Features of degenerative mitral valve prolapse in the North East of China: repair characteristics, and short-term follow-up results.

BACKGROUND: We aimed to assess the clinical and echocardiographic characteristics of patients who underwent surgery for degenerative mitral valve prolapse (MVP) in our center, and its relation to outcomes. METHODS: We enrolled 117 consecutive patients from North-East China with an echocardiographic diagnosis of MVP related mitral regurgitation (MR) between April 2018 and November 2019. A complexity scoring system was used for valve anatomy, and patients were re-evaluated at 3-6 months after surgery. RESULTS: Most patients (57.3%) were 40-59 years old. Ejection fraction was <60% in one third, and pulmonary hypertension was present in 64.3% of operated patients. Etiology was myxomatous in 58.9%, with flail as main lesion. Leaflet involvement was posterior in 59.8% patients, anterior in 32.5%, bileaflet in 6%, and commissural in 25.6%. Lesion score was intermediate in >50% of patients, and myxomatous lesions scored higher compared to fibroelastic deficiency (FED). Degree of MR left atrial volume and estimated wedge pressure were significantly higher in intermediate and complex lesions. Repair was performed in 93/101 patients (95.8% success rate). No in-hospital major adverse events, nor deaths at follow-up were reported. Residual MR was ≤ mild in 86.7% of patients at follow-up and was associated with FED etiology and complex lesions. CONCLUSIONS: Compared to Western countries, in our sample of Chinese population degenerative severe MR occurred in younger patients. The MVP lesion characteristics are similar, can be accurately detected by non-invasive preoperative evaluation, allowing predictable results. Advanced tailored repair techniques allow excellent immediate and short-term results regardless of the underlying complexity.

Can Perceval sutureless valve reduce the rate of patient-prosthesis mismatch?†.

OBJECTIVES: The aim of this study is to compare the theoretical incidence of patient-prosthesis mismatch (PPM) in patients undergoing a sutureless or a sutured aortic valve replacement using an exact statistical matching. METHODS: Between May 2012 and March 2016, 65 patients with severe symptomatic aortic stenosis underwent a sutureless aortic valve replacement with the Perceval bioprosthesis in 2 centres. Moreover, 177 aortic valve replacements with conventional sutured bioprosthesis were performed between August 2003 and September 2015. Perceval and sutured patients were 1:1 exactly matched for sex and body surface area (BSA), resulting in 62 couples (sutureless: BSA 1.77 ± 0.16 m 2 , female 62.9% vs sutured: BSA 1.77 ± 0.15 m 2 , female 62.9%). RESULTS: After matching, the indexed effective orifice area was 1.50 ± 0.18 cm 2 /m 2 and 0.81 ± 0.19 cm 2 /m 2 in the sutureless and the sutured group, respectively ( P < 0.001). No PPM occurred in patients who received a Perceval bioprosthesis ( n = 62). In the sutured group ( n = 62), 38 patients (61.3%) developed a PPM, which was moderate in 41.9% ( n = 26) and severe in 19.4% ( n = 12) ( P < 0.001). CONCLUSIONS: The indexed effective orifice area of the sutureless group was significantly larger than in the sutured one. The incidence of PPM with the conventional sutured biprosthesis was 61.3%, while it decreases to 0% in the sutureless group. No PPM was reported in the sutureless valve group. Therefore, the Perceval sutureless valve provides larger effective orifice areas compared to the sutured conventional bioprosthesis and could be considered as a good option to reduce the risk of a PPM.

Takotsubo Cardiomyopathy Following Pericardiocentesis After Aortic Valve Repair and Ascending Aorta Replacement.

Takotsubo cardiomyopathy is a reversible cardiomyopathy, which generally developes in menopausal women and is characterized by left ventricle dysfunction with apical ballooning in the absence of coronary artery disease. It is often triggered by a stressful event, and its clinical presentation resembles acute anterior myocardial infarction. This condition is a rare adverse event of cardiac operations, and only a few cases are described in the literature, especially after mitral valve operations. We report the case of a 69-year-old man who underwent aortic valve repair and ascending aorta replacement, followed by pericardial effusion 6 months later, requiring pericardiocentesis resulting in Takotsubo cardiomyopathy.

Aortic sutureless Perceval valve for small root in concomitant mitral valve replacement.

