aortic insufficiency (AI) due to cusp disease and/or aortic root dilatation. Based on functional classification and morphology, a systematic surgical approach was used for aortic valve repair (AVr). METHODS: From 2004 to 2014, 152 consecutive patients (mean age 55 ± 7 years) with BAV underwent AVr with or without concomitant aortic root surgery. Cusp pathology was treated with central plication in 60 (39.5%) patients, free edge reinforcement in 45 (29.6%), triangular resection in 28 (18.4%) and pericardial patch in 19 (12.5%). Aortic root dilatation was corrected with valve sparing reimplantation in 65 patients. Mean follow-up was 68 ± 36 months. RESULTS: In-hospital death was 1.3%. Overall 5-year survival was 88.6 ± 3.6%. Freedom from recurrent ≥ grade 2 AI requiring reoperation at 5-year was 93 ± 3.1%. Five-year freedom from reintervention was 98.4 ± 1.6%, 93.3 ± 6.4% and 82.6 ± 9.6 in the group of patients treated with AVr and reimplantation technique, AVr and subcommissural plasty and AVr repair alone (log-rank P = 0.005). Commissural orientation <160°, type 2 Siever's BAV and preoperative annulus diameter >29 mm were identified as predictors for recurrent ≥ grade 2 AI. CONCLUSIONS: BAV repair could be achieved with low incidence of recurrent AI, especially when concomitant annulus stabilization was performed. Systematic preoperative morphological and functional characteristics of the aortic valve should be carried out in order to reduce the risk of repair failure.

Elective Aortic Arch Repair: Factors Influencing Neurologic Outcome in 791 Patients.

BACKGROUND: The aim of this study was to determine perioperative factors influencing neurologic outcome in a single-center cohort of patients undergoing elective aortic arch operations. METHODS: From January 2005 to June 2015, 791 consecutive patients received open aortic arch operations with either antegrade selective cerebral perfusion (ASCP) (636 patients [80.4%]) or deep hypothermic circulatory arrest (DHCA) (155 patients [19.6%]). Main indications were degenerative aneurysm (85%) and chronic postdissection aneurysm (9.1%). RESULTS: Hospital mortality (30 days) was 5.3%. Permanent neurologic dysfunction (PND) was observed in 42 patients (5.3%). Significant risk factors for PND appeared to be femoral artery cannulation (p = 0.003), progressive cardiopulmonary bypass (p = 0.001), circulatory arrest (p = 0.001), and ASCP time (p = 0.011). ASCP, in contrast to DHCA, was protective against PND (odds ratio [OR], 0.37; p = 0.003). Temporary neurologic dysfunction (TND) was observed in 49 patients (6.2%). Preoperative transient ischemic attack (TIA) (p = 0.001), progressive EuroSCORE (p = 0.001), left ventricular ejection fraction (LVEF) less than 50% (p = 0.003), and the use of femoral artery cannulation (p = 0.049) showed correlation in the univariate analysis. Stepwise logistic regression indicated TIA (p = 0.002; OR, 3.24) and the EuroSCORE (p = 0.003; OR, 1.23) as independent predictors of TND. CONCLUSIONS: Contemporary elective aortic arch repair can be achieved with low mortality and a low incidence of neurologic dysfunction. ASCP was confirmed to be the safest method of cerebral protection. The extent of aortic arch replacement (apart from the frozen elephant trunk [FET] procedure) was not related to increased rates of TND or PND.

A Comparison of 2 Mitral Annuloplasty Rings for Severe Ischemic Mitral Regurgitation: Clinical and Echocardiographic Outcomes.

Controversies regarding the choice of annuloplasty rings for treatment of ischemic mitral regurgitation still exist. Aim of the study is to compare early performance of 2 different rings in terms of rest and exercise echocardiographic parameters (transmitral gradient, systolic pulmonary artery pressure, and mitral valve area), clinical outcomes, and recurrence of mitral regurgitation. From January 2008 till December 2013, prospectively collected data of patients who underwent coronary artery bypass grafting and undersizing mitral valve annuloplasty for severe chronic ischemic mitral regurgitation at our Institution were reviewed. A total of 93 patients were identified; among them 44 had semirigid Memo 3D ring implanted (group A) whereas 49 had a rigid profile 3D ring (group B). At 6 months, recurrent ischemic mitral regurgitation, equal or more than moderate, was observed in 4 and 6 patients in the group A and B, respectively (P = 0.74). Group A showed certain improved valve geometric parameters such as posterior leaflet angle, tenting area, and coaptation depth. Transmitral gradient was significantly higher at rest in the group B (P < 0.0001). During exercise, significant increase of transmitral gradient and systolic pulmonary artery pressure was observed in group B (P < 0.0001). Mitral valve area was not statistically significantly smaller at rest in between groups (P = 0.09); however, it significantly decreased with exercise in group B (P = 0.01). At midterm follow-up, patients in group B were more symptomatic. In patients with chronic ischemic mitral regurgitation, use of semirigid Memo 3D ring when compared to the rigid Profile 3D may be associated with early improved mitral valve geometrical conformation and hemodynamic profile, particularly during exercise. No difference was observed between both groups in recurrent mitral regurgitation.

