Direct Cannulation of Ascending Aorta versus Standard Femoral Artery Cannulation in Acute Aortic Dissection Type A.

BACKGROUND: During surgery for ascending aortic dissection, the dissected ascending aorta itself has traditionally been rejected as a cannulation option. The purpose of this study is to prove that direct cannulation of the ascending aorta in patients operated for acute aortic dissection type A (AADA) is at least as effective and safe as classic femoral cannulation. METHODS AND RESULTS: Between September 2008 and January 2015, we operated on 117 patients with AADA through median sternotomy. Cannulation was accomplished in 32 cases (27%) through the femoral artery (group A), and in 85 patients (73%) through the dissected ascending aorta (group B). Moderate hypothermic circulatory arrest with bilateral antegrade cerebral perfusion was used in 108 patients (92%). The mean time of circulatory arrest was 17 minutes (range: 9-52 minutes). The 30-day mortality rate was 22% (7 patients) in group A, and 18% (15 patients) in group B (P = not significant). Temporary neurologic dysfunction (TND) including postoperative confusion, delirium, or agitation occurred in four patients (13%) in group A, and four patients (5%) in group B (P = not significant). The incidence of permanent neurologic dysfunction (stroke) was 9% (3 patients) in group A and 3% (3 patients) in group B. CONCLUSIONS: The direct cannulation of the ascending aorta is a safe alternative for patients with AADA, offering the opportunity for antegrade cerebral perfusion. It is easy to perform, reliable, and associated with acceptable early results.

Mitral valve restoration using the No-React(R) MitroFix™: a novel concept.

BACKGROUND: Mitral Valve Repair (MVRP) has been shown to be significantly superior to Mitral Valve Replacement (MVR). Since the majority of repairs involve the Posterior Mitral Leaflet (PML) and not the Anterior Mitral Leaflet (AML), the monocuspidalisation of the Mitral Valve (MV) can be achieved with a bio-posterior leaflet that imitates a closed PML. This approach may have the benefit of restoring the competence of the MV without reducing its effective orifice area. METHODS: We have used a new concept and device, the MitroFixTM, to correct MV regurgitation due to pathology of the PML. The device comes with functional sizers both of which have identical shape and size. This allows the surgeon to pre-test the success of the restoration. From December 2006 to October 2011, 51 MitroFixTM devices were implanted at three institutions. RESULTS: The mean age of the patients (32 males and 19 females) was 67.7 years. 37 of them were in NYHA class III or IV and all patients suffered from severe mitral valve regurgitation (MR). 31 patients underwent combined surgery. Successful implantation of the MitroFix™ device was performed in 51/53 patients.Mean cross-clamp time was 63.6 min (range: 29-118 min). Six patients had additional reconstructive procedures of the AML (chordae transfer, neo-chordae, triangular resection). At discharge, 33 patients showed no MR in the TTE and 17 patients exhibited trivial (I) or moderate (II) MR. The mean gradient was 4.0 mmHg and mean EOA was 2.52cm^2 (range: 1.5-4.0cm2). All patients were classified as being in NYHA class I or II. CONCLUSION: The MitroFixTM Mitral Valve Restoration Device is a new concept that offers an effective treatment of MR. The restoration of the mitral valve with the MitroFix™ device offers the advantage of preserving the AML and providing good coaptation with a prosthetic PML. Importantly, this preliminary evaluation indicates a mean effective orifice area ( EOA ) of 2.5cm2 in MV receiving a MitroFix™ device, witch is higher than EOA resulting from MVR or MVRP. The present study has also shown that severe regurgitation due to ischemic/rheumatic MR, endocarditis and complex prolapse of the PML are clear candidates for correction with the MitroFix™. Larger studies and a longer follow up period are needed to validate these promising results.

Brain natriuretic peptide--a reliable parameter for the effectiveness of cardiac resynchronization therapy after coronary artery bypass grafting.

OBJECTIVES: Brain natriuretic peptide (BNP) is a valuable marker in heart failure and its therapy, for example cardiac resynchronization therapy (CRT). So far, one finding which is indicative for CRT is dyssynchrony of ventricular contraction obtained by echocardiography. The aim of this study was to show that BNP is also a helpful marker to help decide whether CRT is useful for patients after CABG. METHODS: Forty-two patients with a poor ejection fraction (<35%) underwent elective CABG. Twenty-eight of them received permanent biventricular stimulation for seven days after surgery. Before and on the first, third, seventh and tenth day after surgical treatment, the following parameters were established: left ventricular function obtained by transthoracic echocardiography, myocardium-specific enzymes (such as CK and CKMB), ECG and BNP. RESULTS: There was a very good correlation between the preoperative ejection fraction and BNP (r2=0.98, P<0.005). Patients who had received CRT after CABG had BNP levels similar to preoperative data on postoperative day 7. This decrease of the BNP values in the CRT-group is in accord with an increased left ventricular function as obtained by echocardiography. The control group, which had not received CRT, showed significantly higher BNP levels. CONCLUSIONS: Therefore, we conclude that BNP is a good marker to evaluate CRT in patients undergoing CABG. An extraordinary rise of the BNP level should lead to early therapeutic consequences like CRT. The significantly lower BNP level of the patients with heart failure who received CRT indicates a better prognosis.