Adjustable external Dacron annuloplasty in aortic valve repair.

In aortic valve repair, whilst performing a Yacoub remodelling operation, the external annuloplasty of the aortic ring plays a very important role. Here we present an adjustable external Dacron annuloplasty as an additional tool, in very selected cases, that can help surgeons to further improve their immediate results thus influencing the long-term ones.

Resection of a cardiac tumour with reconstruction of the atria and the superior vena cava.

Cardiac tumours are very rare and their complete resection, when feasible, remains the only curative treatment. We present the case of a patient who had aortic stenosis. The routine preoperative workup also identified stenosis in the left anterior descending and right coronary arteries, and most importantly, an invasive tumour at the confluence of the superior vena cava-right atrium-left atrium. After discussion by the heart team, and as is usually done in our department for non-complex right coronary lesions, the stenosis was treated by inserting a stent. The patient was operated on for an aortic valve replacement with a concomitant left internal mammary artery to left anterior descending artery coronary artery bypass graft. In addition, the tumour was completely resected surgically. Reconstruction included a patch for the left atrium, another for the right atrium and a Dacron tube for the superior vena cava. Histological analysis confirmed the complete resection of a cardiac hibernoma. Three months after the surgery, the patient is doing well without any symptoms.

Reconstruction of a large pulmonary artery aneurysm using a vascular prosthesis.

A pulmonary artery aneurysm is a rare, heterogeneous disease for which there are currently no surgical guidelines. We present the case of a symptomatic patient presenting with a large aneurysm of the distal pulmonary trunk and left pulmonary artery. The aneurysm was resected through a full median sternotomy under cardiopulmonary bypass and aortic cross-clamping. The reconstruction was performed using a straight vascular prosthesis to connect the proximal pulmonary trunk to the left pulmonary artery with the lateral reimplantation of the right pulmonary artery. We find this surgical technique to be simple, effective, and reproducible by colleagues encountering similar cases.

Recent improvement in operative techniques lead to lower pacemaker rate after Perceval implant.

OBJECTIVES: Our goal was to compare pacemaker rate usage following two different operating techniques for implanting the Perceval aortic valve replacement. METHODS: In this retrospective, single-centre study, we studied patients with isolated or concomitant Perceval aortic valve replacement operated on first between April 2013 and January 2016, following traditional operating techniques, with patients operated on between January 2016 and December 2020, after the adoption of a modified protocol based on different annulus sizing, higher positioning of the valve and no ballooning after valve deployment was adopted. The operations were performed by 2 surgeons, and patients were followed-up for a period of 30 days. RESULTS: A total of 286 patients, with a mean age of 77 (4.9) years, had Perceval valves implanted during the study period, of which 79% were isolated aortic valve procedures. Most patients (66.8%) underwent minimally invasive procedures. Cross-clamp time was 55.1 (17.6) min. The overall postoperative pacemaker insertion rate was 8.4%, which decreased decisively after the 2016 change in the implant protocol (16% vs 5.6%; P = 0.005), adjusted odds ratio of 0.31 (95% confidence interval: 0.13-0.74, P = 0.012). Univariable and multivariable analysis showed that larger valve size (P = 0.01) and ballooning (P = 0.002) were associated with higher risk of implanting a pacemaker. Postoperative 30-day mortality was of 4.5%. CONCLUSIONS: Improvement in the operating techniques for implanting the Perceval valve may decrease the rate of pacemakers implanted postoperatively. Although further studies are needed to confirm these results, such a risk reduction may lead to wider use of Perceval valves in the future, potentially benefiting patients who are suitable candidates for minimally invasive surgery.

Right anterior minithoracotomy with total central cannulation.

A right anterior minithoracotomy is gaining wider acceptance among the members of the surgical community for the treatment of isolated aortic valve replacement. Usually, the cardiopulmonary bypass circuit is implanted either totally peripherally or with 1 cannula in a central position and the other in a peripheral one. This procedure has its drawbacks because it adds potential peripheral morbidity during or after the operation. At our center, during the last year, we have developed some tips and tricks in order to establish in most of the patients a total central cardiopulmonary bypass procedure. We explain this technique in our video tutorial. We think that this approach may help other surgical teams to embrace a right anterior minithoracotomy because it is similar to what we do routinely by sternotomy.

Reversed C-shaped Scanner-guided Ministernotomy for Isolated Aortic Valve Replacement.