Aortic stenosis: insights on pathogenesis and clinical implications.

Aortic stenosis (AS) is a common valvular heart disease in the Western populations, with an estimated overall prevalence of 3% in adults over 75 years. To understand its patho-biological processes represents a priority. In elderly patients, AS usually involves trileaflet valves and is referred to as degenerative calcific processes. Scientific evidence suggests the involvement of an active "atherosclerosis-like" pathogenesis in the initiation phase of degenerative AS. To the contrary, the progression could be driven by different forces (such as mechanical stress, genetic factors and interaction between inflammation and calcification). The improved understanding presents potentially new therapeutic targets for preventing and inhibiting the development and progression of the disease. Furthermore, in clinical practice the management of AS patients implies the evaluation of generalized atherosclerotic manifestations (i.e., in the coronary and carotid arteries) even for prognostic reasons. In counselling elderly patients, the risk stratification should address individual frailty beyond the generic risk scores. In these regard, the co-morbidities, and in particular those linked to the global atherosclerotic burden, should be carefully investigated in order to define the risk/benefit ratio for invasive treatment strategies. We present a detailed overview of insights in pathogenesis of AS with possible practical implications.

Minimally invasive aortic valve surgery.

Aortic valve disease is a prevalent disorder that affects approximately 2% of the general adult population. Surgical aortic valve replacement is the gold standard treatment for symptomatic patients. This treatment has demonstrably proven to be both safe and effective. Over the last few decades, in an attempt to reduce surgical trauma, different minimally invasive approaches for aortic valve replacement have been developed and are now being increasingly utilized. A narrative review of the literature was carried out to describe the surgical techniques for minimally invasive aortic valve surgery and report the results from different experienced centers. Minimally invasive aortic valve replacement is associated with low perioperative morbidity, mortality and a low conversion rate to full sternotomy. Long-term survival appears to be at least comparable to that reported for conventional full sternotomy. Minimally invasive aortic valve surgery, either with a partial upper sternotomy or a right anterior minithoracotomy provides early- and long-term benefits. Given these benefits, it may be considered the standard of care for isolated aortic valve disease.

Open thoracoabdominal aortic aneurysm repair in the modern era: results from a 20-year single-centre experience.

OBJECTIVES: The efficacy and durability of actual treatments (open, endovascular and hybrid) for thoracoabdominal aortic aneurysm (TAAA) repair are not yet completely defined. Open surgical repair using a multi-adjunct (ADJ) approach has been the standard of care for many years and may still be an effective treatment option. This study aimed to assess the outcomes of open TAAA repair since the introduction of the available ADJ. METHODS: From 1994 to 2014, 542 consecutive patients underwent open TAAA repair in our institution, routinely receiving aortic distal perfusion and the other ADJ (either for visceral and spinal cord protection). The aetiology of TAAA was identified to be degenerative in 325 (60%) patients and chronic post-dissection in 160 (29.5%) patients. Other causes such as connective tissue disorders, vasculitis and infective aneurysms were less represented (10.5%). Extensive type I and II repair was required in 128 (23.6%) and 285 (52.6%) patients, respectively. All patients were followed up at 3 and 6 months after surgery and yearly thereafter using computed tomography angiogram. RESULTS: The overall 30-day mortality and paraplegia rates were 8.5 and 4.2%, respectively. Age [odds ratio (OR) 1.07 per year, 95% confidence interval (CI) 1.02-1.13], female gender (OR 2.52, 95% CI 1.27-4.99), urgency (OR 2.78, 95% CI 1.12-6.20) and emergency (OR 3.81, 95% CI 1.00-11.50) emerged as independent risk factors for 30-day mortality. Follow-up was 100% complete (mean 6.32 years). Overall 1-, 5- and 10-year survival was 85.9 ± 1.5, 74.2 ± 2.0 and 61.6 ± 2.5%, respectively. The extent of surgical repair did not significantly influence late hospital death (P = 0.56). For patients surviving the first 30 days, a degenerative aneurysm aetiology negatively impaired long-term survival compared with the other diseases [hazard ratio = 1.66; 95% CI (1.13-2.44)]. Five- and 10-year freedom from reoperation was 86.3 ± 1.8 and 80.7 ± 2.3%, respectively, and 8.5% of patients required aortic reinterventions. CONCLUSIONS: In elective cases, open TAAA repair has to be considered an effective option associated with low necessity of reoperation at follow-up. The extent of aortic resection did not affect long-term mortality. Conversely, survival was mainly determined by patient age and preoperative condition.

