Left Ventricular Reconstruction for Postinfarction Left Ventricular Aneurysm: Review of Surgical Techniques.

Different surgical techniques, each with its own advantages and disadvantages, have been used to reverse adverse left ventricular remodeling due to postinfarction left ventricular aneurysm. The most appropriate surgical technique depends on the location and size of the aneurysm and the scarred tissue, the patient's preoperative characteristics, and surgeon preference. This review covers the reconstructive surgical techniques for postinfarction left ventricular aneurysm.

Usefulness of 3D echocardiographic parameters of tricuspid valve morphology to predict residual tricuspid regurgitation after tricuspid annuloplasty.

AIMS: Tricuspid valve (TV) annuloplasty is an effective treatment for tricuspid regurgitation (TR). However, the impact of TV morphology on outcome of TV annuloplasty remains unknown. We sought to investigate the relationship between preoperative TV morphology and residual TR after annuloplasty. METHODS AND RESULTS: Two-dimensional transthoracic and three-dimensional (3D) transesophageal echocardiography were performed in 97 patients with functional TR before and after surgery. 3D quantitative assessment including annular dimension, tenting height and volume, and lengths and tethering angles of the 3 leaflets was performed. The TV morphological score was derived from the preoperative 3D echocardiography to score a leaflet mobility, leaflet thickening, subvalvular thickening, and calcification. TR severity was determined by the averaged vena contracta measured from the apical and parasternal inflow views. Multivariable analysis revealed that a shorter total leaflet length (P = 0.007), larger tenting volume (P < 0.001), and higher TV morphological score (P < 0.001) were independently associated with residual TR. A TV-Echo score was determined as a sum of points based on receiver operator characteristics analysis: total leaflet length >61.0 mm, 61.0 to 53.5 mm, and <53.5 mm; tenting volume <2.3 mL, 2.3 to 3.5 mL, and >3.5 mL; and TV morphological score <7, 7 to 18, and >18; each variable was associated with 0 and 1 point and 2 points, respectively. The TV-Echo score ≥2 was associated with significant residual TR with a sensitivity of 85.7% and a specificity of 71.0%. CONCLUSION: In addition to tethering and short length of the leaflets, TV morphological abnormality predicted residual TR after TV annuloplasty.

Mitral annular motion in patients after transcatheter MitraClip and mitral valve surgery.

BACKGROUND: Longitudinal motion of the mitral annulus is an index that reflects left ventricular (LV) function. The aim of this study was to evaluate and compare the effects of transcatheter mitral valve (MV) repair and open heart surgery for mitral regurgitation (MR) on mitral annular motion (MAM). METHODS: We retrospectively analyzed in total 115 patients who underwent isolated transcatheter MV repair using MitraClip (n=50) or surgical MV interventions (n=65, 50 repairs and 15 replacements) for MR. MAM was assessed by two-dimensional B-mode echocardiography in the four- and two-chamber views. MAM was measured before and within 1 month after the mitral procedure. RESULTS: Compared with patients undergoing MV surgery, patients undergoing the MitraClip procedure were older and had more comorbidities. MR grade improved significantly in both groups after MV intervention. MAM decreased significantly in the surgery group (12.0±3.1 to 8.1±2.2 mm, P<.01), whereas MAM did not change in the MitraClip group (8.8±2.6 to 8.6±2.5 mm, P=.59). In multivariate analysis, mitral surgery was associated with a decrease in MAM when compared to the MitraClip procedure. Furthermore, LV ejection fraction (EF) decreased to a greater degree in patients undergoing surgery than those undergoing MitraClip placement (MV surgery; -10.1±7.6% vs MitraClip; -3.0±10.5%, P<.01). CONCLUSIONS: MitraClip therapy does not adversely influence MAM and is associated with less postprocedural EF reduction compared to surgical intervention. Our results suggest that patients with reduced LV systolic function may benefit from the MitraClip procedure compared to mitral surgery.

Human cardiosphere-derived cells from advanced heart failure patients exhibit augmented functional potency in myocardial repair.