Here we present our technique of aortic valve replacement through a reversed C-shaped ministernotomy in 36 patients operated between 2017 and 2019. All patients had a preoperative computed tomography that guided the surgical approach. The sternum was incised at the level of the first and third or the second and fourth intercostal spaces. Cross-clamp time was of 65.2 ± 15.9 minutes. Median extubation time was of 2 hours. There was no postoperative 30-day mortality. Because the upper and lower parts of the sternum remain intact, this approach may improve postoperative thoracic stability.

The Ross procedure in adults patients with reconstruction of the RVOT with a bioprosthetic valve.

The Ross procedure is now a well established treatment for aortic valve pathology in young adult patients. However, there are several technical aspects of this operation that are still under debate. One of them is the necessity for reconstruction of the right ventricular outflow tract. Cryopreserved or decellularized pulmonary homografts are the gold standard but, in some cases, and especially in urgent patients, their availability cannot be guaranteed. Stentless xenografts (such as the Medtronic Freestyle Aortic Root) can be inappropriate for some patients with large right outflow tracts, because it can be difficult to suture them without tension. The use of bio conduits handmade using straight Dacron grafts and stented xenografts can be helpful as a third choice.  In this video tutorial we demonstrate our technique for right ventricular outflow tract reconstruction in a young adult patient. We believe that our technique should be included in the armamentarium of every Ross surgeon for use in adult patients. However, long-term outcomes for these stented xenografts in the right outflow position should be carefully evaluated in the future.

Axillary TAVR under locoregional anesthesia in a patient with peripheral artery disease.

Transcatheter aortic valve replacement (TAVR) is now a relatively commonly performed procedure and the number of eligible patients is growing exponentially.  In candidates with peripheral arterial disease, the axillary artery approach is an option worth considering. Usually TAVR performed using this approach is done under general anesthesia with tracheal intubation. At our center, however, we have developed a surgical approach to TAVR using the axillary artery under locoregional anesthesia.  This video tutorial demonstrates the technical details of our strategy. Because this procedure is extrathoracic, spares cerebral vessels, and is done under locoregional anesthesia, it is particularly suitable for fragile patients. This combination of both axillary access and locoregional anesthesia has the potential to become a primary main alternative for non-femoral TAVR patients and we hope it will be adopted also by other centers.

A Novel Computed Tomography Scan Tool for Patient Selection in Minithoracotomy Aortic Replacement.

Right anterior minithoracotomy is gaining larger acceptance for isolated aortic valve replacement. In some patients, however, surgical exposure during the intervention may be challenging even for experienced surgeons or centers. In our opinion, proper preoperative selection of the patients by computed tomography scan seems mandatory. We routinely perform right anterior minithoracotomy, and over time, we have found that the angle between the right border of the sternum and the left side of the aorta, at the level of the pulmonary artery, helps with patient selection.

Ventricular Septal Defect Jeopardizes the Autograft in a Ross Operation.

The Ross operation is the gold standard for aortic valve replacement in young patients because it is a durable and anticoagulation-free alternative to mechanical aortic valve replacement. Careful assessment of the pulmonary valve is critical because it should become a durable neoaortic valve. Here we report the case of a patient in whom the pulmonary autograft was jeopardized by a large, doubly committed ventricular septal defect that did not offer sufficient autologous tissue for the proximal suture line. Surgeons should be aware that patients presenting with Laubry-Pezzi syndrome can be poor or challenging candidates for Ross procedures.

Severe Acute Proximal Pulmonary Embolism and COVID-19: A Word of Caution.

Acute pulmonary embolism is an uncharacteristic presentation in patients with coronavirus 2019 (COVID-19). Here we describe the case of a young woman presenting with severe pulmonary embolism, without any associated symptoms of infections. A clot in a patent foramen ovale was noted. Despite emergency surgical embolectomy, her clinical conditions continued to deteriorate. She was put on extracorporeal life support and tested positive for COVID-19. She died of multiorgan failure on day 10. COVID-19 may have a thrombogenic effect, and it may need to be considered in cases of pulmonary embolism and in the absence of any obvious risk factor.

Aortic morphology post type A acute aortic syndrome: Prognosis significance and association with 24-hour blood pressure-monitoring parameters.

