Unicuspid aortic valve: Case series and review.

A unicuspid aortic valve is a very rare valvular lesion. Its physical manifestations vary and are associated with other cardiovascular abnormalities such as aortic stenosis/insufficiency and aortopathy. Echocardiography remains the modality of choice, with computerized tomography or cardiac magnetic resonance used as adjunctive imaging. Herein, we present a case series of three patients with unicuspid aortic valves treated at our institution, with a focus on 2D and 3D echocardiographic imaging.

Left ventricular remodeling after mitral valve repair and papillary muscle approximation.

BACKGROUND: Mitral valve repair with papillary muscle approximation (MVr-PMA) for severe secondary mitral regurgitation (MR) decreases MR recurrence compared with MVr alone. This study assessed the effects of MVr-PMA on left ventricular (LV) remodeling and shape, systolic function and strain mechanics. METHODS: Forty-eight patients who underwent MVr-PMA for severe secondary MR and had follow-up echocardiograms available for review were identified. Student's t-test, linear regression modeling, and receiver-operating characteristic curves were used in the statistical analyses. RESULTS: Median follow-up time was 14.9 months. MVr-PMA was associated with significant LV reverse remodeling with a smaller LV end-diastolic diameter, Systolic Sphericity Index, and interpapillary muscle distance at follow-up. Nine patients (18.8%) experienced moderate recurrent MR. When compared to recurrent MR patients at follow-up, those with durable MVr-PMA had a greater LV ejection fraction (32.8 vs. 22.0%, P=0.03), a smaller end-diastolic diameter (59.6 vs. 67.3 mm, P=0.03), Systolic Sphericity Index (0.35 vs. 0.47, P=0.03), and end-systolic interpapillary muscle distance (16.3 vs. 21.1 mm, P=0.03). A durable MVr-PMA also resulted in stable global longitudinal strain when compared with pre-operative values, while the recurrent MR group experienced a further decline (no recurrent MR: -8.4 vs. -7.5%; recurrent MR: -8.2 vs. -5.4%; P<0.05). A pre-operative LV end-diastolic diameter ≥ 64 mm was a discriminative predictor of MR recurrence (sensitivity=100%, specificity=51%, AUC=0.756, P=0.02). CONCLUSIONS: A durable MVr-PMA confers improved LV geometry and function, and stable LV mechanics. The extent of baseline LV remodeling identifies patients at risk for recurrent MR.

Erythropoietin derivate improves left ventricular systolic performance and attenuates left ventricular remodeling in rats with myocardial infarct-induced heart failure.

BACKGROUND: It has been reported that erythropoietin (EPO) attenuates ischemia-induced damage in a variety of tissues. It is unknown whether EPO alters the left ventricular (LV) remodeling process after ischemic insult. Accordingly, we tested the potential benefits of carbamylated EPO (CEPO) on LV remodeling in rats with myocardial infarction (MI). METHODS: MI was induced by coronary artery ligation in adult male Sprague-Dawley rats. One hour after surgery, rats were randomly assigned to 1 of 2 groups: MI plus placebo injections (placebo, n = 21) and MI plus CEPO injection (CEPO, n = 22). CEPO (10 µg/kg) or placebo was given via tail vein in a blinded fashion daily for the first 3 days, followed by twice a week subcutaneous injection for 6 weeks. Sham surgery was performed in another group of rats (n = 18) without coronary artery ligation. Cardiac function was assessed by echocardiography, hemodynamic, and in vivo and ex vivo LV pressure-volume relationship measurements 6 weeks after MI. RESULTS: In comparison to placebo-treated rats, CEPO significantly improved LV geometry (LV end systolic dimension: 8.6 ± 0.8 vs. 9.6 ± 1.0 mm; LV end systolic volume: 404 ± 83 vs. 516 ± 122 µL, both P < 0.05). CEPO therapy also reduced the decline of systolic function (fractional shortening: -3.7% ± 1.7% vs. -10.9% ± 2.3%; Emax 0.46 ± 0.20 vs. 0.25 ± 0.08 mm Hg/s, both P < 0.05). Passive diastolic properties of the LV were minimally improved by leftward shift in the ex vivo end diastolic pressure-volume relationship. CONCLUSIONS: CEPO administration 1 hour after acute MI improves systolic performance and may attenuate the LV remodeling process. Further studies to determine the mechanism of CEPO responsible for its beneficial effects and optimize dosing and timing regimens are warranted.