OBJECTIVES: This study sought to compare the regenerative potency of cells derived from healthy and diseased human hearts. BACKGROUND: Results from pre-clinical studies and the CADUCEUS (CArdiosphere-Derived aUtologous stem CElls to reverse ventricUlar dySfunction) trial support the notion that cardiosphere-derived cells (CDCs) from normal and recently infarcted hearts are capable of regenerating healthy heart tissue after myocardial infarction (MI). It is unknown whether CDCs derived from advanced heart failure (HF) patients retain the same regenerative potency. METHODS: In a mouse model of acute MI, we compared the regenerative potential and functional benefits of CDCs derived from 3 groups: 1) non-failing (NF) donor: healthy donor hearts post-transplantation; 2) MI: patients who had an MI 9 to 35 days before biopsy; and 3) HF: advanced cardiomyopathy tissue explanted at cardiac transplantation. RESULTS: Cell growth and phenotype were identical in all 3 groups. Injection of HF CDCs led to the greatest therapeutic benefit in mice, with the highest left ventricular ejection fraction, thickest infarct wall, most viable tissue, and least scar 3 weeks after treatment. In vitro assays revealed that HF CDCs secreted higher levels of stromal cell-derived factor (SDF)-1, which may contribute to the cells' augmented resistance to oxidative stress, enhanced angiogenesis, and improved myocyte survival. Histological analysis indicated that HF CDCs engrafted better, recruited more endogenous stem cells, and induced greater angiogenesis and cardiomyocyte cell-cycle re-entry. CDC-secreted SDF-1 levels correlated with decreases in scar mass over time in CADUCEUS patients treated with autologous CDCs. CONCLUSIONS: CDCs from advanced HF patients exhibit augmented potency in ameliorating ventricular dysfunction post-MI, possibly through SDF-1­mediated mechanisms.

Three hundred robotic-assisted mitral valve repairs: the Cedars-Sinai experience.

OBJECTIVE: The study objective was to review our first 300 consecutive robotic-assisted mitral repairs performed from June 2005 to October 2012 and to compare the surgical outcomes of our previously reported initial 120 cases with the subsequent 180 procedures. METHODS: Our initial 120 robotic-assisted mitral repairs were previously reported, and we now compare our early experience with the recent 180 consecutive procedures for a total of 300 robotic-assisted mitral repairs. There was no patient selection. Every patient in need of isolated mitral valve repair underwent this procedure. All patients received an annuloplasty band and 1 or more of the following: leaflet resection, secondary chordal transposition, or polytetrafluoroethylene neochordal replacement and edge-to-edge repair. RESULTS: All 300 patients had preoperative echocardiographic findings of severe mitral regurgitation. There were no differences (P = not significant) between the initial and the recent cohorts for preoperative characteristics, including age (58.4 ± 10.5 years vs 59.9 years), female gender (35.8% vs 36.1%), ejection fraction (61.9% vs 60.6%), congestive heart failure (35.0% vs 36.7%), creatinine (0.94 mg/dL vs 0.98 mg/dL), and New York Heart Association class. The incidence of anterior and posterior leaflet prolapse was similar in both groups, whereas Barlow syndrome was higher in group 2 (5.8% vs 27.8%). There was 1 (0.33%) hospital mortality and no deaths in the last 180 cases. Overall, 8 patients (2.7%) required subsequent mitral valve replacement via a median sternotomy, 6 (5.0%) in the first group and 2 (1.1%) in the second group (P = .06). One patient in each group had mitral valve re-repair through a right mini-thoracotomy, and 1 patient in the first group required a mitral valve replacement via a mini-thoracotomy during the original procedure. Two of the 180 patients had documented cerebrovascular accident, but both fully recovered clinically. There was no cerebrovascular accident in the last 120 patients. Crossclamp times decreased from 116 minutes to 91 minutes in the second group despite starting a training program with a junior associate performing part of the procedure at the console in the last 100 cases. Post-pump echocardiograms showed no/trace mitral regurgitation in 86.1% of the last 180 patients and mild mitral regurgitation in 11.1%. Follow-up echocardiography for the last 180 patients from 1 month to more than 1 year showed no/trace mitral regurgitation in 64.6% of patients and mild mitral regurgitation in 23.1% of patients. Seven patients (10.8%) had moderate mitral regurgitation, and 1 patient (1.5%) had severe mitral regurgitation. CONCLUSIONS: The majority of complications and reoperations occurred early in our experience, especially using the first-generation da Vinci robot (Intuitive Surgical Inc, Sunnyvale, Calif). The newer da Vinci Si HD system with the addition of an adjustable left atrial roof retractor together with increased experience has made robotic-assisted mitral repair of all types of degenerative mitral valve pathology reproducible. The training of young surgeons in a stepwise fashion in high-volume centers will help to avoid the complications encountered during the introduction of this technology.

Coronary artery bypass graft surgery using the radial artery as a secondary conduit improves patient survival.

