Surgical management of outflow tract obstruction after transapical mitral valve implantation.

Left ventricular outflow tract (LVOT) obstruction due to systolic anterior motion of the anterior mitral valve leaflet (AML) is a known complication after mitral valve repair or transfemoral/transapical mitral valve implantation (TMVI). We present a patient with a previous mitral valve repair who developed LVOT obstruction after TMVI in whom the AML was surgically resected using a transaortic approach.

A metabolic protective strategy could improve long-term survival in patients with LV-dysfunction undergoing CABG.

OBJECTIVE: Adverse outcome after CABG is closely related to postoperative heart failure precipitated by ischemia and myocardial infarction. Restrictive use of inotropes is therefore desirable. Patients with preoperative left ventricular dysfunction are a high-risk group in this respect. To reduce myocardial oxygen expenditure we evolved a metabolic strategy for perioperative care. DESIGN: Observational study on 104 consecutive patients with severe left ventricular dysfunction undergoing CABG. The metabolic strategy implied physiological measures to minimize myocardial oxygen expenditure including restrictive use of inotropes and specific measures such as extended CPB and metabolic support to facilitate myocardial recovery. Hemodynamic state was primarily assessed by mixed venous oxygen saturation (SvO(2)). Follow-up averaged 9.7+/-1.4 years. RESULTS: LVEF was 0.30+/-0.05 (range 0.20-0.37) and 3.5+/-1.3 vessels were bypassed. Inotropes were used in 6.7% for weaning from CPB. Increase of s-creatinine by > or =50% compared to preoperative values was observed in 2.9%. Logistic EuroSCORE was 8.3% whereas observed 30-day mortality was 1.0%. Crude 5-year survival was 89.4%. CONCLUSIONS: The metabolic strategy allowed restrictive use of inotropes and was associated with encouraging long-term survival. Renal function was well preserved suggesting that SvO(2) served as an adequate marker of circulation. Randomized trials with metabolic support are warranted.

Correction to: Resection of a plasma cell granuloma combining a conventional posterolateral left-sided thoracotomy with a minimally invasive valve approach.

The corresponding author name should read as "Kvitting JP" in PubMed and other indexing websites.

Resection of a plasma cell granuloma combining a conventional posterolateral left-sided thoracotomy with a minimally invasive valve approach.

Plasma cell granuloma (PCG) is a rare benign tumor that is difficult to differentiate from malignancy. Depending on the location of the PCG, surgical management can be challenging. We describe a patient with a PCG involving the left lower lobe extending into the left atrium, that was resected en bloc using a conventional posterolateral thoracotomy combined with a surgical approach predominantly used for minimally invasive mitral valve surgery. This case illustrates how it is possible to utilize a technique used for cardiac surgery for tumors of pulmonary origin involving the heart.

Measurement of physical work capacity in patients with chronic aortic regurgitation: a potential improvement in patient management.

BACKGROUND: Timing of surgery in aortic regurgitation (AR) is important. Exercise testing is recommended upon uncertainty about functional limitations but reports on cardiopulmonary exercise testing (CPET) in populations with pure chronic AR are scarce. METHOD: Twenty-eight patients referred for surgery because of chronic AR (13 in NYHA I, 10 in NYHA II and five in NYHA III) were tested by CPET pre- and 6 months postoperatively. Echocardiography, with measurement of left ventricular ejection fraction (LVEF), diameters (LVED, LVES) and volumes (LVEDV, LVESV) was also performed. RESULTS: The patients had normal LVEF pre- and postoperatively. LV diameters and volumes diminished significantly postoperatively (LVED from 67 to 57, LVES from 49 to 41 mm; P < 0.001). The majority of the patients had a 'low' physical work capacity, none of them performed better than 'average' according to Astrand's classification preoperatively and there was no significant postoperative improvement. The mean peak oxygen uptake (VO(2peak)) was 25 ml kg(-1) min(-1) both pre- and postoperatively, and six of the 28 patients had a VO(2peak) of less than 20 ml kg(-1) min(-1). VO(2peak) was not significantly related to NYHA class. CONCLUSION: LVEF, diameters and volumes at rest did not fulfil the criteria for surgery in most of our AR patients, of whom 46% were asymptomatic. However, many had a remarkably low work capacity, which was neither improved 6 months postoperatively nor correlated to echocardiographic LV dimensions. CPET predicted the postoperative work capacity and may, therefore, be a useful complement for timing of surgery in patients with chronic AR.

Myocardial uptake and release of substrates in patients operated for unstable angina: impact of glutamate infusion.

OBJECTIVE: To study cardiac uptake and release of substrates and the influence of intravenous glutamate in patients operated for unstable angina requiring intravenous nitrates. DESIGN: Nineteen patients were randomized to blinded infusion of glutamate or saline. Arterial-coronary sinus differences of substrates were measured before cardiopulmonary bypass (CPB) and during early reperfusion. RESULTS: Before CPB the only major substrates that were extracted by the heart in the saline group were free fatty acids (FFAs). During reperfusion uptake of glucose and glutamate was found but FFAs remained the major substrate extracted by the heart. Initially transient low oxygen extraction and lactate release were found. Conversion to lactate uptake was not observed. Glutamate infusion was associated with an uptake of glutamate and in contrast to the control group there was also uptake of lactate before CPB and at the end of the study period. CONCLUSION: The metabolic situation before CPB with a reliance on myocardial FFA uptake is less than ideal with regard to ischemia. Early reperfusion was characterized by dynamic changes and a shift towards myocardial glucose uptake but FFAs remained the major substrate extracted. The qualitative findings associated with glutamate infusion agree with previous animal and human studies but have to be interpreted cautiously due to lack of flow measurements