Long-term effects of B-type natriuretic peptide infusion after acute myocardial infarction in a rat model.

INTRODUCTION: The effects of exogenous B-type natriuretic peptide (BNP) on postmyocardial infarction (MI) are not known. We tested the hypothesis that in vivo infusion of BNP would improve cardiac function and affect left ventricular (LV) remodeling in an experimental model of MI. METHODS: MI was induced by coronary ligation in rats and confirmed by echocardiography. 19 rats were randomized to 1 of 3 groups: sham (n = 7), MI + saline (n = 5), MI + BNP (400 ng.kg(-1).minute(-1)) (n = 7). Infusions were delivered for 7 days via venous catheters tunneled to an infusion pump. Rats were followed for 8 weeks. Echocardiography, hemodynamics, histology, and in vivo and ex vivo pressure-volume relationships were examined. RESULTS: LV systolic pressure, LV dP/dtmax, and infarct size improved with BNP treatment versus control MI group (132 +/- 4 vs.110 +/- 2 mm Hg, 8097 +/- 317 vs. 5816 +/- 378 mm Hg/s, 19.3% +/- 1.6% vs. 23.3% +/- 1.9%, respectively; all P < 0.05). Ex vivo end-diastolic pressure-volume relationship demonstrated reduced diastolic dysfunction after BNP therapy (P < 0.05 vs. control MI). Serum BNP levels confirmed delivery of BNP. CONCLUSIONS: We demonstrate beneficial effects on LV function and decreased LV remodeling with BNP infusion in an experimental model of acute MI.

Tricuspid regurgitation and in-hospital outcomes after transcatheter aortic valve replacement in high-risk patients.

BACKGROUND: The prognostic impact of tricuspid regurgitation (TR) following transcatheter aortic valve replacement (TAVR) is uncertain, and the management of patients with severe aortic stenosis and significant TR undergoing TAVR is unclear. METHODS: Retrospective study investigating the role of TR severity on hospital outcomes in high risk patients with severe aortic stenosis undergoing TAVR. RESULTS: A total of 174 participants were included in the present study. The median age was 84 years and 48% were women. The median (IR) STS score was 7.3 (4.7-13.6). The pre-procedural mean (SD) aortic valve area (AVA) was 0.69 (0.2) cm2 and the average (SD) peak and mean gradients were 71 [23]/42 [15] mmHg. Pre TAVR, 28.7% of patients had significant (moderate or severe) TR. Significant TR pre-TAVR increased the risk of in-hospital cardiovascular (CV) and all-cause and mortality [adjusted relative risk (RR) (95% CI): 14.67 (1.35-159.51) and 5.09 (1.14-22.72), respectively], and those with severe TR post-TAVR had longer hospital stay [median (IR): 9.9 (2.9-17.0) days]. No improvement or worsened TR (greater than mild) post-TAVR was associated with higher CV and all-cause mortality [adjusted RR (95% CI): 21.5 (1.81-255.96) and 8.19 (1.67-40.29), respectively]. Right ventricular systolic pressure (RVSP) was independently associated with TR severity pre and post TAVR. CONCLUSIONS: Significant TR was common among patients undergoing high risk TAVR, and is associated with increased in hospital mortality and longer hospital stay. Patients with elevated RVSP and persistent moderate or severe TR after TAVR are at higher risk of in hospital death.

Transthoracic versus intra-operative transesophageal echocardiography in right heart assessment.