Surgical management of aortic root in type A acute aortic dissection: a propensity-score analysis.

OBJECTIVES: Surgical management of the aortic root in type A acute aortic dissection (TAAAD) is controversial. This study compares short- and long-term outcomes of root replacement (RR) versus conservative root management (CR). METHODS: Between 1999 and 2014, 296 patients with TAAAD were treated in our department. The mean age was 63.7 years. Of the total, 69% were male. Ten patients (3%) presented with Marfan syndrome or bicuspid aortic valve. RR was performed in 119 (40%) patients, whereas CR in 177 (60%). Pre- and intraoperative data were stratified according to root management, and treatment bias was addressed by propensity-score (PS) analysis. Independent predictors of hospital and long-term mortality and proximal aortic reoperation were identified using multivariable logistic and Cox regression models. RESULTS: Using PS analysis, we obtain two groups of 82 patients. The matched cohort hospital mortality rate was 21% in the CR group and 26% in the RR group (P = 0.45). The unadjusted comparison showed no statistical difference in early and long-term mortality between the groups. This result was confirmed after standard logistic regression and propensity-adjusted logistic regression. Freedom from proximal aortic reintervention was higher in the RR group (at 7 years RR: 96 ± 3% vs CR: 80 ± 6%, log-rank P = 0.02) and remained high in the matched cohort of patients (at 7 years RR: 98 ± 2 vs CR: 86 ± 6, log-rank P = 0.06). CONCLUSIONS: Conservative and aggressive root management in acute aortic dissection provided similar results for early and late mortality. Nevertheless, a more extensive root intervention appeared to be protective against aortic reintervention.

Total Arch Replacement Versus More Conservative Management in Type A Acute Aortic Dissection.

BACKGROUND: Surgical management of aortic arch in type A acute dissection (TAAD) is controversial. This study compared short-term and long-term outcomes of total arch replacement (TAR) interventions versus more conservative arch management (CAM). METHODS: Between 1997 and 2012, 240 patients underwent TAAD surgery in our institution; 53 (22.1%) received TAR and 187 (77.9%) received CAM. Compared with CAM patients, those undergoing TAR were younger (59.1 vs 64.4 years, p = 0.004) and were less likely to present with cardiogenic shock (3.8 vs 14.4, p = 0.02). Distal site of intimal tear (arch or descending aorta) was predictive of TAR management (odds ratio [OR], 9.1; p < 0.001). RESULTS: Hospital mortality was similar in the groups (24.1% vs 22.6%; p = 0.45), and no other significant differences were observed in terms of major postoperative complications. Age (OR, 1.047; p = 0.007) and cardiopulmonary bypass time (OR, 1.005 per minute; p = 0.05) emerged as independent predictors of hospital death. The TAR management did not affect hospital mortality (propensity score [PS] adjusted OR: 1.51, p = 0.36). On Kaplan-Meier analysis, 7-year survival (TAR, 52.1% ± 0.9% vs CAM, 57.2% ± 4.2%, log-rank p = 0.9) and freedom from aortic re-intervention (TAR, 71.6% ± 1.3% vs CAM, 85.4% ± 3.9%, log-rank p = 0.3) were similar. The PS-adjusted Cox regression showed no relationship between type of arch management and follow-up survival (hazard ratio [HR], 1.001; p = 0.8) or need for re-intervention (HR, 1.507; p = 0.4). CONCLUSIONS: In our experience TAR and CAM were associated with similar hospital mortality and morbidity rates. Nevertheless, the more extensive arch interventions were not protective for long-term survival and freedom from aortic re-intervention. Thus, in TAAD patients TAR remains indicated by site of intimal tear and patient-specific factors.