Conventional valves have a sewing ring that reduces the effective orifice area for a given valve size. In patients with small aortic roots, the implantation of a stented conventional prosthesis can be very difficult or may lead to patient-prosthesis mismatch. In the case of the Sorin Perceval sutureless aortic valve, concomitant mitral valve replacement (MVR) is an exclusion criterion because the latter valve's rigid ring may interfere with the self-expandable stent anchorage of the Sorin Perceval sutureless valve, or cause it to become distorted. The case is reported of very small, 77-year-old woman with severe aortic valve stenosis, severe mitral regurgitation and asymmetric hypertrophy of the left ventricle with systolic anterior motion. The patient underwent MVR and concomitant off-label implantation of the Sorin Perceval S sutureless valve due to the extremely small size of the aortic annulus. Echocardiography performed on completion of surgery, at discharge from hospital and at after a four-month follow up, documented a normal mitral prosthesis position and function, a normal aortic prosthesis position, and mild central regurgitation in both valves.

[Cardiovascular involvement in Erdheim-Chester syndrome: clinical and therapeutic implications]. / Coinvolgimento cardiovascolare nella sindrome di Erdheim-Chester: aspetti clinici e terapeutici.

Erdheim-Chester disease (ECD) is a rare form of non-Langerhans' cell histiocytosis of unknown etiology and its incidence is constantly increasing. ECD is characterized by a xantomatous or xanthogranulomatous infiltration of various tissues by foamy histiocytes surrounded by fibrosis. ECD is characterized by multi-organ involvement and is generally associated with a poor prognosis with a median survival of 32 months after diagnosis. Cardiovascular involvement concerns mainly the thoraco-abdominal aorta and pericardium. Less frequently, infiltration affects the myocardial tissue, especially the right atrium, and the valvular endocardium. Recently, the involvement of the vena cava has also been described. The diagnosis of ECD is made by the identification of foamy histiocytes CD68 positive and CD1a/S100 negative embedded in a polymorphic inflammatory tissue on biopsy. Despite the adoption of several therapeutic strategies until now prognosis has remained poor. Interferon-α can be considered the first line therapy, but its effects on central nervous system and cardiovascular localization have been shown to be often poor. In this context a combined treatment with the anti-TNFα monoclonal antibody infliximab and methotrexate seems to be effective and well tolerated.

Vacuum-assisted venous drainage in extrathoracic cardiopulmonary bypass management during minimally invasive cardiac surgery.

The diffusion of minimally invasive cardiac surgery (MICS) during open-heart surgery has increased the use of assisted venous drainage support for cardiopulmonary bypass (CPB). Peripheral cannulation with small cannulae and vacuum-assisted venous drainage (VAVD) during MICS has been adopted in our institution since 1998. After the Heartport technique (HP) experience, the trans-thoracic clamp technique is now currently used. The aim of this study is to report our experience with extrathoracic CPB with VAVD application (on CPB) during open-heart MICS. From October 1999 to June 2006, 193 patients underwent MICS. Thirty-seven (19.2%) patients were treated with the HP--13 (35%) with robotic technology and 156 (80.8%) with trans-thoracic aortic clamping (TTAC). Mean age was 39 years (range: 12-77), and 114 patients (59.1%) were female. A total of 128 patients (66.3%) underwent mitral valve surgery, 57 (29.6%) atrial septal defect closure, five (2.6%) cardiac mass removal, and three (1.5%) tricuspid valve repair. Four patients (2.0%) had a previous cardiac procedure. Peripheral CPB was established with a standard coated circuit. A 14 Fr arterial cannula was inserted into the right jugular vein and positioned at the atrial/superior vena cava junction. A 21 or 28 percutaneous femoral cannula, depending on body surface area, was inserted in the femoral vein and an arterial cannula in the right femoral artery. Gravitational drainage was combined with VAVD. To improve the safety and effectiveness of this technique, we monitored the pressure on each venous cannula and in the reservoir. The mean CPB time was 74.8 +/- 30 min (TTAC) and 119 +/- 48 min (HP); mean aortic clamping time was 51 +/- 19 min (TTAC) and 73 +/- 29 min (HP). We did not record any neurological complication. Two patients (1.0%), one from each group, were converted to sternotomy. Three patients (1.5%) underwent re-exploration for bleeding. In-hospital mortality was 0.5% (N = 1) (HP). Mechanical ventilation time and intensive care unit stay were comparable to those recorded with conventional sternotomy. In conclusion, we found that extrathoracic CPB and VAVD during trans-thoracic clamping is a safe, simple, and effective technique for MICS. However, there is a potential risk of haemolysis and air embolism, which can be prevented with vacuum monitoring, and with the addition of gravitational drainage to reduce vacuum pressure.