METHODS: Fifty-four patients who had combined mitral and tricuspid valve surgery were included. Right heart measurements were performed in the TTE apical 4-chamber (A4C) and RV inflow views, and TEE mid-esophageal 4-chamber (ME4C) and transgastric RV inflow views at end-diastole. Spearman correlation coefficients (r) were applied to test for associations between the imaging modalities. RESULTS: The mean age was 65 years and 39% were male. All patients had ≥ moderate tricuspid regurgitation (TR), and a secondary/functional etiology was present in 89%. The median TAd and RV basal (RVd) diameters in the TTE-A4C view measured 37 mm [interquartile range (IQR), 34-44] and 43 mm (IQR, 40-51), respectively. The TTE-A4C TAd strongly correlated with the TEE-ME4C measurement (r=0.72), with an overestimation of 1 mm (IQR, -2 to 4) by TEE (P<0.01). For RVd, the TTE-A4C measurement correlated moderately with the TEE-ME4C view (r=0.61), underestimating the RVd by -1 mm (IQR, -4 to 3.3) (P<0.01). No correlation was observed between TAPSE measured by TTE and TEE (r=0.22, P=0.13). CONCLUSIONS: Intra-operative TEE may reliably quantitate TA and RV size and geometry. The current findings are best interpreted as hypothesis-generating for future validative studies.

Cardiac improvement during mechanical circulatory support: a prospective multicenter study of the LVAD Working Group.

BACKGROUND: Myocardial recovery after left ventricular assist device (LVAD) support has been reported. The LVAD Working Group Recovery Study was a prospective multicenter trial to assess the incidence of myocardial recovery in patients bridged to cardiac transplantation. METHODS AND RESULTS: After LVAD implantation, patients were evaluated with the use of rest echocardiograms with partial LVAD support and cardiopulmonary exercise testing. Dobutamine echocardiography with hemodynamic measurements was performed in those patients with left ventricular ejection fraction >40% during resting studies. Histological analysis was performed on myocardial samples taken at LVAD implantation and explantation. Sixty-seven LVAD patients with heart failure participated in the study. After 30 days, significant improvement occurred in left ventricular ejection fraction (17+/-7% versus 34+/-12%; P<0.001) and reductions in left ventricular end-diastolic diameter (7.1+/-1.2 versus 5.1+/-1.1 cm; P<0.001) and left ventricular mass (320+/-113 versus 194+/-79 g; P<0.001) compared with before LVAD. Thirty-four percent of patients had left ventricular ejection fraction >40% with partial device support. Left ventricular ejection fraction decreased over time to pre-LVAD measurement by 120 days. Peak VO2 improved with mechanical support (13.7+/-4.2 versus 18.9+/-5.5 mL/kg per minute, 30 versus 120 days; P<0.001). Tissue analysis revealed significant reductions in myocyte size, collagen content, and cardiac tumor necrosis factor-alpha. Six subjects (9%) underwent LVAD explantation for recovery. CONCLUSIONS: Cardiac function improves significantly after device implantation. Although cellular recovery and improvement in ventricular function are observed, the degree of clinical recovery is insufficient for device explantation in most patients with chronic heart failure.

Mitral Valve and Subvalvular Repair for Secondary Mitral Regurgitation: Rationale and Clinical Outcomes of the Papillary Muscle Sling.

Secondary mitral regurgitation (MR) is a common finding in patients with dilated cardiomyopathy, and it is associated with poor outcomes. It is the result of incomplete systolic closure of the mitral valve (MV) as a consequence of left ventricular dilatation, papillary muscle displacement with impaired systolic shortening, and mitral leaflet tethering. MV surgery may be performed in cases of significant secondary MR despite guideline-directed medical therapy. However, MV repair, which is most commonly performed with an undersized ring annuloplasty, is associated with a 30-60% recurrence of moderate or greater MR at mid-term follow-up. To improve MV repair durability, several adjunctive subvalvular procedures have been proposed, one of which is the addition of papillary muscle approximation utilizing a papillary muscle sling. Recent studies comparing the outcomes of a conventional undersized ring annuloplasty with a MV repair utilizing a papillary muscle sling have reported a significant reduction in recurrent moderate or severe MR, greater left ventricular reverse remodeling, and improved MV apparatus geometry with the addition of the papillary muscle sling. We present a comprehensive review of the pathophysiology of secondary MR, and the rationale and clinical outcomes of MV repair with papillary muscle sling placement for the treatment of secondary MR.

Emergent Surgical Embolectomy for Massive Pulmonary Embolism Causing Intraoperative Cardiac Arrest.