Aortic Root Replacement With Biological Valved Conduits.

The execution of Bentall procedures using biological valved conduits is expanding owing to the increased incidence of aortic valve and root diseases in the aging population. To review the available data, a systematic search identified 29 studies with a total of 3,298 patients. Although evidence on short-term results suggested favorable outcomes after biological Bentall operations, data beyond 5 years are limited and highlight the urgent need for further investigations with longer follow-up.

Frozen elephant trunk surgery in acute aortic dissection.

OBJECTIVES: Acute aortic dissection is a catastrophic condition, for which emergency surgery is the mainstay of therapy. In approximately 70% of patients who survive surgery, a dissected distal aorta remains, posing a risk of late aneurysmal degeneration, rupture, and malperfusion, and secondary extensive interventions are often required. METHODS: In order to improve the long-term prognosis, a more extensive intervention, the frozen elephant trunk (FET) procedure, has been introduced. This involves the simultaneous replacement of the aortic arch and antegrade stenting of the descending thoracic aorta (DTA). Although FET is assumed to produce total thoracic aortic remodeling by inducing both coverage of secondary entry tears located in the proximal DTA and obliteration of the false lumen at the proximal DTA, its role in patients with acute dissection remains controversial mostly because of its technical complexity and increased risk of paraplegia. RESULTS: Data available in literature show that, after FET interventions, hospital death, stroke, and spinal cord injury occur in 10.0%, 4.8%, and 4.3% of patients with acute dissection, respectively. Available long-term data are sparse but suggest that aortic remodeling with partial or complete thrombosis of the persistent false lumen can be expected in approximately 90% of cases. CONCLUSIONS: The FET technique is a promising approach in patients with acute dissection. Solid long-term data are warranted to validate the assumed short- and long-term benefits, but we believe that thoughtful patient selection criteria remain crucial.

Long-term outcomes after aortic arch surgery: results of a study involving 623 patients.

OBJECTIVES: To assess early and long-term outcomes in a large cohort of patients undergoing open aortic arch surgery. METHODS: From 1996 to 2012, 623 consecutive patients (mean age: 62.8 years) underwent aortic arch interventions in our institution. Of these, 208 (33.4%) presented with an acute aortic syndrome (AAS) and 415 (66.6%) with a chronic aortic pathology (CAP). During the study period, our surgical strategy involved extensive resections of the diseased aortic tissue at elective interventions, and a tear-oriented aortic replacement in patients with acute dissection. More extensive interventions were often performed in younger patients, and in those with connective tissue diseases and bicuspid aortic valves. A total arch replacement was frequently performed (53.3%). Antegrade selective cerebral perfusion was used in all cases. RESULTS: Overall in-hospital mortality was 23.1% in patients with AAS and 11.1% in patients with a CAP; in the same groups, postoperative permanent neurological dysfunction (PND) occurred in 9.6 and 5.6%, respectively. The follow-up was 94.4% complete. For in-hospital survivors, 5- and 10-year survival (%) were 79.4 ± 2.1 and 60.9 ± 3.2, respectively, not influenced by the underlying aortic disease. Cox regression identified age (hazard ratio [HR]: 1.048; P < 0.001), preoperative renal failure (HR: 2.3; P = 0.003), diabetes (HR: 1.805; P = 0.005) and PND (HR: 2.4; P = 0.03) to be independent predictors for the follow-up mortality. Overall, 109 (59% endovascular) aortic reinterventions were performed: 18.3% were proximal and 81.7% distal to the aortic arch. Five- and 10-year freedom from aortic redo (%) were 82.8 ± 1.9 and 77.7 ± 2.6, respectively. Aortic dissection (HR: 1.7; P = 0.03) was the only independent predictor of reoperative surgery at the follow-up. CONCLUSIONS: Aortic arch surgery was associated with satisfactory early and long-term outcomes. Survival was largely determined by patient comorbidities and postoperative PND. While the underlying aortic disease did not affect long-term mortality, chronic dissection was associated with increased need for aortic reinterventions.

The classic elephant trunk technique for staged thoracic and thoracoabdominal aortic repair: long-term results.

