Homograft Aortic Root Replacement for Destructive Prosthetic Valve Endocarditis: Results in the Current Era.

Background: Destructive aortic prosthetic valve endocarditis portends a high morbidity and mortality, and requires complex high-risk surgery. Homograft root replacement is the most radical and biocompatible operation and, thus, the preferred option. Methods: A retrospective analysis was conducted on 61 consecutive patients who underwent a cardiac reoperation comprising homograft aortic root replacement since 2010. The probabilities of survival were calculated with the Kaplan-Meier method, whereas multivariable regression served to outline the predictors of adverse events. The endpoints were operative/late death, perioperative low cardiac output and renal failure, and reoperations. Results: The operative (cumulative hospital and 30-day) mortality was 13%. The baseline aspartate transaminase (AST) and associated mitral procedures were predictive of operative death (p = 0.048, OR [95% CIs] = 1.03 [1-1.06]) and perioperative low cardiac output, respectively (p = 0.04, OR [95% CIs] = 21.3 [2.7-168.9] for valve replacement). The latter occurred in 12 (20%) patients, despite a normal ejection fraction. Survival estimates (±SE) at 3 months, 6 months, 1 year, and 3 years after surgery were 86.3 ± 4.7%, 82.0 ± 4.9%, 75.2 ± 5.6, and 70.0 ± 6.3%, respectively. Survival was significantly lower in the case of AST ≥ 40 IU/L (p = 0.04) and aortic cross-clamp time ≥ 180 min (p = 0.01), but not when excluding operative survivors. Five patients required early (two out of the five, within 3 months) or late (three out of the five) reoperation. Conclusions: Homograft aortic root replacement for destructive prosthetic valve endocarditis can currently be performed with a near 90% operative survival and reasonable 3-year mortality and reoperation rate. AST might serve to additionally stratify the operative risk.

Three-Dimensional Finger Test: A New Echocardiographic Method to Locate the Best Access Site During NeoChord Procedure.

OBJECTIVE: Transventricular beating-heart mitral valve repair (TBMVR) with artificial chordae implantation is a technique to treat mitral valve prolapse. Two-dimensional (2D) echocardiography completed with simultaneous biplane view during surgeon finger pushing on the left ventricular (LV) wall (finger test [FT]) is currently used to localize the desired LV access, on the inferior-lateral wall, between the papillary muscles (PMs). We aimed to compare a new three-dimensional (3D) method with conventional FT in terms of safety and better localization of LV access. METHODS: During TBMVR, conventional FT was completed using 3D transesophageal echocardiography by placing the sample box in the bicommissural view of the LV, including the PMs and the apex. The 3D volume was subsequently edited to visualize the LV from above (surgical view) to localize the bulge of the operator's finger pushing on the LV. We asked the first operator, the second operator, and the cardiac surgery fellow, separately, to evaluate the location of their finger pushing, both with the 2D method and the 3D method, to estimate the interoperator concordance. RESULTS: From 2019 to 2021, 42 TBMVRs were performed without complications related to access using FT completed with the 3D method. Regarding the choice of the right and safe entry site, the operator's agreement was higher using 3D rendering compared with conventional FT (mean agreement 0.59 ± 0.29 for 2D vs 0.83 ± 0.20 for 3D), while full operator agreement was 10 of 42 for 2D and 23 of 42 for 3D (P = 0.004). CONCLUSIONS: Three-dimensional FT is easy to perform and facilitates surgeons choosing the best access for TBMVR in term of anatomical localization and safety.

New Echocardiographic Parameters Predicting Successful Trans-Ventricular Beating-Heart Mitral Valve Repair with Neochordae at 3 Years: Monocentric Retrospective Study.