BACKGROUND: A massive pulmonary embolism (PE) is associated with high mortality once cardiac arrest occurs. Surgical embolectomy is indicated in patients who have massive PE. CASE REPORT: A 62-year-old male emergently underwent surgical embolectomy after sustaining an intraoperative cardiac arrest caused by a massive PE during an open reduction with internal fixation of a closed comminuted midshaft tibia fracture. Postoperatively, the patient developed pulmonary hypertension and acute renal failure. He was treated with aerosolized epoprostenol for right ventricular strain secondary to pulmonary hypertension. He survived the hospital course and was discharged without any other major complications. CONCLUSION: Surgical embolectomy is a viable option for massive PE, and aerosolized epoprostenol can be used as adjuvant treatment for right ventricular strain secondary to acute pulmonary hypertension.

Mitral valve repair and subvalvular intervention for secondary mitral regurgitation: a systematic review and meta-analysis of randomized controlled and propensity matched studies.

BACKGROUND: Combining a ring annuloplasty (Ring) with a mitral subvalvular intervention (Ring + subvalvular) in patients with secondary mitral regurgitation (MR) may improve mitral valve (MV) repair durability. However, the outcomes of this strategy compared with a Ring only, have not been clearly defined. METHODS: A systematic review and meta-analysis was performed utilizing randomized controlled and propensity matched studies which compared a Ring + subvalvular versus Ring MV repair for the treatment of secondary MR. Risk ratio (RR), weighted mean difference (MD), and the 95% confidence interval (CI) were calculated by the Mantel-Haenszel and inverse-variance methods, for clinical outcomes and echocardiographic measures of follow-up MR, left ventricular (LV) reverse remodeling, and MV apparatus geometry. RESULTS: Five studies were identified, with a total of 397 patients. Baseline characteristics were similar between groups, and all patients had moderate to severe secondary MR, with the vast majority in the setting of ischemic cardiomyopathy. A Ring + subvalvular repair consisted of papillary muscle approximation (n=2), papillary muscle relocation (n=2), or secondary chordal cutting (n=1). Follow-up ranged from 10.1 (mean range =0.25-42) to 69 [interquartile range (IQR) =23-82] months. When compared with Ring only at last follow-up, a Ring + subvalvular MV repair was associated with: (I) a smaller MR grade (MD =-0.44, 95% CI -0.69 to -0.19; P=0.0005); (II) a reduced risk of moderate or greater recurrent MR (RR =0.43, 95% CI, 0.27-0.66; P=0.0002); (III) a smaller mean LV end-diastolic diameter (MD =-3.56 mm, 95% CI -5.40 to -1.73; P=0.0001) and a greater ejection fraction (MD =2.64%, 95% CI, 0.13-5.15; P=0.04); and, (IV) an improved MV apparatus geometry. There were no differences in operative mortality, post-operative morbidity, or follow-up survival between surgical approaches. CONCLUSIONS: When compared with Ring only, a Ring + subvalvular MV repair is associated with greater LV reverse remodeling and systolic function, less recurrence of moderate or greater MR, and an improved geometry of the MV apparatus at short and mid-term follow-up.

Outcomes of minimally invasive double valve surgery.

BACKGROUND: Double valve surgery is associated with an increased peri-operative morbidity and mortality. A less invasive right thoracotomy approach may be a viable alternative to median sternotomy surgery in these higher-risk patients. METHODS: We retrospectively analyzed the baseline demographics, operative characteristics, and post-operative outcomes of patients who underwent minimally invasive double valve surgery between January 2009 and December 2011 at our institution. RESULTS: The cohort consisted of 117 patients, of which 68 (58.1%) were female. The mean age was 73±11 years, and the mean left ventricular ejection fraction was 52±11%. There were 43 (36.8%) patients with a history of congestive heart failure, 45 (38.5%) with chronic obstructive pulmonary disease, and 5 (4.3%) had a history of chronic kidney disease. The patients underwent primary (90.6%) or re-operative (9.4%) double valve surgery, which consisted of 50 (42.7%) aortic valve replacement and mitral valve repair, 31 (26.5%) mitral and tricuspid valve repair, 18 (15.4%) aortic and mitral valve replacement, 17 (14.5%) mitral valve replacement with tricuspid valve repair, and 1 (0.9%) aortic valve replacement with tricuspid valve repair. Post-operatively, there were 40 (34.2%) cases of prolonged ventilation, 9 (7.7%) acute kidney injury, 6 (5.1%) re-operations for bleeding, 1 (0.9%) cerebrovascular accident, and 15 (12.8%) cases of atrial fibrillation. The mean total hospital length of stay was 12±12 days, with an in-hospital mortality of 2 (1.7%). CONCLUSIONS: A minimally invasive right thoracotomy approach to primary or re-operative double valve surgery is feasible, may be utilized with acceptable peri-operative morbidity and mortality.

