Respect or resect in Barlow disease.

Mitral regurgitation in Barlow disease may still be challenging to be repaired. Most often it involves the posterior leaflet. Many techniques and concepts are currently available; the main goal being to restore a good surface of coaptation. Basic principles such as thorough analysis is still required whatever the approach to assess excess tissue height, width, and prolapse. Nowadays it seems that two different ways of treating mitral prolapse coexist: the nonresection one and the resection one. Both will be discussed and analyzed. Similarly, the use of artificial chordae seems to have a preponderant role to support the free edge and correct a prolapse. Native secondary chord transfer are easy and reliable but seem abandoned by many. Anterior leaflet prolapse is also dealt with and fewer options are available to address this leaflet. Then commissural prolapse is mentioned. It is an important area of the valve which should deserve better treatment than commissuroplasty. Finally, a special entity will be described; mitro annular disjunction. The approach is not or no longer an issue as only good long-term results are important in an era where percutaneous therapy is the only noninvasive technique.

Mitral valve repair with minimally invasive approaches vs sternotomy: A meta-analysis of early and late results in randomized and matched observational studies.

BACKGROUND AND AIM OF THE STUDY: Minimally invasive cardiac surgery (MICS) for mitral valve repair (MVRp) has been increasingly used. This study aimed to evaluate the early and late results of MICS for MVRp vs conventional sternotomy. MATERIALS AND METHODS: A systematic review of randomized controlled trials or observational studies (with matched populations) comparing MICS and conventional MVRp reporting any of the following outcomes: mortality, MVRp failure, complications, blood transfusion, readmission within 30 days after discharge, long-term reoperation for mitral regurgitation, operative times, mechanical ventilation time, intensive care unit (ICU) stay, or hospital stay. The pooled treatment effects were calculated using a random-effects model. RESULTS: Ten studies involving 6792 patients (MICS: 3396 patients; Conventional: 3296 patients) met the eligibility criteria. In the pooled analysis, MICS significantly reduced the risk for blood transfusion (odds ratio [OR], 0.654; 95% confidence interval [CI] 0.462-0.928; P = .017) and readmission within 30 days after discharge (OR, 0.615; 95% 0.456-0.829; P = .001). MICS was associated with a significantly longer cross-clamp time (mean difference 14 minutes; 95% CI, 7.4-21 minutes; P < .001), CPB time (24 minutes; 95% CI, 14-35 minutes; P < .001), and total operative time (36; 95% CI, 15-56 minutes; P < .001), but a significantly shorter ICU stay (-8.5; 95% CI -15; -1.8; P = .013) and hospital stay (-1.3, 95% CI -2.1; -0.45; P = .003). This meta-analysis found no significant difference regarding the risk of in-hospital and long-term mortality, nor complications. CONCLUSIONS: Despite longer operative times, MICS for MVRp reduces ICU and hospital stay, as well as readmission rates and the need for transfusion.

Incremental value of normal adenosine perfusion cardiac magnetic resonance: Long-term outcome.

BACKGROUND: The purpose of the study was to determine the long-term prognostic value of normal adenosine stress cardiac magnetic resonance imaging (CMR) in patients referred for evaluation of myocardial ischemia. METHODS: We reviewed 300 consecutive patients (age 65 ± 11 years, 74% male) with suspected or known coronary disease and normal wall motion who had undergone adenosine stress CMR negative for ischemia and scar. Most patients were at intermediate risk of coronary artery disease. The end points studied were all causes of mortality and major adverse cardiac events, including cardiac death, myocardial infarction, revascularization, and hospitalization for unstable angina. RESULTS: During a mean follow-up of 5.5 years (mean = 5.4 ± 1.1), 16 patients died because of various causes (cardiac death in 5 patients). Three patients had a nonfatal myocardial infarction, 7 patients were hospitalized for revascularization, and 11 were medically treated for unstable angina. The annual cardiac event rate was 1.3% (0.78% in the first 3 years and 1.9% between the fourth and sixth years). The predictors of major adverse cardiac events in a multivariate analysis model were as follows: advanced age (hazard ratio [HR] 1.15, 95% confidence interval [95% CI] 1.02-1.30), diabetes (HR 17.5, 95% CI 2.2-140), and the habit of smoking (HR 5.9, 95% CI 1.0-35.5). For all causes of mortality, the only predictor was diabetes (HR 11.4, 95% CI 1.76-74.2). Patients with normal stress CMR had an excellent outcome during the 3 years after the study. The cardiac event rate was higher between the fourth and sixth years. CONCLUSION: Over a 5.5-year period, a low event rate and excellent prognosis occurred in patients with normal adenosine stress CMR. Low- to intermediate-risk patients with a normal CMR are at low risk for subsequent cardiac events.

