Operator and Institutional Requirements for Transcatheter Mitral Valve Therapies in Australia: a CSANZ and ANZSCTS Position Statement.

This expert Position Statement is a description of the requirements for Accreditation for transcatheter mitral valve therapy (TMVT) in Australia. The requirements include the need for a multidisciplinary Heart Team review of individual cases, mandatory reporting of outcome data to a national TMVT Registry, and accreditation of individuals and institutions by the Conjoint Accreditation Committee, the assigned accreditation authority.

Risk stratification using serum lactate in patients undergoing surgical pulmonary embolectomy.

BACKGROUND: Surgical pulmonary embolectomy (SPE) has been around since the early days of cardiac surgery. But with the increase in thrombolytic and intervention options, indications of SPE have been limited. Literature suggests that risk stratification has been a key step in getting good results. We are analyzing serum lactate levels for risk stratification in massive and submassive pulmonary embolism (PE). METHODS: This study is a retrospective analysis of 82 cases that underwent SPE between January 1997 and January 2020. Patients were divided into two groups stratified by venous serum lactate levels on the first admission (Group I: normolactatemia <2 mmol/L, Group II: hyperlactatemia, >2 mmol/L). Primary endpoints were all-cause in-hospital mortality and secondary endpoints were cardiopulmonary bypass time, extracorporeal membrane oxygenator (ECMO) insertion, low cardiac output, blood product use, and right ventricular functions in the follow-up. RESULTS: Our study had an overall follow-up of 23 years with a median of 3.18 years. Overall, the in-hospital mortality rate was 8.54%. Group II had a higher mortality rate (P = .015) and morbidity incidences like cardiopulmonary bypass time (P = .008), ECMO insertion (P = .036), and open chest after surgery (P = .015). Although 5-year survival was better in group I a compared to group II (81%, 95% CI, 69%-93% vs 65%, 95% CI, 46%-84%), the log rank test showed no statistical survival difference among both groups on long-term follow-up. CONCLUSIONS: Long term survival after SPE is good and these results can further be improved by proper PE risk stratification. Alongside computed tomography and echocardiography, the importance of biomarkers like serum lactate can be explored in the PE management algorithm.

Acute Structural Failure of the Trifecta Aortic Valve Bioprosthesis.

Advancements in bioprosthetic valve technology have greatly enhanced the haemodynamic performance and long-term durability of tissue valves. These features, along with the key advantage of avoiding lifelong anticoagulation, have made bioprosthetic valves increasingly attractive for clinicians and patients alike. The St Jude Trifecta valve is a novel, bovine pericardial bioprosthesis with promising early data for performance and safety. However, no prosthetic valve is perfect and prosthesis failure can occur with even the most reliable and well-designed devices. We report a case of early and acute structural deterioration (stent-post leaflet rupture) of the Trifecta valve, explanted after 33 months, in a 76-year-old male.

The MitraClip Asia-Pacific registry: Differences in outcomes between functional and degenerative mitral regurgitation.

OBJECTIVES: The objective of this study is to describe and compare the use of the MitraClip therapy in mitral regurgitation (MR) patients with degenerative MR (DMR) and functional MR (FMR). INTRODUCTION: Percutaneous edge-to-edge repair of severe MR using the MitraClip device is approved for use in the USA for high risk DMR while European guidelines include its use in FMR patients as well. METHODS: The MitraClip in the Asia-Pacific Registry (MARS) is a multicenter retrospective registry, involving eight sites in five Asia-Pacific countries. Clinical and echocardiographic characteristics, procedural outcomes and 1-month outcomes [death and major adverse events (MAE)] were compared between FMR and DMR patients treated with the MitraClip. RESULTS: A total of 163 patients were included from 2011 to 2014. The acute procedural success rates for FMR (95.5%, n = 84) and DMR (92%, n = 69) were similar (P = 0.515). 45% of FMR had ≥2 clips inserted compared to 60% of those with DMR (P = 0.064).The 30-day mortality rate for FMR and DMR was similar at 4.5% and 6.7% respectively (P = 0.555). The 30-day MAE rate was 9.2% for FMR and 14.7% for DMR (P = 0.281). Both FMR and DMR patients had significant improvements in the severity of MR and NYHA class after 30 days. There was a significantly greater reduction in left ventricular end-diastolic diameter (P = 0.002) and end systolic diameter (P = 0.017) in DMR than in FMR. CONCLUSIONS: The MitraClip therapy is a safe and efficacious treatment option for both FMR and DMR. Although, there is a significantly greater reduction in LV volumes in DMR, patients in both groups report clinical benefit with improvement in functional class. © 2015 Wiley Periodicals, Inc.