Minimally invasive valve surgery in high-risk patients.

The use of minimally, or less invasive, approaches to cardiac valve surgery has increased over the past decade. Because of its less traumatic nature, early studies in lower risk patients demonstrated the approach to be associated with an enhanced recovery, increased patient satisfaction, and good operative outcomes. With time, despite a steep learning curve, surgeons expanded this approach to perform more complex procedures, and include patients with more co-morbidity. The aim of this publication is to review the current literature involving the use of minimally invasive valve surgery (MIVS) in higher-risk patients.

Hybrid repair of aortic arch aneurysms: a comprehensive review.

Open total arch replacement (TAR) has become safer with refinements in cerebral protection techniques. The frequent extension of aortic arch aneurysms into the descending thoracic aorta customarily requires a two-staged conventional elephant trunk procedure, carrying relatively high mortality and morbidity risks and high rates of rupture in the interval between the two open surgeries. The technical demands and invasive nature of TAR has therefore precluded many high-risk patients from being surgical candidates for aneurysm repair. As a result, hybrid techniques and approaches to the aortic arch have become common since the adoption of thoracic endovascular aortic repair (TEVAR) and advancement in the commercial grafts that are available. The results of hybrid aortic arch repairs have been encouraging, though with higher rates of re-interventions than TAR and variable reported rates of stroke and spinal cord ischemia. The aim of this publication is to review the current literature on hybrid repair of aortic arch aneurysms.

Staged percutaneous coronary intervention followed by minimally invasive mitral valve surgery versus combined coronary artery bypass graft and mitral valve surgery for two-vessel coronary artery disease and moderate to severe ischemic mitral regurgitation.

BACKGROUND: The optimal treatment for concomitant two-vessel coronary artery disease (CAD) and moderate to severe ischemic mitral regurgitation (IMR) remains unclear. We compared the results of a staged percutaneous coronary intervention followed by minimally invasive mitral valve surgery (PCI+MIVS) versus combined coronary artery bypass graft and mitral valve surgery (CABG+MVS) in this population. METHODS: All consecutive patients with two-vessel CAD and moderate to severe IMR, who underwent PCI+MIVS or CABG+MVS at our institution between February 2009 and April 2014, were retrospectively evaluated. RESULTS: There were nine patients identified who underwent PCI+MIVS, and 15 who underwent CABG+MVS, with a mean age of 71±7, and 70±7 years, respectively (P=0.86). The remaining baseline characteristics were similar between both groups, with the exception of a higher prevalence of pre-operative clopidogrel administration (78% versus 27%, P=0.03) and left anterior descending plus left circumflex CAD (78% versus 27%, P=0.03), in those who underwent PCI+MIVS. The PCI+MIVS approach was associated with decreased mean cardiopulmonary bypass (111±41 versus 167±49 min, P=0.01) and aortic cross-clamp (79±32 versus 129±35 min, P=0.003) times, and less median number of intraoperative packed red blood transfusions {2 [interquartile range (IQR), 0-2] versus 3 units (IQR, 1-4), P=0.05}, when compared with CABG+MVS. The rate of mitral valve repair, postoperative complications, 30-day mortality, and 1-year survival did not differ between the surgical approaches. CONCLUSIONS: PCI+MIVS for two-vessel CAD and moderate to severe IMR is feasible, and associated with satisfactory outcomes, as compared with CABG+MVS.

Outcomes of a hybrid approach of percutaneous coronary intervention followed by minimally invasive aortic valve replacement.