The NeoChord procedure is an echo-guided trans-ventricular beating-heart mitral valve repair technique to treat degenerative mitral regurgitation (MR) due to prolapse and/or flail. The aim of this study is to analyze echocardiographic images to find pre-operative parameters to predict procedural success (≤moderate MR) at 3-year follow-up. Seventy-two consecutive patients with severe MR underwent the NeoChord procedure between 2015 and 2021. MV pre-operative morphological parameters were assessed using 3D transesophageal echocardiography with dedicated software (QLAB, Philips). Three patients died during their hospitalization. The remaining 69 patients were retrospectively analyzed. At follow-up, MR > moderate was found in 17 patients (24.6%). In the univariate analysis, end-systolic annulus area (12.5 ± 2.5 vs. 14.1 ± 2.6 cm2; p = 0.038), end-systolic annulus circumference (13.2 ± 1.2 vs. 14 ± 1.3 cm; p = 0.042), indexed left atrial volume (59 ± 17 vs. 76 ± 7 mL/m2; p = 0.041), and AF (25% vs. 53%; p = 0.042) were lower in the 52 patients with ≤ MR compared to those with > moderate MR. Annular dysfunction parameters were the best predictors of procedural success: 3D early-systolic annulus area (AUC 0.74; p = 0.004), 3D early-systolic annulus circumference (AUC 0.75; p = 0.003), and 3D annulus area fractional change (AUC 0.73; p = 0.035). Patient selection relying on 3D dynamic and static MA dimensions may improve the maintenance of procedural success at follow-up.

Lung Transplantation for Primary Ciliary Dyskinesia and Kartagener Syndrome: A Multicenter Study.

Primary ciliary dyskinesia, with or without situs abnormalities, is a rare lung disease that can lead to an irreversible lung damage that may progress to respiratory failure. Lung transplant can be considered in end-stage disease. This study describes the outcomes of the largest lung transplant population for PCD and for PCD with situs abnormalities, also identified as Kartagener's syndrome. Retrospectively collected data of 36 patients who underwent lung transplantation for PCD from 1995 to 2020 with or without SA as part of the European Society of Thoracic Surgeons Lung Transplantation Working Group on rare diseases. Primary outcomes of interest included survival and freedom from chronic lung allograft dysfunction. Secondary outcomes included primary graft dysfunction within 72 h and the rate of rejection ≥A2 within the first year. Among PCD recipients with and without SA, the mean overall and CLAD-free survival were 5.9 and 5.2 years with no significant differences between groups in terms of time to CLAD (HR: 0.92, 95% CI: 0.27-3.14, p = 0.894) or mortality (HR: 0.45, 95% CI: 0.14-1.43, p = 0.178). Postoperative rates of PGD were comparable between groups; rejection grades ≥A2 on first biopsy or within the first year was more common in patients with SA. This study provides a valuable insight on international practices of lung transplantation in patients with PCD. Lung transplantation is an acceptable treatment option in this population.

Surgical left ventricle remodeling to treat functional mitral valve regurgitation.

A left ventricular aneurysm complicates an acute myocardial infarction in 4-20% of patients. The loss of the physiological geometry of the ventricle can lead to a dislocation of the papillary muscles with subsequential mitral valve regurgitation. The goal of this case report is to demonstrate that a proper operation to restore the left ventricular anatomy can be a feasible procedure to correct functional mitral regurgitation.

HLA-DRB1 mismatch-based identification of donor-derived cell free DNA (dd-cfDNA) as a marker of rejection in heart transplant recipients: A single-institution pilot study.

BACKGROUND: Donor-derived cell-free DNA (dd-cfDNA) is considered a reliable marker of organ damage with potential applications in the follow-up of transplant recipients. METHODS: In this work we present an assay based on the donor-recipient HLA-mismatch (human leukocyte antigen) at the HLA-DRB1 locus to monitor rejection by quantifying the percentage of dd-cfDNA using a droplet digital PCR (polymerase chain reaction) technique. A panel of probes targeting the HLA-DRB1 locus and covering >85% genetic variability was validated and used to assess dd-cfDNA levels in a prospective cohort of 19 adult heart transplant recipients (mean age 50.9±14.8 years). The assay was carried out on a total of 232 liquid biopsies collected at the same time as endomyocardial biopsy (EMB) during routine post-transplant follow-up. RESULTS: Results show a significant increase of dd-cfDNA related to ischemia-reperfusion injury (2.22±2.09%) and to acute cellular rejection (1.71±3.10%) compared to stable conditions (0.43±1.04%, p < 0.0001). On the contrary, no increase was observed during infections or vascular complications, underlining the potential role of this biomarker for rejection monitoring. With a cut-off of 0.11%, the test showed 70.8% specificity (95% CI, 58.17% - 81.40%) and 64.2% sensitivity (95% CI, 49.80% - 76.86%) in discriminating acute rejection from no rejection. CONCLUSIONS: These data demonstrate that this HLA mismatch-based droplet digital PCR method is effective for monitoring rejection in heart transplant recipients. Compared to next generation sequencing approaches, it is far more flexible, less expensive and provides faster results.

