Comparison of modified Del Nido and Custodiol® cardioplegia in minimally invasive mitral valve surgery.

OBJECTIVES: In this study, we evaluated if modified Del Nido cardioplegia delivers comparable cardiac protection in comparison to Custodiol® in patients undergoing isolated minimally invasive mitral valve repair. METHODS: From January 2018 to October 2021, all patients undergoing non-emergent isolated minimally invasive mitral valve repair were included in this study. The cardioplegia was chosen at the surgeons' discretion. The primary end points of this study were peak postoperative cardiac enzyme levels. Secondary end points were in-hospital mortality, hospital stay, occurrence of cardiac arrhythmias, pacemaker implantations, postoperative lactate and sodium levels and postoperative incidence of renal failure requiring dialysis. RESULTS: A total of 355 patients were included in this study. The mean age of patients was 57. After propensity score matching, a total of 156 pairs were identified. There was no difference in cross-clamp time between both groups. Postoperative creatine kinase levels were higher in patients receiving Custodiol on the 1st and 2nd postoperative days. Creatine kinase isoenzyme MB levels were higher in patients receiving Custodiol on the 2nd postoperative day (0.5 ± 0.2 vs 0.4 ± 0.1 µmol/l s; P < 0.001). Postoperative Troponin T concentrations were similar between both groups. Maximum lactate concentrations were higher in patients receiving Custodiol on the day of surgery (2.4 ± 1.9 vs 2.0 ± 1.1 mmol/l; P = 0.04). The overall hospital stay was longer in patients receiving Del Nido cardioplegia (10.6 ± 3.2 vs 8 ± 4.1 days; P < 0.01). CONCLUSIONS: Modified Del Nido cardioplegia based on Ionosteril® solution offers equivalent protection compared to Custodiol for isolated minimally invasive mitral valve repair.

Percutaneous versus open surgical cannulation for minimal invasive cardiac surgery; immediate postprocedural outcome analysis.

Objectives: Open surgical cannulation (SC) is traditionally used for cardiopulmonary bypass cannulation in minimally invasive cardiac surgery (MICS). The percutaneous cannulation (PC) technique using arterial closure devices has also been used in select centers. The aim of this study was to compare outcomes between patients undergoing the PC or SC approach, with a particular focus on cannulation-related groin complications. Methods: A retrospective analysis of patients undergoing MICS at our institution between January 2018 and April 2022 was performed. Starting from June 2020, 3 surgeons at our institution started using the PC approach. For patients in the PC group, a primary suture-based technique (ProGlide) complemented by a small-sized plug-based closure device (AngioSeal) was used. The primary end point of the study was groin complications following the procedures. Results: A total of 524 patients underwent MICS through a right lateral minithoracotomy during the study time period. Of these, 88 patients (17%) were cannulated using PC approach and 436 (83%) using SC approach. The total number of cannulation-related groin complications was greater in the SC group (4% vs 0%, P = .05). Propensity score matching resulted in 2 comparable groups, with 172 patients in the SC group and 86 patients in the PC group. The number of groin complications remained greater in the SC group (P = .05). In-hospital mortality was comparable between groups (1% PC vs 0% SC, P = .3). Conclusions: The PC approach is a safe cannulation technique for patients undergoing MICS. It minimizes postoperative groin complications with no obvious negative impact on outcomes.

Outcome of aortic valve replacement for active infective endocarditis in patients on chronic hemodialysis.

BACKGROUND: The high risk of morbidity and mortality for patients on hemodialysis who are undergoing cardiac surgery is increased for those with active infective endocarditis (AIE). This retrospective observational single-center study evaluated the impact of chronic hemodialysis on the outcome of aortic valve replacement in patients with aortic AIE. METHODS: Data were retrospectively collected for consecutive patients undergoing aortic valve surgery for AIE diagnosed according to modified Duke criteria between October 1994 and January 2011. Characteristics and outcomes of patients receiving preoperative chronic hemodialysis were analyzed. RESULTS: Aortic valve AIE was present in 992 patients. Forty-five (4.5%) of the aortic valve AIE patients were receiving long-term hemodialysis preoperatively, 19 of whom (42.2%) had diabetes mellitus. Mean logistic EuroSCORE was 64.2% ± 32.2%. Twenty-four preoperative septic emboli were found in 15 patients. Results of microbiologic cultures were positive in 36 patients, with the major causative organisms identified as Staphylococcus aureus (n = 17) and Enterococcus faecalis (n = 10). Isolated aortic valve replacement was performed in 19 patients (42.2%), and 26 patients (57.8%) underwent concomitant procedures. The mean follow-up was 5.3 ± 5.2 years (range, 0.1 to 17.1 years). Postoperative complications occurred in 30 patients (66.7%). Nineteen patients (42.2%) died within 30 days of surgery, which in 8 patients was attributable to a cardiac cause. CONCLUSIONS: In patients receiving chronic hemodialysis who undergo aortic valve replacement for acute AIE, postoperative mortality is high, especially in patients undergoing aortic root replacement or culture-negative AIE.