18-FDG PET/ CT Scan in the Diagnosis and Follow-up of Chronic Q fever Aortic Valve Endocarditis.

Chronic Q fever endocarditis is a rare but important infection associated with risk of morbidity and mortality. Echocardiography rarely visualises the vegetative lesion. We describe the first Australian report of chronic Q fever aortic valve endocarditis confirmed with the use of 18 -FDG PET/ CT scan. Following valvular replacement, the patient had ongoing high serological titres despite active treatment and he was managed with yearly serial PET/ CT scan to confirm the absence of active infection. The utility of serial PET /CT scan imaging as a follow-up management strategy has not been described in the literature previously and should be investigated further.

Refractory ascites - a rare presentation of severe aortic regurgitation.

A 47 year-old male with a history of refractory ascites presented to our centre complaining of dyspnoea, abdominal distention, and weight gain. He was admitted under a medical team for investigation and management. Work-up excluded all common aetiologies of ascites. Echocardiography revealed severe aortic regurgitation (AR) with a dilated left ventricle but no right heart pathology or pulmonary hypertension. He underwent mechanical aortic valve replacement. Intra-operatively, a prolapsing left coronary leaflet of the aortic valve with frayed edges raised suspicion of resolved infective endocarditis. Postoperative course was uneventful. Following replacement of the aortic valve, the patient was completely free of ascites. This case demonstrates that ascites can be an unusual clinical presentation of severe aortic regurgitation, which may respond to aortic valve replacement.

Minimally invasive mitral valve surgery using single dose antegrade Custodiol cardioplegia.

OBJECTIVE: Our unit began a minimally invasive mitral surgery (MIMS) program utilising antegrade Custodiol solution as the sole cardioplegia. The aim of this paper is to report our results of this program. PATIENTS/METHODS: Early clinical outcomes were identified and assessed for the first consecutive 100 MIMS patients with comparisons made to a historical group operated via a sternotomy (n=113). The efficacy of myocardial protection was assessed using surrogate outcomes of myocardial protection with serial sodium concentrations also analysed. RESULTS: Six hours postoperatively 12 patients required inotropic support. Peak troponin-I in the first 24 hours was 5.1 (0.8-40 µg/L [median(range)]. Sodium levels decreased following administration of Custodiol but by six hours postoperatively the sodium had returned to greater than 130 mmol/L in all but five patients. Blood transfusion was smaller in the MIMS versus historical group (RBC 17% vs. 65%). MIMS patients had a shorter duration of ventilation, hospital stay and one-year mortality rate (0%). CONCLUSIONS: In this series of patients undergoing MIMS, single dose antegrade Custodiol offers satisfactory and safe myocardial protection. Early clinical outcomes were also satisfactory. Whilst our findings are observational, they nevertheless support the use of this less invasive approach to mitral surgery using single dose Custodiol for myocardial protection.

Right ventricular perforation during femoral venous cannulation--lessons learned.

Peripheral cannulation for cardiopulmonary bypass is increasingly used for minimally invasive and re-operative cardiac surgery. Transoesophageal echo (TOE) is used routinely to guide placement of the peripheral venous cannula in the right atrium/superior vena cava (SVC). We here present a case where despite use of TOE, placement of the venous cannula led to perforation of the right ventricular apex. We describe the surgical management of the problem and highlight strategies to avoid this complication.

A propensity score-adjusted retrospective comparison of early and mid-term results of mitral valve repair versus replacement in octogenarians.