BACKGROUND: The clinical benefits of the left internal thoracic artery-to-left anterior descending coronary artery graft are well established in coronary artery bypass graft surgery (CABG). However, limited data are available regarding the long-term outcome of the radial artery (RA) as a secondary conduit over the established standard of the saphenous venous graft. METHODS AND RESULTS: We compared the 12-year survival outcome in a set of propensity-matched CABG patients who received either the RA or the saphenous vein as a secondary conduit. A multivariable logistic regression that included 18 baseline characteristics was used to define the propensity of receiving an RA graft. The propensity model resulted in 260 matched pairs who underwent first-time isolated CABG from 1996 to 2001 with similar preoperative characteristics (C statistic=0.86). The cumulative 12-year survival estimated by use of the Kaplan-Meier method was higher for the RA graft patients (hazard ratio 0.76; P=0.03). This survival advantage was especially significant in diabetics (P=0.005), in women (P=0.02), and in the elderly (P=0.04.) The protective effect appeared beginning at year 5 post surgical intervention. CONCLUSION: The RA as a secondary conduit provided superior long-term survival after CABG, especially in diabetic patients, women, and the elderly. This effect was most pronounced >5 years after surgery.

Impact of virtual cross match on waiting times for heart transplantation.

BACKGROUND: Heart transplantation for sensitized patients has been a significant challenge. In this study, outcome of heart transplantation in sensitized patients with virtual cross match was compared with prospective cross match. METHODS: Prior to July 2007, prospective cross match was used and afterward, virtual cross match with Luminex (One Lambda, Inc, Canoga Park, CA) based antibody analysis was used for potential heart transplant recipients. Prospectively collected data for the 3 years before and after July 2007, in sensitized (panel reactive antibody greater than 10%) and nonsensitized heart transplant recipients were reviewed. RESULTS: One hundred sixty-eight patients met inclusion criteria for analysis (78 patients for prospective cross match and 90 patients for virtual cross match). Multiple parameters were compared for the prospective cross match and virtual cross match eras. Three-year survivals in nonsensitized patients were 84.6% and 77.2% and in sensitized patients were 76.9% and 77.4% (p = 0.49) for prospective cross match and virtual cross match eras, respectively. Freedom from 3A (2R) cellular rejection in nonsensitized patients was 96.9% and 95.3%, and in sensitized patients was 90.9% and 100% (p = 0.83). Freedom from antibody-mediated rejection in nonsensitized patients was 95.3% and 96.8%, and in sensitized patients was 90.9% and 90.5% (p = 0.65). Mean waiting time was 129 ± 246 days (mean ± SD) for the period before virtual cross match and 59 ± 78 days with virtual cross match (p = 0.018). Donor geographic area was similar for prospective and virtual cross match. CONCLUSIONS: In sensitized heart transplant candidates, virtual cross match may shorten waiting time to heart transplantation without increasing subsequent occurrence of cellular rejection, antibody mediated rejection, and mortality after heart transplantation.

Is robotic mitral valve repair a reproducible approach?

OBJECTIVE: We sought to review the surgical outcomes of our initial 120 robotic mitral valve repairs from June 2005 through April 2009. METHODS: The initial 74 repairs were performed with the first-generation da Vinci robot (Intuitive Surgical, Inc, Sunny Vale, Calif), and the last 46 were performed with the da Vinci Si HD model. All patients received an annuloplasty band and 1 or more of the following: leaflet resection; annuloplasty; basal chord transposition, polytetrafluoroethylene neochordal replacement, or both; and edge-to-edge repair. RESULTS: The overall mean age was 58.4 +/- 10.5 years, and 64% were male. There was 1 (0.8%) hospital mortality. Five patients required mitral valve replacement for a failed repair. Another patient had mitral valve rerepair on postoperative day 2. Except for 2 early reoperations for postoperative bleeding, all of the complications and failed repairs requiring operative revision occurred with the original robot. Postdischarge transthoracic echocardiographic follow-up was available on 107 (93%) of 115 patients, with a median follow-up of 321 days. None to mild mitral regurgitation was seen in 102 (89%) patients, moderate mitral regurgitation was seen in 9 (8.4%) patients, and severe mitral regurgitation was seen in 3 (2.8%), with 1 patient undergoing mitral valve replacement and 2 patients being medically managed. CONCLUSIONS: The majority of complications and all the repeat operations for failed mitral valve repair occurred with the older-model da Vinci robot. The newer da Vinci Si HD system, with the addition of an adjustable left atrial roof retractor, improves mitral valve exposure, enhancing the surgeon's ability to repair and test the valve. We have progressed to successful repair of all types of degenerative mitral valve pathology and have found the approach reproducible.