BACKGROUND: In patients requiring coronary revascularization and aortic valve replacement, a combined approach of percutaneous coronary intervention followed by minimally invasive aortic valve replacement may be a viable treatment strategy. METHODS: The outcomes of 123 consecutive patients with significant coronary artery and aortic valve disease, who underwent percutaneous coronary intervention followed by elective minimally invasive aortic valve replacement between February 2009 and April 2014, were retrospectively evaluated. RESULTS: The cohort consisted of 80 males and 43 females, with a mean age of 75.7±8.1 years. Drug-eluting stents were used in 69.9% of the patients, and 64.2% were on dual anti-platelet therapy at the time of aortic valve replacement. Within a median of 39 days (IQR 21-64), 83.7% of the patients underwent primary and 16.3% underwent re-operative minimally invasive aortic valve replacement. Post-operatively, there was 1 (0.8%) cerebrovascular accident, 1 patient (0.8%) required a re-operation due to bleeding, and 2 (1.6%) developed acute kidney injury. Thirty-day mortality occurred in 2 (1.6%) patients. Follow-up was available for all of the patients, and at a mean follow-up period of 14.3±12.5 months, 4 (3.3%) had an acute coronary syndrome, and 1 (0.8%) required a repeat target vessel revascularization. The actuarial survival rate at 1- and 3-year was 92.7% and 89.4%, respectively. CONCLUSIONS: In a select group of patients with coronary artery and aortic valve disease, a combined approach of percutaneous coronary intervention followed by minimally invasive aortic valve replacement can be safely performed with excellent short-term and midterm outcomes.

Percutaneous coronary intervention followed by minimally invasive valve surgery compared with median sternotomy coronary artery bypass graft and valve surgery in patients with prior cardiac surgery.

BACKGROUND: In patients with prior cardiac surgery requiring re-operative coronary and valve surgery, a hybrid approach of percutaneous coronary intervention followed by minimally invasive valve surgery (PCI + MIVS) may be an alternative to the standard median sternotomy coronary artery bypass and valve surgery (CABG + valve). METHODS: The outcomes of patients with prior cardiac surgery, presenting with coronary artery and valvular disease, who underwent PCI + MIVS (N=39) were retrospectively compared with those who underwent CABG + valve (N=28) via a repeat median sternotomy, between February 2009 and April 2014. RESULTS: The mean age for the PCI + MIVS versus CABG + valve group was 75±9 and 72±11 years (P=0.54), respectively. The baseline characteristics were similar between groups, with the exception of a greater prevalence of 1-vessel coronary artery disease and clopidogrel or dual antiplatelet therapy at the time of surgery in the PCI + MIVS group, and more 3-vessel coronary artery disease in those undergoing CABG + valve surgery. The PCI + MIVS approach was associated with a decreased aortic cross-clamp (94 vs. 131 minutes, P=0.001) and cardiopulmonary bypass (128 vs. 190 minutes, P<0.001) times, fewer intraoperative packed red blood transfusions (1.3 vs. 3.8 units, P=0.001), shorter intensive care unit length of stay (41 vs. 71 hours, P<0.001), and decreased incidence of prolonged mechanical ventilation (12.8% vs. 35.7%, P=0.03), re-intubation (2.6% vs. 17.9%, P=0.04), when compared with CABG + valve. The thirty-day and two-year mortality were similar, being 7.7% vs. 7.1% (P=0.66), and 12.8% vs. 10.7% (P=0.55), in the PCI + MIVS vs. CABG + valve group, respectively. CONCLUSIONS: Hybrid PCI + MIVS in patients with prior cardiac surgery is associated with shorter operative times and intensive care unit length of stay, less need for intraoperative blood cell transfusions, decreased use of mechanical ventilation, and similar short-term and follow-up survival, when compared with CABG + valve surgery via median sternotomy. Randomized trials and multicenter registries are needed to further evaluate this approach.

Hybrid approach of percutaneous coronary intervention followed by minimally invasive mitral valve surgery: a 5-year single-center experience.