Complex Iatrogenic Dissection Complicating Thoracic Endovascular Aneurysm Repair.

BACKGROUND: To report one the most feared complication of thoracic endovascular aneurysm repair (TEVAR); a retrograde aortic dissection who can involve the aortic arch or ascending aorta, which require commonly coextensive open surgical repair. CASE REPORTS: We report 2 cases of combined retrograde and antegrade dissection after endovascular treatment of an aneurysm of the descending aorta. In both cases, a dissection was identified at short-term follow-up; which required open surgical repair in one case and an additional endovascular treatment for the second case. CONCLUSIONS: The incidence of extensive iatrogenic dissection after TEVAR is relatively low, open repair should be considered as a primary option in some cases with limited aortic dilatation to avoid such life-threatening complications.

Coronary artery bypass surgery with or without mitral valve annuloplasty in moderate functional ischemic mitral regurgitation: final results of the Randomized Ischemic Mitral Evaluation (RIME) trial.

BACKGROUND: The role of mitral valve repair (MVR) during coronary artery bypass grafting (CABG) in patients with moderate ischemic mitral regurgitation (MR) is uncertain. We conducted a randomized, controlled trial to determine whether repairing the mitral valve during CABG may improve functional capacity and left ventricular reverse remodeling compared with CABG alone. METHODS AND RESULTS: Seventy-three patients referred for CABG with moderate ischemic MR and an ejection fraction >30% were randomized to receive CABG plus MVR (34 patients) or CABG only (39 patients). The study was stopped early after review of interim data. At 1 year, there was a greater improvement in the primary end point of peak oxygen consumption in the CABG plus MVR group compared with the CABG group (3.3 mL/kg/min versus 0.8 mL/kg/min; P<0.001). There was also a greater improvement in the secondary end points in the CABG plus MVR group compared with the CABG group: left ventricular end-systolic volume index, MR volume, and plasma B-type natriuretic peptide reduction of 22.2 mL/m(2), 28.2 mL/beat, and 557.4 pg/mL, respectively versus 4.4 mL/m(2) (P=0.002), 9.2 mL/beat (P=0.001), and 394.7 pg/mL (P=0.003), respectively. Operation duration, blood transfusion, intubation duration, and hospital stay duration were greater in the CABG plus MVR group. Deaths at 30 days and 1 year were similar in both groups: 3% and 9%, respectively in the CABG plus MVR group, versus 3% (P=1.00) and 5% (P=0.66), respectively in the CABG group. CONCLUSIONS: Adding mitral annuloplasty to CABG in patients with moderate ischemic MR may improve functional capacity, left ventricular reverse remodeling, MR severity, and B-type natriuretic peptide levels, compared with CABG alone. The impact of these benefits on longer term clinical outcomes remains to be defined.

Reversal of severe heart failure with a continuous-flow left ventricular assist device and pharmacological therapy: a prospective study.