Thoracic aortic arteriosclerosis in patients with degenerative aortic stenosis with and without coexisting coronary artery disease.

BACKGROUND: The association between the severity of arteriosclerosis in the thoracic aorta in patients with isolated aortic stenosis (AS) and with concomitant coronary artery disease (CAD) has been not evaluated. Therefore, the aim of our study was to compare the thoracic aortic atheroma extent and severity in patients with severe AS alone and with concomitant CAD by intraoperative transesophageal echocardiography. METHODS: We retrospectively evaluated echocardiograms of 105 consecutive patients with severe degenerative AS who underwent aortic valve replacement. Sixty patients had concomitant CAD (AS/CAD) on coronary angiography and 45 had no CAD (AS alone). These patients were compared with 54 sex- and age-matched patients without AS or CAD. Aortic atheroma (localized intimal thickening of >3 mm) prevalence and morphology in three segments of aorta were assessed with echocardiography. RESULTS: There were 62 men, mean age 75.3 +/- 9.4 years. No difference was observed in age, sex, and risk factors for arteriosclerosis other than hypercholesterolemia among AS/CAD, AS alone, and control groups (88%, 67%, 41%, respectively; p < 0.0001). The AS/CAD group had a significantly higher rate of aortic root calcification (68%, 36%, 26%, respectively; p < 0.0001) and aortic atheroma (ascending aorta [26%, 20%, 14%, respectively; p = 0.03]; aortic arch [78%, 36%, 30%, respectively; p < 0.0001]; descending aorta [72%, 42%, 29%, respectively; p < 0.0001]) than AS alone or control subjects. Patients with AS/CAD also had more complex atheromas in the aortic arch (48%, 20%, 7%, respectively; p < 0.0001). Significant differences in extension of aortic arteriosclerosis (presence of plaques in two or three segments) were observed among the groups (70%, 31%, 18%, respectively; p < 0.0001). CONCLUSIONS: Patients with severe AS and coexisting CAD have more extensive arteriosclerotic changes in the thoracic aorta compared with those with AS alone and control subjects. Preoperative evaluation of the thoracic aorta and more aggressive lipid therapy should be considered in these patients.

Risk factors associated with reoperation and mortality in 252 patients after aortic valve replacement for congenitally bicuspid aortic valve disease.

BACKGROUND: We aimed to determine the risk factors associated with mortality in patients with congenitally bicuspid aortic valve disease and dilation (<5 cm) of the ascending aorta after aortic valve replacement. METHODS: We reviewed 252 patients with bicuspid aortic valve undergoing aortic valve replacement at our institution from 1971 through 2000. Patients undergoing concomitant replacement of the ascending aorta were excluded. RESULTS: The average patient age was 61 +/- 15 years; 66.3% were male, and 40.5% of patients had coronary artery disease. The ascending aorta was normal (<4.0 cm) in 60.3%, mildly dilated (4.0 to 4.4 cm) in 24.2%, and moderately dilated (4.5 to 4.9 cm) in 15.5% of patients. Patients with moderate aortic dilatation had significantly lower prevalence of coronary artery disease compared with patients with normal ascending aortas (20.5% and 45.4%; p = 0.006). Mean follow-up was 8.9 +/- 6.3 years. Long-term survival was significantly different across the three groups (p = 0.004). The 5-, 10-, and 15-year estimates were 78%, 59%, and 37%, respectively, in the normal aorta group; 88%, 77%, and 46%, respectively, in the mild aortic dilation group; and 92%, 83%, and 70%, respectively, in the moderate aortic dilation group. No significant difference in cardiac death was found among the groups (p = 0.08). The significant predictors of survival using the Cox regression model were coronary artery disease, age, decade of surgery, and ejection fraction. Aortic dilation was not significant after adjusting for these other variables. At follow-up, 18 patients required reoperation, 17 for aortic valve prosthesis failure and 1 for ascending aorta aneurysm. CONCLUSIONS: The present study highlights the important adverse effect of concomitant coronary artery disease, advanced age, earlier decade of surgery, and reduced left ventricular ejection fraction on survival after aortic valve replacement for bicuspid aortic valve in patients with no or mild and moderate (<5 cm) dilation of the ascending aorta.