Noncalcific Mechanisms of Bioprosthetic Structural Valve Degeneration.

Bioprosthetic heart valves (BHVs) largely circumvent the need for long-term anticoagulation compared with mechanical valves but are increasingly susceptible to deterioration and reduced durability with reoperation rates of ≈10% and 30% at 10 and 15 years, respectively. Structural valve degeneration is a common, unpreventable, and untreatable consequence of BHV implantation and is frequently characterized by leaflet calcification. However, 25% of BHV reoperations attributed to structural valve degeneration occur with minimal leaflet mineralization. This review discusses the noncalcific mechanisms of BHV structural valve degeneration, highlighting the putative roles and pathophysiological relationships between protein infiltration, glycation, oxidative and mechanical stress, and inflammation and the structural consequences for surgical and transcatheter BHVs.

Use of a photo-realism 3D rendering technique to enhance echocardiographic visualization of the anatomical details during beating-heart mitral valve repair.

The NeoChord procedure is an innovative microinvasive, transventricular, beating-heart chordal replacement technique for patients with severe degenerative mitral valve regurgitation resulting from prolapsed or flail leaflets. Use of three-dimensional (3D) transoesophageal echocardiographic imaging is crucial to the physician operator for device navigation during the procedure and to assess the functional results of the repair at the end of the procedure. Photo-realistic, 3D rendering techniques have been recently developed for medical use. Philips TrueVue (Philips Healthcare, Eindhoven, NL) is a photo-realism technique that employs the use of a virtual light source that simulates the interaction of light on 3-dimensional surfaces. Use of photo-realism techniques, in conjunction with 3D echocardiography, improves the visualization of morphological characteristics of the mitral valve before, during, and after beating-heart mitral valve repair procedures.

Extracorporeal membrane oxygenation after lung transplantation: risk factors and outcomes analysis.

BACKGROUND: Lung transplantation is the treatment of choice for end-stage pulmonary disease in selected patients. However, severe primary graft dysfunction is a significant complication of transplant and requires the implantation of an extracorporeal support. The aim of the study is to evaluate the impact of extracorporeal membrane oxygenation (ECMO) after transplant in our center. METHODS: From January 2008 till June 2018, 195 consecutive unselected patients receiving a lung transplant were considered. Mean age was 49±15 years. Main indications for transplant were idiopathic pulmonary fibrosis in 72 patients, chronic obstructive pulmonary disease in 60 patients, and cystic fibrosis in 40 patients. Prior to transplant, 18 patients were on mechanical ventilation and 14 were on ECMO. RESULTS: Twenty-five patients required venous-venous ECMO after transplant. Vascular disease as cause of transplant [relative risk (RR) 7.8, 95% CI: 1.5-41, P=0.02], donor age (RR 1.6, 95% CI: 1.03-2.3, P=0.03) and need for cardiopulmonary by-pass during transplant (RR 3.1, 95% CI: 1.02-9, P=0.04) were associated with ECMO implantation. Patients requiring post-transplant ECMO received more transfusions (P<0.01), had a longer mechanical ventilation (P<0.01) and ICU stay (P<0.01) and had a higher hospital mortality (P<0.01). Post-transplant ECMO significantly influenced one- and five-year survival [hazard ratio (HR) 5.5, 95% CI: 3-10, P<0.001 and HR 3.5, 95% CI: 2-6, P<0.001, respectively]. However, conditional survival after t months is similar for patients with or without post-transplant ECMO. CONCLUSIONS: In our experience, although ECMO is a reliable and effective strategy to support pulmonary function, severe graft dysfunction after lung transplantation still has a significant impact on early and late results.

Off-Pump NeoChord Mitral Valve Repair to Simultaneously Treat Posterior Leaflet Prolapse and Systolic Anterior Motion.

This case represents the first report of complete elimination of systolic anterior motion by beating-heart implantation of artificial chordae tendineae on a prolapsing and redundant posterior leaflet.