OBJECTIVE: The classic elephant trunk (ET) technique has become the standard approach for patients with diffuse aortic disease requiring a staged thoracic and thoracoabdominal aortic repair. The aim of this study was to assess long-term outcomes and predictors for survival after surgical repair of extensive thoracic aortic disease with the ET technique. METHODS: Between 1984 and 2013, 248 consecutive patients were treated in our institution and analyzed retrospectively. Follow-up consisted of outpatient clinic visits including postoperative computed tomography imaging at 3 months and annually thereafter. Second-stage intervention was indicated if the diameter of the descending or thoracoabdominal aorta was greater than or equal to 60 mm, in case of a rapidly growing aneurysm and/or symptoms. RESULTS: Mean age was 65 ± 10 years; 44% were male. After first-stage ET, in-hospital mortality was 8% and permanent neurologic deficits were observed in 2% of patients. Median follow-up after the first stage was 48 months (range, 1-210 months). One hundred twelve patients (45%) underwent second-stage ET. Overall survival after first-stage ET was 75% and 67% at 5 and 10 years, respectively. Survival in patients with second-stage ET was 87%, compared with 65% in the group who did not undergo second-stage ET at the 5-year follow-up (P < .001) and 67% compared with 36% at the 10-year follow-up (P < .001). Predictor for mortality was the absence of second-stage ET (P = .044). CONCLUSIONS: A 2-stage approach for diffuse aortic disease is a safe method. The acceptable mortality at the first stage justifies the use of the classic ET technique and allows subsequent repair of the distal aorta. Long-term survival is increased when both stages are completed.

Surgical management of moderate ischemic mitral valve regurgitation: Where do we stand?

Ischemic mitral regurgitation (IMR) represents a common complication after myocardial infarction. The valve is anatomically normal and the incompetence is the result of papillary muscles displacement and annular dilatation, causing leaflets tethering. Functionally the leaflets present a restricted systolic motion due to tethering forces that displaces the coaptation surface toward the left ventricle apex. The patients present poor left ventricular function at the time of surgery and the severity of the mitral regurgitation increases the risk of mortality. Currently there is general agreement to treat surgically severe IMR nevertheless strong evidences for patient with moderate insufficiency remains poor and proper treatment debated. The most effective surgical approach for the treatment of IMR remains debated. Some authors demonstrated that coronary artery bypass graft (CABG) alone is beneficial in patients with IMR. Conversely, in most patients, moderate IMR will persist or worsen after CABG alone which translate in higher long-term mortality as a function of residual mitral regurgitation severity. A probable reason for this unclear surgical management of functional MR is due to the contemporary suboptimal results of reparative techniques. The standard surgical treatment of chronic IMR is CABG associated with undersized annuloplasty using complete ring. Though, the recurrence of mitral regurgitation remains high (> 30%) because of continous left ventricle remodeling. To get better long term results, in the last decade, several subvalvular procedures in adjunct to mitral anuloplasty have been developed. Among them, surgical papillary muscle relocation represents the most appreciated option capable to restore normal left ventricle geometry. In the next future new preoperative predictors of increased mitral regurgitation recurrence are certainly needed to find an individual time period of treatment in each patient with moderate IMR.

Papillary muscle relocation and mitral annuloplasty in ischemic mitral valve regurgitation: midterm results.

OBJECTIVES: The surgical approach for ischemic mitral regurgitation remains unclear. Many studies are in favor of adding the subvalvular procedure to mitral annuloplasty to reduce recurrent mitral regurgitation. This study reports the clinical and echocardiographic outcomes of papillary muscle relocation combined with mitral annuloplasty. METHODS: From 2003, 115 patients with severe ischemic mitral regurgitation who underwent papillary muscle relocation plus nonrestrictive mitral annuloplasty and coronary artery bypass grafting were retrospective analyzed. Patients' mean age was 52±12.8 years, New York Heart Association class III or IV was 71%, and preoperative left ventricular ejection fraction was 43%±6%. The study end points were New York Heart Association functional class, reversal in left ventricle remodeling, reduction of mean tenting area and mean coaptation depth, freedom from cardiac-related deaths and events, and freedom from recurrent mitral regurgitation. Follow-up data were obtained in all patients and were 100% complete. Mean follow-up was 45±6 months. RESULTS: Five-year freedom from cardiac-related death and events was 91.3%±1.6% and 84%±2.2%, respectively. Recurrent mitral regurgitation more than moderate occurred in 3 patients (2.7%). Reversal in left ventricular remodeling, measured by a change in the end-diastolic and systolic diameter, was observed in our patients (P<.05). The postoperative mean tenting area and mean coaptation depth were 1.1±0.2 cm2 and 0.5±0.2 cm, respectively; 95% of the patients were in New York Heart Association functional class I and II. CONCLUSIONS: In patients with ischemic mitral regurgitation, papillary muscle relocation plus nonrestrictive mitral annuloplasty promotes a significant reversal in left ventricular remodeling, with a considerable decrease in tenting area and coaptation depth. Our approach is a durable method to reduce the recurrence of mitral insufficiency.