BACKGROUND: After an emergent surgery for type A acute aortic syndrome, medical management is based on optimal blood pressure (BP) control. We assessed the prognostic significance of BP monitoring and its relationship with aortic morphology following type A acute aortic syndrome. METHODS: The data of 120 patients who underwent BP monitoring after a type A acute aortic syndrome from January 2005 to June 2016 were retrospectively collected. The first CT angiogram performed after surgery was used for the morphological analysis. RESULTS: The population included 79 males, with an overall mean age of 60 ± 12 years. Seven patients (5.8%) died during a median follow-up of 5.5 years. The median delay between BP monitoring and discharge was 3 (1-5) months. The mean 24-hour BP of the cohort was 127/73 mm Hg ± 10/17. During follow-up, different parameters of BP monitoring were not associated with the risk of aortic events. However, the diameter of the false lumen of the descending thoracic aorta was the best predictor associated with the risk of new aortic events during follow-up, particularly for the threshold of 28 mm or more (P < .001; Hazard ratio 4.7[2.7-8.2]). The diameter of the false lumen was associated with night-time systolic BP (P = .025; r = .2), 24-hour pulse pressure (P = .002; r = .28), and night-time pulse pressure (P = .008; r = .24). CONCLUSION: The risk of new aortic events following type A acute aortic syndrome is associated with the size of the residual false lumen, but not directly with BP parameters. Night-time BP parameters are associated with the size of the residual false lumen.

Axillary Transcatheter Aortic Valve Replacement in Patients With Peripheral Vascular Disease.

The axillary artery seems an interesting alternative in nonfemoral transaortic valve replacement (TAVR) patients. This study describes our experience with this technique and its short-term follow-up results. This is a retrospective single center study. All axillary TAVR performed in our department between 2015 and 2017 were included in the study. Mean follow-up was 13.2 ± 9.5 months. All reporting was done according to the VARC-2 criteria. During the period covered, 43 patients had an axillary TAVR. Most patients were men (62.7%), had a mean age of 83.9 ± 5.3 years and presented with EuroSCORE I, II, and STS score of 27.9 ± 13.5%, 5.6 ± 4.9%, and 7.7 ± 4.05%, respectively. Vascular access was successful in all patients with a higher frequency of left approach (69.7%, n = 30). Both Medtronic CoreValve 37.2% (n = 16) and Edwards Sapien3 62.8% (n = 27) valves were used. An apical Certitude delivery system was preferentially used (24/27) in the latter group. There were no reported instances of valve migration or need for a second valve implantation. A single case (2.3%) of arterial vascular complication was reported. Central neurologic morbidity was 2.3%. No patient experienced brachial plexus injury. A pacemaker was implanted in 18.6% of cases (n = 8), with no significant difference between the 2 valves patient groups (S3 14.8% vs CV 25%, P 0.67). The 30-day mortality was 6.9% (n = 3) and 1-year survival was 86% [95% CI 72.6, 93.4]. Axillary TAVR is associated with acceptable morbidity, mortality, and leads to satisfactory short-term clinical outcomes. It has the potential to become the main alternative access route in nonfemoral TAVR patients.

Direct axillary artery cannulation in cardiac surgery: clinical outcomes.

Objective Axillary artery cannulation is still regarded with distrust by surgeons because the artery is supposed to be fragile, difficult to access, and its cannulation is often considered time-consuming. This study was carried out to assess our results in a series of patients, using a simplified surgical approach to axillary artery cannulation. Methods Data were collected retrospectively from our prospective database. All patients operated on in our department between January 2004 and October 2016 and scheduled for various cardiac procedures with direct axillary artery cannulation were included in this study. In this twelve-year period, 246 patients had direct axillary artery cannulation during a cardiac surgical procedure. The mean age was 67.3 ± 14.7 years. The artery was approached at the level of the deltopectoral groove and cannulated by the direct Seldinger technique. Results The main indications for axillary artery cannulation were: right minithoracotomy aortic valve replacement ( n = 93), aortic dissection ( n = 57), extracorporeal life support ( n = 36), transarterial valve replacement ( n = 27), ascending aortic aneurysm ( n = 16), and others ( n = 17). The cannulation was right-sided in 90.6% of patients. Axillary cannulation-related morbidity was 6.1%. Axillary cannulation-related mortality was 0.8% (2 patients). Conclusions The axillary artery is a reliable site for rapid cannulation, carrying a low risk of morbidity and mortality. Our findings show that this artery is solid and can be very useful in everyday cardiac surgical practice.

A Standardized Loop Technique for Mitral Valve Repair.

The loop technique is widely used for mitral valve repair. However, estimation of the correct loops' length remains challenging. We describe a standardized technique with implantation of standardized 15- and 25-mm loops for posterior and anterior mitral prolapses. The number of loops and the site of their implantation are decided after a careful surgical valve analysis. This has shown reliable results in our initial experience in eight patients both, in sternotomy and minimally invasive surgery repairs, but needs further long-term evaluation.