AIMS: Feasibility and efficacy of mitral repair in the elderly remain controversial. This study aims to compare outcomes of mitral repair and replacement in octogenarians. METHODS AND RESULTS: We compared the outcomes of 322 consecutive octogenarian patients (mean age 82.6 ± 2.2 years) who underwent mitral repair (n = 227, 70%) or replacement (n = 95, 30%) at Mount Sinai Medical Center and Leipzig Herzzentrum between 1998 and 2008 using propensity score adjustment and univariate and multivariate analyses. Patients undergoing aortic valve replacement were excluded. Coronary bypass was performed in 47.5% (n = 153), and 31.1% (n = 100) required tricuspid repair. Propensity score adjustment yielded comparable groups. Thirty-day mortality in patients undergoing primary elective mitral repair for degenerative disease was 5.1% (2/39). Overall 90-day mortality was 18.9% (43/227) for repair compared with 31.6% (30/95) for replacement (P = 0.014). Pre-discharge echocardiography revealed less than moderate residual regurgitation in 99% of patients (231/232). Adjusted 1-, 3-, and 5-year survival for patients undergoing mitral repair was 71 ± 3, 61 ± 4, and 59 ± 4%, respectively, compared with 56 ± 5, 50 ± 6, and 45 ± 6% for patients undergoing mitral replacement (P = 0.046). Multivariate analysis demonstrated emergency surgery, previous myocardial infarction, concomitant coronary artery bypass surgery, and mitral replacement to be strong independent predictors of early mortality; mitral valve replacement was an independent predictor of reduced survival in degenerative patients. CONCLUSION: Elective mitral repair can be performed with low operative mortality and good long-term outcomes in selected octogenarians with degenerative mitral disease, and is associated with better long-term survival than mitral replacement. The survival benefit associated with surgery for non-degenerative disease is more questionable.

Cavernous haemangioma of anterior mitral valve leaflet: diagnostic utility of 3D echocardiography.

Mitral valve (MV) haemangiomas are rare primary cardiac tumours which may cause progressive cardiac failure as well as sudden death. We present a case of a 44-year-old woman referred for surgical correction of symptomatic severe mitral regurgitation. Preoperative two-dimensional transthoracic and transoesophageal echocardiography (TOE) were reported as demonstrating complex bi-leaflet prolapse causing severe mitral regurgitation. The patient was listed for MV surgery. Only on preoperative CT coronary angiogram was a filling defect noted, leading to suspicion of a cardiac tumour. Prior to skin incision, three-dimensional (3D) TOE revealed a 2×3 cm mass attached to the anterior leaflet of the MV. The tumour was subsequently resected, and the MV replaced. Postoperative histopathology confirmed a large cavernous haemangioma of the anterior MV leaflet. This case highlights a rare cause of severe mitral regurgitation and demonstrates the utility of 3D TOE as an adjunctive modality in confirming the suspected diagnosis of a cardiac tumour.

Minimally invasive isolated tricuspid valve surgery.

BACKGROUND AND AIM OF THE STUDY: Outcomes after minimally invasive isolated tricuspid valve (TV) surgery have not been well described. Hence, an assessment was made of the authors' results for minimally invasive, isolated TV surgery. METHODS: Between September 2000 and January 2008, at the authors' institution, a total of 35 patients (15 males, 20 females; mean age 59.2 +/- 14.9 years) underwent isolated TV surgery for TV regurgitation, using a right lateral mini-thoracotomy. The preoperative left ventricular ejection fraction was 57 +/- 11%. The TV pathology included annular dilatation (n = 22), recurrent regurgitation after previous repair (n = 4), ruptured chordae (n = 4), endocarditis (n = 2), intracardiac tumor (n = 2), and blunt chest trauma (n = 1). Twenty patients had previously undergone a total of 30 cardiac operations, eight of which involved the TV. RESULTS: A TV repair was performed in 27 patients (77%), and involved the implantation of an annuloplasty ring in all cases. A leaflet repair was performed in addition to an annuloplasty in two patients, and eight patients underwent TV replacement. The hospital mortality was 5.7%, with two deaths due to low cardiac output syndrome on days 1 and 9 after surgery. The latter patient underwent reoperation on day 7 for recurrent TV regurgitation and a ventricular septal defect. Early and mid-term echocardiographic follow up revealed no TV regurgitation in 19 patients, but trivial and mild regurgitation each in eight patients. The mean follow up time was 35 +/- 40 months, and was 100% complete. A Kaplan-Meier analysis revealed an estimated five-year survival of 90% (95% CI: 73-97). CONCLUSION: Isolated TV surgery can be performed through a minimally invasive approach, with good results. A high repair rate can be achieved, and the procedure has been particularly valuable in redo surgery.