BACKGROUND: We have previously shown that a specific combination of drug therapy and left ventricular assist device unloading results in significant myocardial recovery, sufficient to allow pump removal, in two thirds of patients with dilated cardiomyopathy receiving a Heartmate I pulsatile device. However, this protocol has not been used with nonpulsatile devices. METHODS AND RESULTS: We report the results of a prospective study of 20 patients who received a combination of angiotensin-converting enzymes, ß-blockers, angiotensin II inhibitors, and aldosterone antagonists followed by the ß2-agonist clenbuterol and were regularly tested (echocardiograms, exercise tests, catheterizations) with the pump at low speed. Before left ventricular assist device insertion, patient age was 35.2 ± 12.6 years (16 male patients), patients were on 2.0 ± 0.9 inotropes, 7 (35) had an intra-aortic balloon pump, 2 were hemofiltered, 2 were ventilated, 3 had a prior Levitronix device, and 1 had extracorporeal membrane oxygenation. Cardiac index was 1.39 ± 0.43 L · min⁻¹ · m⁻², pulmonary capillary wedge pressure was 31.5 ± 5.7 mm Hg, and heart failure history was 3.4 ± 3.5 years. One patient was lost to follow-up and died after 240 days of support. Of the remaining 19 patients, 12 (63.2) were explanted after 286 ± 97 days. Eight had symptomatic heart failure for ≤6 months and 4 for >6 months (48 to 132 months). Before explantation, at low flow for 15 minutes, ejection fraction was 70 ± 7, left ventricular end-diastolic diameter was 48.6 ± 5.7 mm, left ventricular end-systolic diameter was 32.3 ± 5.7 mm, mV(O2) was 21.6 ± 4 mL · kg⁻¹ · min⁻¹, pulmonary capillary wedge pressure was 5.9 ± 4.6 mm Hg, and cardiac index was 3.6 ± 0.6 L · min⁻¹ · m⁻². Estimated survival without heart failure recurrence was 83.3 at 1 and 3 years. After a 430.7 ± 337.1-day follow-up, surviving explants had an ejection fraction of 58.1 ± 13.8, left ventricular end-diastolic diameter of 59.0 ± 9.3 mm, left ventricular end-systolic diameter of 42.0 ± 10.7 mm, and mV(O2) of 22.6 ± 5.3 mL · kg⁻¹ · min⁻¹. CONCLUSIONS: Reversal of end-stage heart failure secondary to nonischemic cardiomyopathy can be achieved in a substantial proportion of patients with nonpulsatile flow through the use of a combination of mechanical and pharmacological therapy.

Tricuspid valve replacement: The old and the new.

Tricuspid regurgitation is a frequent and serious condition but tricuspid valve (TV) surgery, that may be a valve replacement when a repair is not feasible, is rarely performed. Recent development of transcatheter TV interventions offers new options for those high-surgical risk patients, especially TV replacement for patients who are not eligible for transcatheter TV repair. In this review, we describe indications and outcome after surgical TV replacement, and devices available or in development for transcatheter TV replacement.

Outcome of consistent guideline-based tricuspid management in patients undergoing degenerative mitral regurgitation correction.

Objectives: Despite coherent guidelines, management of functional tricuspid regurgitation (FTR) consequences on outcome in the context of degenerative mitral regurgitation (DMR) remains controversial due to lacking series of large magnitude with rigorous application of tricuspid guidelines and strict long-term echocardiographic follow-up. Thus, we aimed at gathering such a cohort to examine outcomes of patients undergoing DMR surgery following tricuspid surgery guidelines. Methods: All consecutive patients with isolated DMR 2005-2015 operated on with baseline FTR assessment and tricuspid annulus diameter measurement were identified. Operative complications, postoperative tricuspid regurgitation incidence, and survival were assessed overall and stratified by guideline-based tricuspid annuloplasty (TA) indication (severe FTR or tricuspid annulus diameter ≥40 mm). Results: Among 441 patients with DMR undergoing mitral repair (66 ± 13 years, 30% female, ejection fraction 66 ± 10%, systolic pulmonary artery pressures 39 ± 12 mm Hg) followed 6 [3-9] years, patients with TA (n = 234, 53%) had generally similar presentation versus without TA (n = 207, 47%; all P ≥ .2) except for more atrial fibrillation and larger left ventricle (both P ≥ .0003). Patients with TA showed longer bypass time, more maze procedures (all P ≤ .001), but hospital stay, renal-failure, pacemaker implantation, and operative mortality (overall 0.9%) were comparable (all P ≥ .2). Postoperative incidence of moderate/severe FTR (0% at 1 year) became over time greater among patients without TA (5-year 8% [4%-13%] vs 3% [1%-11%] and 10-year 10% [6%-16%] vs 4% [1%-16%], P = .01). Survival (95% confidence interval) throughout follow-up was 85% (77%-89%) at 10 years, with hazard ratio 0.57 (0.29-1.10), P = .09. for patients with TA versus without. Conclusions: In this large surgical DMR cohort, guideline-based FTR management was safe and effective. While long-term mortality did not reach significance, postoperative incidence of moderate/severe FTR, overall low, was nevertheless greater in patients who did not appear to require TA at surgery and linked to tricuspid annular dimension. Thus, future multicenter prospective cohorts with long-term follow-up are warranted to re-examine thresholds for TA performance and impact on survival.

Delayed pericardial effusions: life-threatening complication presenting up to 100 days after chest trauma.

