Asymmetric ring annuloplasty for ischemic mitral regurgitation: early and mid-term outcomes.

BACKGROUND AND AIM OF THE STUDY: The Carpentier-McCarthy-Adams IMR ETlogix annuloplasty ring was specifically designed to treat ischemic mitral regurgitation (IMR) associated with asymmetric mitral annular dilation and leaflet tethering. The study aim was to review, retrospectively, the results of mitral annuloplasty with this asymmetric ring in a representative number of patients. METHODS: Between January 2005 and July 2012, the IMR ETlogix ring was implanted in 190 consecutive patients (mean age 69.5 +/- 7.6 years) with grade > or =2+ IMR (graded from 0 to 3+). Preoperatively, 37 patients (19.5%) were in NYHA class IV, and 73 (38.4%) suffered from unstable angina. The operative risk according to the European System for Cardiac Operative Risk Evaluation II was 15.6 +/- 14.5%. Using two- dimensional echocardiography, postoperative changes in mitral annular diameter (MAD) and tenting height (TH) of the mitral valve in four-chamber, two-chamber and long-axis views, were assessed at mid-systole. RESULTS: Thirty-eight patients (20.0%) received one or more concomitant major cardiac surgical procedure(s) other than, or in addition to, coronary artery bypass grafting or tricuspid valve annuloplasty. Nineteen (10.0%) hospital deaths occurred, and one patient underwent immediate reoperation for residual MR. During the follow up (mean 4.8 +/- 2.1 years) there were 26 cardiac deaths, 14 non-cardiac deaths, and three mitral valve replacements. The seven-year actuarial survival, freedom from grade > or =2+ MR and reoperation were 62.0%, 93.1% and 97.6%, respectively. Renal impairment (p = 0.012) and extracardiac arteriopathy (p = 0.047) were predictors of death; bilateral internal thoracic artery grafting was a protective factor (p = 0.033). Heart failure symptoms were improved (p <0.01). Left ventricular reverse remodeling was achieved in 50.6% of patients. The MAD and TH were each decreased in all three echocardiographic views (p < 0.001), the reductions being greater in the long-axis view. CONCLUSION: By restoring the mitral apparatus geometry and competence, asymmetric annuloplasty with the IMR ETlogix ring provides good mid-term outcomes and helps left ventricular reverse remodeling in IMR.

Aortoaxillary bypass during cardiac operation.

AIMS: The aim of the present study was to analyze our experience in the use of the aortoaxillary bypass during cardiac operation in a limited series of patients with proximal atherosclerotic lesion of the subclavian artery combined with cardiac disease amenable to surgical treatment. METHODS: Of 1953 consecutive patients who underwent cardiac operation at our unit between April 2009 and July 2012, nine (0.5%; four women and five men; mean age 69.0 ±â€Š6.2 years) suffered from symptomatic occlusive disease of the subclavian artery, and underwent concomitant aortoaxillary bypass. A ring-reinforced polytetrafluoroethylene vascular graft was anastomosed to the proximal segment of the axillary artery, introduced into the pleural cavity through the first or the second intercostal space, and anastomosed to the ascending aorta. All perioperative data were collected prospectively. RESULTS: Seven (77.8%) left and two (22.2%) right aortoaxillary bypasses were achieved. Ten concomitant cardiac operations were performed. There were no early postoperative complications related to the subclavian artery revascularization. At a mean follow-up of 27.3 ±â€Š15.5 months, both the symptoms of the subclavian artery disease and those of the heart disease improved. High-resolution computed tomography angiography confirmed an excellent patency of the aortoaxillary bypass in all the patients but one. CONCLUSION: Concomitant aortoaxillary bypass and cardiac operation may be an option to keep in mind for patients with coexisting subclavian artery occlusion and heart disease, after the evidence that the combined operation does not increase the risk. Attention should be paid to the course of the bypass graft toward the axillary artery.

Protecting the crossover right internal thoracic artery bypass graft with a pedicled thymus flap.

The right internal thoracic artery graft is placed in jeopardy during repeat sternotomy as it crosses the aorta anteriorly to reach its left-sided coronary targets. We have devised a way of protecting it by means of a pedicled flap taken from the thymic remnants. The flap is easily developed without unduly increasing operative time and morbidity, and it is expected to prevent inadvertent injuries to the graft in the case of mediastinal reentry. Starting in 1999, suitable flaps were obtained in 955 of 1,034 patients (92.4%) receiving an anteaortic crossover right internal thoracic artery-to-coronary graft in our division.