Relocation of papillary muscles for ischemic mitral valve regurgitation: the role of three-dimensional transesophageal echocardiography.

OBJECTIVE: The assessment of the mitral valve apparatus (MVA) and its modifications during ischemic mitral regurgitation (IMR) is better performed by three-dimensional (3D) transesophageal echocardiography (TEE). The aim of our study was to carry out nonrestrictive mitral annuloplasty in addition to relocation of papillary muscles (PPMs) oriented by preoperative real-time 3D TEE through the mitral valve quantification dedicated software. METHODS: Since January 2008, a total of 70 patients with severe IMR were examined both before and after mitral valve repair. The mean (SD) coaptation depth and the mean (SD) tenting area were 1.4 (0.4) cm and 3.2 (0.5) cm2, respectively. Intraoperative 3D TEE was performed, followed by a 3D offline reconstruction of the MVA. A schematic MVA model was obtained, and a geometric model as a "truncated cone" was traced according to preoperative data. The expected truncated cone after annuloplasty was retraced. A conventional normal coaptation depth of approximately 6 mm was used to detect the new position of the PPMs tips. RESULTS: Perioperative offline reconstruction of the MVA and the respective truncated cone was feasible in all patients. The expected position of the PPMs tips, desirable to reach a normal tenting area with a coaptation depth of 6 mm or more, was obtained in all patients. After surgery, all parameters were calculated, and no statistically significant difference was found compared with the expected data. CONCLUSIONS: Relocation of PPMs plus ring annuloplasty reduce mitral valve tenting and may improve mitral valve repair results in patients with severe IMR. This technique may be easily and precisely guided by preoperative offline 3D echocardiographic mitral valve reconstruction.

Visceral organ protection in aortic arch surgery: safety of moderate hypothermia.

OBJECTIVES: Although antegrade selective cerebral perfusion (ASCP) provides good brain protection during aortic arch surgery, the issue of distal organ protection during circulatory arrest remains to be clarified. The aim of the study was to retrospectively evaluate the outcome of aortic arch surgery using ASCP at different temperatures, focusing on visceral functions (VFs). METHODS: Three hundred and thirty-four patients underwent elective aortic arch surgery using ASCP from November 1996 to March 2011. Those patients without early postoperative low cardiac output syndrome were included. VFs were evaluated by comparing preoperative and postoperative creatinine, aspartate amino transferase, alanine amino transferase and bilirubin. Univariate and multivariate analysis were performed. RESULTS: Three hundred and four patients represent the cohort of the study. Deeper systemic hypothermia (≤25°C) (Group A) was used in 194 patients (63.8%) and moderate hypothermia (>25°C) (Group B) in 110 patients (36.2%). The 30-day mortality rate was 3.6% in Group B and 5.2% in Group A (P = NS). Permanent neurological deficits occurred in 4 (3.6%) and in 14 patients (7.2%) of Group A and Group B, respectively (P = NS). Postoperative renal insufficiency requiring dialysis occurred in 6 patients (5.4%) in Group A and in 15 patients (7.7%) in Group B, the differences were not statistically significant. Biochemical markers of VFs increased in the postoperative period without differences between groups. At the multivariate analysis, cardiopulmonary bypass time >180 min (odds ratio (OR) = 2.16) was the only significant risk factor for renal dysfunction with or without liver dysfunction, while cardiopulmonary bypass time longer than 180 min (OR = 2.28) and hypothermia higher than 25°C (OR = 0.54) were found to be independently related to liver dysfunction. CONCLUSIONS: Our results confirmed that ASCP with moderate hypothermia at 26°C is a safe method for brain protection. Moreover, during circulatory arrest, moderate hypothermia also offers good protection of visceral organs and it should be preferred for limited periods (<60 min) of visceral ischaemia because it may reduce the systemic inflammatory response and the reperfusion organ injury.