Stab wounds are often managed conservatively with simple wound assessment and closure. However, even apparently minor thoracic wounds can cause delayed pericardial effusions presenting as life-threatening tamponade sometimes days, weeks or months later. Patients suffering stab wounds to the chest should receive echocardiographic follow-up to exclude delayed pericardial effusions.

Non-physiologic closing of bi-leaflet mechanical heart prostheses requires a new tri-leaflet valve design.

Mechanical heart valve prostheses are based on older designs without changes during the last 40 years. Today, there is an unmet need for less thrombogenic mechanical prostheses. Analysis of the relationship between flow characteristics and thromboembolic complications is possible using numerical and biomolecular flow studies that have shown that the reverse rather than the forward flow is responsible for local platelet activation and thrombosis. After peak flow, leaflets experience flow deceleration and the leaflets are still widely open when the flow becomes zero. The closure of the valve starts with the onset of reverse flow. Therefore, the valve closes extremely fast with most of the leaflet traveling angle occurring in <10 ms with excessively high reverse flow velocities. The pivoting spaces, so-called "Hot Spots" should be eliminated to prevent pathologic shear stress that result in thrombosis. A novel tri-leaflet valve combines favorable hemodynamics with the durability of mechanical heart valve. This valve closes within 60 ms, much slower than bi-leaflet valves and similar to the closing mode of a tissue valve. Micro-particle image velocimetry did not show critical regions of flow stagnation and zones of excessive shear in the pivoting region suggesting low potential for thrombogenic events that should allow to avoid long-term anticoagulation.

Quadruple valve replacement for carcinoid heart disease.

Cardiac surgery for symptomatic carcinoid heart disease in conjunction with adjunctive therapy is being increasingly shown to improve the long-term outlook of patients with carcinoid heart disease. Herein is reported the case of a female patient with heart failure, secondary to carcinoid heart disease affecting all four cardiac valves, who successfully underwent quadruple valve replacement in the same sitting. The patient made an uneventful postoperative recovery, and had an excellent quality of life at the one-year follow up examination.

Tricuspid Regurgitation: Predicting the Need for Intervention, Procedural Success, and Recurrence of Disease.

Interest in tricuspid valve pathology has rapidly expanded in response to reported poor clinical outcome for functional tricuspid regurgitation and the limited indications and options for treatment. In the past few years, different transcatheter technologies have emerged as alternatives to conventional surgery to serve this untreated high-risk population. In this review, the authors explore the indications for intervention in tricuspid regurgitation according to current guidelines, the published research to support the expansion of these indications including the role of transcatheter interventions, and the risk factors for therapy failure, which may help define the appropriate patient population for treatment.

Propensity score analysis of early and late outcome after redo off-pump and on-pump coronary artery bypass grafting.

BACKGROUND: The purpose of this study was to compare early and late results of redo-CABG with (redo-ONCAB) and without (redo-OPCAB) cardiopulmonary bypass. METHODS: From April 2001 to September 2006 redo-CABG was performed in 110 patients (redo-ONCAB=50 and redo-OPCAB=60). Applying the propensity score, 43 OPCAB patients were matched with 43 ONCAB patients. The mean EuroScore was 5+/-4.7 and 5+/-3.4 for redo-ONCAB and redo-OPCAB, respectively (p=0.5). The number of diseased coronary arteries was 3+/-0.5 and 2+/-0.8 in redo-ONCAB and redo-OPCAB, respectively (p<0.01). RESULTS: Twelve patients underwent OPCAB through anterior thoracotomy while the rest of the patients (n=74) underwent median sternotomy. Mean number of grafts performed was 3+/-0.8 in redo-ONCAB and 2+/-0.6 in redo-OPCAB (p<0.05). The need for postoperative insertion of intra-aortic balloon pump (IABP) was higher (p=0.02) in redo-ONCAB (n=9, 21%) than redo-OPCAB (n=1, 2%). The duration of postoperative ventilation was 55+/-98.7 h for redo-ONCAB and 10+/-12.8h for redo-OPCAB (p=0.008). No differences were found in the incidence of other postoperative complications. The 30-day mortality rate was 6.9% for redo-ONCAB (n=3) and 2.3% redo-OPCAB (n=1; p=NS). Mean follow-up for redo-ONCAB was 30+/-21.3 months (range 0.1-63 months) and that of redo-OPCAB was 37+/-19.2 months (0.1-62.5 months). Actuarial survival at 5 years was 87+/-5.5% for redo-ONCAB and 95+/-3.2% for redo-OPCAB (p=0.17). Event-free survival was 71+/-8.0% for redo-ONCAB and 78+/-7.2% for redo-OPCAB (p=0.32). CONCLUSION: OPCAB is an acceptable strategy in selected patients requiring redo-CABG. Employing a strategy of OPCAB for those patients with 2 or fewer lesions and ONCAB for those with more diffuse disease, redo-OPCAB and redo-ONCAB have similar early and late outcomes.