BACKGROUND: The current study evaluated the safety and feasibility of staged ("hybrid") percutaneous coronary intervention (PCI) followed by isolated minimally invasive mitral valve (MV) surgery [PCI + minimally invasive mitral valve surgery (MIMVS)], for patients with concomitant coronary artery and MV disease. METHODS: A total of 93 patients who underwent PCI + MIMVS for coronary artery and MV disease between February 2009 and April 2014 were retrospectively analyzed. RESULTS: There were 54 (58.1%) men and 39 (41.9%) women. The mean age was 73±8 years, and all patients had severe mitral regurgitation. PCI was performed for single-vessel coronary artery disease in 40 (43%) patients, two-vessel in 49 (52.7%), and three-vessel in 4 (4.3%). Within a median of 48 days (IQR, 18-71) after PCI, 78 (83.9%) patients underwent primary valve surgery, and 15 (16.1%) underwent re-operative valve surgery, with 56 (60.2%) having MV replacement, and 37 (39.8%) having MV repair. Sixty-five (69.9%) patients were being treated with dual anti-platelet therapy at the time of surgery. The median number of transfused intra-operative red blood cell units was 1 (IQR, 0-2), and the intensive care unit and hospital lengths of stay were 46 hours (IQR, 27-76) and 8 days (IQR, 5-11), respectively. Post-operatively, there was 1 (1.1%) cerebrovascular accident, 2 (2.2%) patients developed acute kidney injury, and 4 (4.3%) required a re-operation for bleeding. Thirty-day mortality occurred in 4 (4.3%) patients. At a mean follow-up of 15.3±13.2 months, 3 (3.4%) patients required target-vessel revascularization. The survival rate was 89% and 85% at 1 and 3 years, respectively. CONCLUSIONS: In patients with concomitant coronary artery and MV disease, PCI + MIMVS can be safely performed and is associated with good short-term and follow-up outcomes.

Aortic valve replacement in patients with a left ventricular ejection fraction ≤35% performed via a minimally invasive right thoracotomy.

BACKGROUND: We evaluated the outcomes of patients with aortic valve pathology in the setting of a left ventricular ejection fraction ≤35% who underwent minimally invasive aortic valve replacement (AVR), with or without concomitant mitral valve (MV) surgery. METHODS: All minimally invasive AVR in patients with a left ventricular ejection fraction ≤35%, performed via a right thoracotomy for aortic stenosis or regurgitation between January 2009 and March 2013, were retrospectively evaluated. The operative characteristics, perioperative outcomes, and 30-day mortality were analyzed. RESULTS: There were 75 patients identified: 51 who underwent isolated AVR, and 24 who had combined AVR plus MV surgery for moderate to severe mitral regurgitation. In patients undergoing MV surgery, there were 22 (91.7%) MV repairs [ring annuloplasty =7 (37.5%), transaortic edge-to-edge repair =15 (62.5%)], and 2 (8.3%) replacements. No patient required conversion to sternotomy for inadequate surgical field exposure. The median total mechanical ventilation time and intensive care unit length of stay were 14 (IQR, 8-20) and 42 hours (IQR, 26-93 hours) in the isolated AVR group, and 16.5 hours (IQR, 12-61.5 hours) and 95.5 hours (IQR, 43.5-159 hours) in the AVR plus MV surgery group, respectively. The most common post-operative complication was new-onset atrial fibrillation, which occurred in 15 (29.4%) isolated AVR and 4 (16.7%) AVR plus MV surgery patients. The median hospital length of stay and 30-day mortality was 7 days (IQR, 5-12 days) and 1 (2%) in the isolated AVR group, and 10.5 days (IQR, 5-21 days) and 1 (4.3%) for AVR plus MV surgery. CONCLUSIONS: In patients with aortic valve pathology in the setting of a left ventricular ejection fraction ≤35%, minimally invasive AVR can be performed, with or without concomitant MV surgery, with a low morbidity and mortality.

Mitral Valve Replacement With Sapien 3 Transcatheter Valve in Severe Mitral Annular Calcification.

Transcatheter valve implantation in the mitral position with severe calcific mitral stenosis has been described in patients who are at an increased risk for conventional mitral valve surgical procedures. We report the direct deployment of the Sapien 3 valve in the mitral position with severe mitral annular calcification through a sternotomy in an arrested heart in two cases.