Repair of the anterior mitral leaflet prolapse.

Repair of anterior mitral leaflet prolapse is one of the most challenging aspects in mitral valve repair surgery. In this review, we discuss the various techniques developed over the past three to four decades for the repair of anterior mitral leaflet prolapse, debate the pros and cons of each and compare their results, keeping reoperation for recurrent mitral regurgitation as the focal point of follow-up. At our center, chordal replacement with artificial expanded polytetrafluoroethylene sutures in the form of premeasured loops is the most commonly used technique for repair of anterior mitral leaflet prolapse for the past decade. We recommend and provide justification for the use of this technique, especially when mitral valve repair is performed through a minimally invasive approach. We believe that the trend towards a minimally invasive approach for mitral valve repair will exponentially increase in the next 5-10 years, at least until percutaneous techniques, if at all, become more reliable and safe.

Concomitant tricuspid valve repair in patients with minimally invasive mitral valve surgery.

BACKGROUND: The aim of this study was to investigate the 10-year Leipzig experience with minimally invasive mitral valve (MIMV) surgery in combination with tricuspid valve (TV) surgery. METHODS: Between January 2002 and December 2011, a total of 441 patients with mitral valve (MV) dysfunction and concomitant TV regurgitation (TR) underwent MIMV surgery at the Leipzig Heart Center. The mean age was 68.7±10.0 years, mean LVEF was 56.7%±13.1% and 184 patients (41.7%) were male. The Average logEuroSCORE was 8.3%±7.2%, and patients had an average follow-up of 3.4±2.4 years. RESULTS: Pre-discharge echocardiography showed no or mild mitral regurgitation (MR) in 95.1% and no or mild TR in 84.1%. Overall 30-day mortality was 4.3% with nineteen deaths. Five-year survival was 77.2%±2.5%. Five-year freedom from TV-related reoperation was 91.0%±1.8%. CONCLUSIONS: Our 10-year experience show that MIMV surgery in combination with TV surgery can be performed routinely with good peri- and post-operative results. Our observations support current recommendations to perform concomitant TV repair, particularly if tricuspid annular dilation is present.

Mitral valve pathology in severely impaired left ventricles can be successfully managed using a right-sided minimally invasive surgical approach.

OBJECTIVES: We sought to review our experience in patients with severely impaired left ventricular function (ejection fraction (EF) ≤ 30%) who underwent minimally invasive mitral valve (MV) surgery (Mini-MV). METHODS: Between 1999 and 2010, a total of 3450 patients underwent Mini-MV surgery at our institution. Of these, 177 had severely impaired left ventricular function (EF < 30%, including ischaemic and non-ischaemic cardiomyopathy). Primary indication for surgery was MV regurgitation in all but 5 patients (2.8%), who were diagnosed with mixed regurgitation and stenosis. Mean age of patients was 67 ± 11 years and 110 were male (62.1%). Mean EuroSCORE predicted risk of mortality was 14.7 ± 13.6%. RESULTS: MV repair was accomplished in 86.4% of patients (n = 153), and MV replacement was performed in 13.6% (n = 24). Primary MV repair included implantation of a rigid annuloplasty ring (mean size 29.5 ± 2.2 mm) in 95.4% of patients, and additional MV procedures as required. Concomitant procedures consisted of tricuspid valve surgery in 15.3% of patients, atrial fibrillation ablation in 27.1% and atrial septal defect/persistent foramen ovale closure in 5.6%. The duration of cardiopulmonary bypass was 123 ± 64 min and aortic cross-clamp time was 67 ± 27 min. Thirty-day mortality was 7.9%. The mean follow-up time was 3 ± 2.5 years, and the follow-up was 94.0% complete. Ten-year survival was 45.5% (95% CI: 35.2-55.9) for the overall group. The rate of MV-related reintervention was 4%, while heart transplantation was performed in 6%. CONCLUSIONS: Mini-MV surgery in patients with significantly impaired left ventricular function can be performed with a reasonable operative mortality and acceptable long-term survival for this high-risk patient cohort.

Gender-specific remodeling in atrial fibrillation?

BACKGROUND: The authors wanted to investigate whether the remodeling process in AF regarding gap junction proteins, collagen I, and amyloid may be gender dependent in humans. METHODS: In total, 123 patients with sinus rhythm (SR, n = 41) or atrial fibrillation (AF, n = 82) suffering from mitral valve disease undergoing cardiac surgery were included. Of the 123 patients, 66 patients (SR: n = 17, AF: n = 49) were investigated biochemically for the expression of the atrial gap junction proteins connexin40 (Cx40), connexin43 (Cx43) and collagen I and 57 patients (SR: n = 24; AF: n = 33) using histochemical methods for possible amyloid depositions. RESULTS: AF led to increased levels of Cx40, Cx43, and collagen I protein. Regarding Cx40 this upregulation was significantly higher in female than in male patients. For AF-induced changes in collagen or Cx43, there were no significant gender-dependent differences. Amyloid depositions were found with increasing age, but were not significantly related to AF or gender. CONCLUSIONS: Remodeling in AF seems to be similar in men and women, with a tendency for women exhibiting somewhat stronger AF-induced changes in Cx40, which is probably a secondary effect because there is nothing known about hormone sensitivity of the Cx40 promoter, and a not significant tendency for higher Cx43 and collagen I.