The Healthy Heart-Mind Trial: Randomized Controlled Trial of Melatonin for Prevention of Delirium.

OBJECTIVES: Delirium is a serious medical condition with increased incidence in at-risk surgical populations. We sought to determine if melatonin use reduces the incidence of delirium in individuals undergoing major cardiac surgery. DESIGN: Randomized double-blind placebo-controlled clinical trial (two arms, 1:1 allocation, parallel design). SETTING: The trial took place in two metropolitan hospitals (public tertiary and private) in Perth, Western Australia. PARTICIPANTS: We recruited 210 adults aged 50 years or older who were due to undergo coronary artery bypass grafting or valve replacement surgery. INTERVENTION: Participants were randomly assigned (1:1) to 7 days of treatment with melatonin 3 mg at night or matching placebo, starting 2 days before the surgery. MEASUREMENTS: The primary outcome of interest was incident delirium within 7 days of surgery as assessed via daily clinical assessment that included the Confusion Assessment Method. Secondary outcomes of interest included duration and severity of delirium, length of hospital stay, cognitive function, and mood and anxiety symptoms at discharge and 3 months after the surgery. RESULTS: The groups were well balanced for demographic and clinical parameters. Forty-two participants developed delirium, but it was evenly distributed between the groups (melatonin 21/98, 21.4%; placebo 21/104, 20.2%; adjusted odds ratio [OR] = .78; 95% confidence interval [CI] = .35-1.75). The median duration of delirium was 3 (interquartile range [IQR] = 2-4) and 2 (IQR = 1-3) days for people treated with melatonin and placebo, respectively (z = -1.03; P = .304). A similar proportion of participants experienced severe episodes of delirium in each group (melatonin 9/21, 42.9% vs placebo 6/21, 28.6%; χ2 = .93; P = .334; adjusted OR = 1.98; 95% CI = .40-9.78). The groups did not differ in terms of length of stay, mood, anxiety, and cognitive performance. CONCLUSION: The findings of this randomized double-blind placebo-controlled trial do not support the prophylactic use of melatonin to prevent delirium after major cardiac surgery. J Am Geriatr Soc 68:112-119, 2019.

Outcomes of video-assisted thoracoscopic surgery lobectomy in septuagenarians.

BACKGROUND: Spread of technology and increased surveillance have led to more patients with lung cancers being identified than ever before. Increasingly, patients from the elderly population are referred for surgery; however, many studies do not focus on this patient group. We reviewed the outcomes of septuagenarians who underwent lobectomy via an open thoracotomy (OT) or video-assisted thoracoscopic surgery (VATS) approach to determine whether the VATS approach would result in superior post-operative outcomes. METHODS: Between January 2010 and June 2016, a total of 96 patients aged 70 years or older underwent a lobectomy for non-small cell lung carcinoma. Patients who underwent resection for metastatic disease, small cell lung cancer or neuroendocrine tumour were excluded. Demographic details, early and late post-operative outcomes including post-operative arrhythmia, myocardial infarction, respiratory failure, cerebrovascular events, infection, prolonged air leak, delirium, readmission and 30-day mortality were studied. Mean follow-up duration was 23 ± 19.1 months. RESULTS: Seventy-five patients underwent lobectomy via a VATS approach and 21 patients underwent lobectomy via an OT approach. There was no 30-day mortality and no difference in overall survival between the two techniques (P = 0.25). There was no significant difference between the two techniques with regard to post-operative stroke, myocardial infarction, atrial fibrillation, pneumonia, delirium or bronchopleural fistula. VATS patients had a significantly shorter mean hospital length of stay (VATS 4.7 days, OT 9.3 days, P = 0.005). CONCLUSION: Septuagenarians with non-small cell lung carcinoma can successfully undergo curative lung resection with a low incidence of post-operative complications.

Surgical Management of Caseous Calcification of the Mitral Annulus.

Caseous calcification of the mitral annulus (CCMA) is a rare variant of mitral annular calcification; it can manifest with conduction abnormalities or systemic embolization. It typically involves the posterior mitral annulus, and surgery is indicated for severe mitral valve dysfunction, for embolic complications or when the diagnosis is not certain. We describe a structured approach to the surgical management of CCMA using bovine pericardium to repair the defect.