Right-Sided Heart Structural and Functional Remodeling in Mitral Regurgitation Secondary to Mitral Valve Prolapse.

Preoperative evaluation of the mitral valve but also of tricuspid valve and right ventricular (RV) function is mandatory in primary mitral regurgitation (MR) secondary to mitral valve prolapse (MVP). Tricuspid annulus (TA) diameter plays a pivotal role in the surgical decision to perform preventive combined tricuspid valve annuloplasty. Cardiac magnetic resonance (CMR) is the gold standard for the assessment of RV size and function. Based on 70 consecutive patients (17 women; mean age 64 ± 12) with severe MR secondary to MVP referred for CMR, we sought to assess RV geometry and function and TA dimensions and to study the interaction between TA dilatation and right-sided cardiac chambers. Frequency of RV dilatation, RV systolic dysfunction, and TA dilatation (TA diameter ≥ 40 or 21 mm/m²) were 11%, 51%, and 49%, respectively. Left ventricular (LV) end-diastolic volume index was the only independent predictor of RV dilatation. Presence of symptoms, larger LV end-diastolic volume index, and LV ejection fraction <60% were independently associated with RV dysfunction. Absolute TA diameter was 36 ± 6 mm and TA diameter index was 20 ± 3 mm/m². Reproducibility TA diameter measurement was excellent (coefficient of variation ≤10%). TR velocity >220 cm/s (odds ratio = 20.17; [3.57 to 113.90]; p = 0.001 and right atrial volume index ≥ 38 ml/m² (odds ratio = 13.44; [3.57 to 50.54]; p = 0.0001) were independent predictors of TA diameter ≥40 or 21 mm/m². CMR provides accurate right-sided cardiac chambers assessment and may help surgical planning of concomitant tricuspid valve annuloplasty before mitral valve repair in severe MR secondary to MVP. In conclusion, TA dilatation, RV enlargement, and dysfunction are related to pulmonary pressure and left-sided cardiac chambers enlargement, reflecting the long-standing consequences of severe MR.

"Respect when you can, resect when you should": A realistic approach to posterior leaflet mitral valve repair.

OBJECTIVE: Avoiding resection to treat posterior leaflet prolapse has become popular to repair degenerative mitral regurgitation. We never subscribed to such simplification but advocated an alternative approach based on the "respect when you can, resect when you should" concept. The present study reviewed posterior leaflet prolapse in degenerative disease with the aim to expose the 10-year experience with this surgical policy, in particular long-term outcomes such as survival, recurrent/severe mitral regurgitation, and reoperation. METHODS: From January 2005 to December 2015, 701 consecutive patients with severe mitral regurgitation underwent mitral valve repair in 2 distinct institutions. Mitral regurgitation was degenerative in 441 patients, of whom the 376 with posterior leaflet prolapse constituted the study population. Patients were followed up by echocardiograms until December 2017. Longitudinal data stratified by institution were analyzed by mixed-effects models. Outcome measures were analyzed by Kaplan-Meier test. RESULTS: Patients with posterior leaflet prolapse (24.7% isolated P2 and 75.3% P2 associated with other segments) were aged 65.8 ± 13 years, and 70.5% were male. Median follow-up was 61.1 months. There were 3 hospital deaths (0.8%). Reoperation was necessary in 7 patients (1.9%). After 1, 5, and 10 years, overall survival was 97.8%, 93.6%, and 86.7%, respectively; the overall survival of the proportion of patients with recurrent/residual >2+ mitral regurgitation was estimated at 0.7%, 1.9%, and 5.9% and that of patients with New York Heart Association III/IV at 0.8%, 1.9%, and 5.3%. CONCLUSIONS: The "resect with respect" approach yields low operative mortality, no systolic anterior motion, good surface of coaptation, and low incidence of residual/recurrent mitral regurgitation and of reoperation, thus supporting resection when required concept.