"First-in-man" MitraClip via pulmonary vein access through a right mini-thoracotomy in a patient with agenesis of the inferior vena cava.

AIMS: Transcatheter mitral valve repair has become a promising alternative treatment option for severe symptomatic mitral regurgitation in patients at high risk for open heart surgery with heart-lung bypass. METHODS AND RESULTS: We describe the first successful procedure of mitral clipping through a right lateral mini-thoracotomy via the right upper pulmonary vein in a patient with an agenesis of the inferior vena cava. The set-up of the MitraClip system on a separate table located at 70¡ on the right side of the patient and the fixation of the steerable sheath at the entry into the thorax with constant posterior pressure enabled clip implantation using the usual manoeuvres with marked reduction of the mitral insufficiency. CONCLUSIONS: The access through the right upper pulmonary vein using the usual right mini-thoracotomy enabled a successful mitral clipping even in the absence or occlusion of the inferior vena cava.

How should I treat dislocation of a TAVI SAPIEN prosthesis into the left ventricle?

BACKGROUND: Despite the technical advancements of the transcatheter aortic valve implantation (TAVI) procedure, valve embolisation into the left ventricle remains a challenging situation requiring expedited management through the Heart Team. INVESTIGATION: The advantages and pitfalls of an interventional transfemoral approach, a transapical extraction of the dislocated prosthesis or the conversion to open heart surgery have to be balanced depending on the overall situation and the specific characteristics of the patient. DIAGNOSIS: A transfemoral approach would be the first choice for most TAVI implanters. We discuss the different options and present an elegant solution solving this challenging situation, leading to a good immediate and long-term outcome. MANAGEMENT: Attempts at pulling the prosthesis out of the ventricle using a balloon remained unsuccessful. After grasping of the prosthesis with a goose-neck snare, the valve was pulled into the annulus. A second SAPIEN XT prosthesis was implanted and fixed the first prosthesis within the annulus. After post-dilatation, there was a good result without relevant gradient and minimal aortic regurgitation.

Systemic stress hormone response in patients undergoing open heart surgery with or without cardiopulmonary bypass.

BACKGROUND: Cardiopulmonary bypass often causes a stress hormonal response with subsequent changes in hemodynamics and organ perfusion. Leptin, an adipocyte-derived factor, has been proposed to play a role in systemic inflammation. We examined perioperative release of leptin and cortisol in patients undergoing open heart surgery with or without cardiopulmonary bypass. METHODS: Forty-nine patients were enrolled in this prospective study. Conventional coronary artery bypass grafting was performed in 19 patients (ONCABG; group I), and heart valve surgery in 15 patients (group II). Fifteen patients (group III) received off-pump coronary artery bypass grafting (OPCABG). Blood samples were collected preoperatively and for as long as 72 hours postoperatively. Plasma levels of leptin and cortisol were measured by enzyme-linked immunosorbent assay. RESULTS: Leptin serum levels decreased during the operation, reaching 73.2% of the baseline in group I, 85.3% in group II, and 38.9% in group III (p < 0.05), 2 hours postoperatively. Thereafter, leptin levels increased gradually to 218.6% of the baseline in group I and 313.7% in group II 24 hours after the operation (p < 0.01). However, patients in the OPCABG group showed only a moderate increase in serum leptin levels. Plasma cortisol levels rose to a maximum of 532.9% of baseline in group I, 526.4% in group II, and 280% in group III 12 hours postoperatively (p < 0.01). CONCLUSIONS: Open heart surgery is associated with acute perioperative changes in plasma levels of neurohormonal stress factors leptin and cortisol. A different pattern of leptin and cortisol release was observed in patients operated on without cardiopulmonary bypass.

The Edwards MIRA heart valve prosthesis: a 2-year study.

BACKGROUND: The Edwards MIRA mechanical heart valve is designed to optimize hemodynamics, reduce thrombogenicity, and avoid mechanical failure with a special hinge mechanism. The purpose of the study was to investigate the clinical performance and postoperative hemodynamic results of the first European patients receiving Edwards MIRA mechanical heart valves. METHODS: From March 1998 to March 1999 a total of 54 Edwards MIRA valves model numbers 3600 (aortic, n = 44) and 9600 (mitral, n = 10) were implanted in 52 (36 male, 16 female; mean age 61 +/- 10.1 years) consecutive patients undergoing mechanical valve replacement in a prospective study. Follow-up of the patients including physical examination, ECG, blood tests, and Doppler were performed prior to discharge, at 6 months, at 1 year, and at least 2 years postoperatively. RESULTS: Through October 2001 a total of 172 follow-up examinations were completed (51 patients at discharge, 46 patients at 6 months, 43 patients at 12 months, 32 patients at 2 years or beyond). All patients were in NYHA class I and II at the 6-month and 2+-year follow-up. All the patients stated an improved quality of life. Hospital mortality was 1.9%. There were no complications related to anticoagulation. Mean international normalized ratio at 6 months was 3.2 (range 1.9 to 4.3); lactate dehydrogenase was slightly increased with 264 +/- 103 U/L on average (normal value 80 to 240 U/L). No signs of valvular dysfunction or paravalvular leakage were observed. Mean pressure gradients were related to valve diameter: after mitral valve replacement (size 27, 29, 31 mm: 4.8, 3.2, 2.1 mmHg); after aortic valve replacement (size 19, 21, 23, 25 mm: 12.1, 13.1, 9.3, 8.2 mmHg). CONCLUSIONS: These preliminary data suggest good hemodynamic function and a low rate of valve-related complications of the Edwards-MIRA mechanical prosthesis.

Long-term effectiveness of operative procedures for stanford type a aortic dissections.

BACKGROUND: The object was to evaluate the long-term effectiveness of strategies for managing the aortic root and distal aorta in type A dissections. METHODS: From 1990 to 1999, 50 patients (32 men (64.07%); 18 women, (36.0%); mean age 57.4 +/- 11.1 years) underwent operation for ascending aortic dissection. Surgical strategies included aortic root replacement with a composite graft (21/50; 42.0%), valve replacement with supracoronary ascending aortic graft (3/50, 6%), and valve preservation or repair (26/50; 52.0%). RESULTS: Overall hospital mortality rate was 18.0%. Follow-up was completed for 47 patients (94.0%) and ranged from 1 month to 10.5 years (mean 28.8 months). Actuarial survival for patients discharged from the hospital was 84% at 1 year, 75% at 5 years, and 66% at 10 years. There was no significant difference between the various procedures regarding mortality, neurological complications, long-term survival, and proximal reoperations. The ascending aorta alone was replaced in 8 of 50 patients (16%), ascending and hemiarch in 30 of 50 patients (60%), and arch and proximal descending aorta in 12 of 50 patients (24%). Hospital mortality (11.5%, 20.0%, and 16.7%, respectively; p > 0.05) and 5- and 10-year survival (p > 0.05) were not statistically dependent on the extension of the resection distally. Residual distal dissection was not associated with a decrease in late survival. With regard to emergency surgery (36/50) there was no significant difference in hospital mortality (p > 0.05) and 5-year survival (p > 0.05) between those who had undergone coronary angiography (19/36; 52.8%) on the day of surgery with those who had not (17/36; 47.2%). CONCLUSIONS: Preservation or repair of the aortic valve can be recommended in the majority of patients with type A dissection. Distal extension of the resection does not increase surgical risk. Residual distal dissection does not decrease late survival. Preoperative coronary angiography may not affect survival in patients undergoing emergency surgery.