Modified Valsalva Maneuver for Venous Cannulation in Cardiopulmonary Bypass for Minimal Incision Mitral Valve Surgery.

A 69-year-old man underwent minimal incision mitral valve repair for severe symptomatic mitral regurgitation. The echocardiography showed that he had normal left ventricular function with a moderately to severely dilated left atrium, a mildly dilated right atrium, and a large patent foramen ovale. The multistage venous cannulation was very challenging because we could not negotiate the guide wire from the inferior vena cava via the right atrium into the superior vena cava. Despite several attempts, the guide wire would pass into the patent foramen ovale. Methods that we routinely attempt with difficult cannulations such as withdrawing and reinserting, twisting, and to-and-fro movements did not result in success. Eventually, we attempted a novel maneuver, the modified "Valsalva maneuver," that worked incredibly well.

Transient occlusion of the right coronary artery by a calcific bicuspid aortic valve mass - An interesting case of inferior STEMI.

Calcified bicuspid aortic valves are a commonly encountered clinical problem. Less common and possibly underreported, however, are embolic events secondary to a calcified valve. Events, including stroke and myocardial infarction, have been documented in the literature. We report the case of a myocardial infarction caused by transient occlusion of the right coronary artery, secondary to a mobile calcified lesion attached to a bicuspid aortic valve. .

The Healthy Heart-Mind trial: melatonin for prevention of delirium following cardiac surgery: study protocol for a randomized controlled trial.

BACKGROUND: Delirium is a common occurrence in patients undergoing major cardiac surgery and is associated with a number of adverse consequences for the individual, their family and the health system. Current approaches to the prevention of delirium include identifying those at risk together with various non-pharmacological and pharmacological strategies, although the efficacy of these is often modest. Emerging evidence suggests that melatonin may be biologically implicated in the development of delirium and that melatonin supplementation may be beneficial in reducing the incidence of delirium in medical and surgical patients. We designed this trial to determine whether melatonin reduces the incidence of delirium following cardiac surgery compared with placebo. METHODS/DESIGN: The Healthy Heart-Mind trial is a randomized, double-blind, placebo-controlled clinical trial of 3 mg melatonin or matching placebo administered on seven consecutive days for the prevention of delirium following cardiac surgery. We will recruit 210 adult participants, aged 50 and older, undergoing elective or semi-elective cardiac surgery with the primary outcome of interest for this study being the difference in the incidence of delirium between the groups within 7 days of surgery. Secondary outcomes of interest include the difference between groups in the severity and duration of delirious episodes, hospital length of stay and referrals to mental health services during admission. In addition, we will assess differences in depressive and anxiety symptoms, as well as cognitive performance, at discharge and 3 months after surgery. DISCUSSION: The results of this trial will clarify whether melatonin reduces the incidence of delirium following cardiac surgery. TRIAL REGISTRATION: The trial is registered with the Australian Clinical Trials Registry, trial number ACTRN12615000819527 (10 August 2015).

Bioglue: a review of the use of this new surgical adhesive in thoracic surgery.

BACKGROUND: Alveolar air leaks and broncho-pleural fistulae after thoracic surgical procedures contribute significantly to hospital morbidity and mortality. BioGlue has offered the thoracic surgeon an alternative to the products presently used to reduce the incidence of these complications. This retrospective study reviews our experience with this new adhesive. METHODS: Forty patients upon whom BioGlue was used were identified through operation records. Pre-, intra- and postoperative data were collected to establish use, indications and outcome. RESULTS: The predominant underlying pathology was malignancy. In 32 patients BioGlue was used during the primary procedure while in the remaining eight, persistent air- or lymph-leak led to a further procedure requiring the use of glue. The indications for BioGlue use were alveolar air leak (36), broncho-pleural fistula (2) and lymph leak (2). There was one death. In 35 out of 36 patients with alveolar air leak, BioGlue controlled the leak at the site of application. CONCLUSIONS: Our results in this particular patient group indicate that BioGlue is a reliable adjunct in the reduction of alveolar air leaks. Although further studies are necessary to establish the role of BioGlue in thoracic surgery in comparison to other sealants, these initial results are promising.