Gender differences in mitral valve surgery.

BACKGROUND: Knowledge regarding gender-specific mitral valve (MV) pathology and postoperative outcome is rare. We herein describe a single-center experience focusing on gender differences in MV surgery. MATERIALS AND METHODS: A total of 3,761 patients underwent minimal invasive MV surgery at our institution between 1999 and 2011. Demographic data, pre-, intra-, and postoperative characteristics have been collected, including details on MV pathology and surgical technique. Patient data have been analyzed with consideration of gender-specific differences. RESULTS: The cohort consisted of 2,124 male (56.5%; 58.8 ± 12.5 years) and 1,637 female (43.5%; 64.5 ± 13 years) patients. Mitral regurgitation was observed equally in women (91.3%) and men (92.4%). Additional MV stenosis has been diagnosed in 2.7% of men but in 13.9% of women (p < 0.001). Calcification of the posterior MV leaflet showed a similar trend: 20.1% in women compared with 6.5% in men. Prolapse of the posterior leaflet was present predominantly in men with 63.1 versus 35.7% in women (p < 0.001). Distinct MV repair differences were retrospectively detected between genders: posterior mitral leaflet resection was performed in 17.9% of men versus 10.1% of women; posterior mitral leaflet chordae replacement was performed in 39.3% of men compared with 20.4% of women. Prosthetic MV replacement was necessary in 26.8% of women compared with only 10.7% of men. Concomitant tricuspid valve surgery was mostly performed in women (14.4 versus 8.2%). Male patients showed a significant better postoperative long-term survival than females, with 96, 89, and 72% compared with 92, 82, and 58% after 1, 5, and 10 years, respectively (p < 0.0001). CONCLUSION: Substantial gender-specific differences regarding MV pathology, operative strategy, and long-term outcome are present that need to be addressed in clinical practice.

Isolated tricuspid valve surgery in patients with previous cardiac surgery.

OBJECTIVES: Few studies have been published in literature on outcomes of isolated tricuspid valve (TV) surgery when performed as a reoperation. Hence, we analyzed our early and midterm results of TV surgery in this unique group of patients. METHODS: We performed a retrospective analysis of 82 consecutive patients who underwent isolated TV surgery as a reoperation at our institution between 1997 and 2010. Symptomatic TV regurgitation (84.2%), acute endocarditis (14.6%), and valve thrombosis after TV repair (1.2%) were the indications for surgery. A minimally invasive access through a right anterolateral thoracotomy was the preferred approach in 60% of the patients. Previous cardiac operations included mitral, aortic, and TV surgery in 60%, 29%, and 27% and coronary bypass surgery in 18%, usually performed as combined procedures. Elective surgery was performed in 67.1% of the patients. Mean patient age was 64.1 ± 11.9 years, 28% being male with an average logistic EuroSCORE of 16.4% ± 14.3%. Follow-up was 96% complete, with a mean duration of 2.6 ± 2.4 years. RESULTS: Overall thirty-day mortality was 14.6%; for patients without and with endocarditis, it was 12.9% and 25%. Thirty-day mortality for patients undergoing elective surgery was 4.0%. Overall 2-year survival was 63.0% ± 5.5%. The 2-year freedom from TV-related reoperation was 93.5% ± 3.3%. CONCLUSIONS: Postoperative results of isolated TV surgery as a reoperation are acceptable when performed electively but dismal in patients undergoing nonelective surgery. Thus, redo TV surgery, when indicated, should be performed sooner rather than later. Minimally invasive surgery through a right lateral minithoracotomy is a safe approach for patients with elective surgery.

Minimally invasive mitral valve repair for anterior leaflet prolapse.

OBJECTIVE: Mitral valve repair for anterior mitral leaflet prolapse is technically challenging. We report here our experience with minimally invasive anterior mitral leaflet repair. METHODS: Our institutional database for minimally invasive mitral valve surgery was screened for patients with mitral regurgitation caused by isolated prolapse of the anterior mitral leaflet. Patient characteristics, intraoperative data, and short- and long-term outcomes are analyzed and reported. RESULTS: A total of 180 patients presented with mitral regurgitation caused by isolated anterior mitral leaflet prolapse. All patients underwent minimally invasive surgery at our institution between 1999 and 2010. Mitral valve repair was performed in 170 cases (94.4%), and these patients form the focus of this study. The mean age of the patients was 59.7 ± 14.8, and their mean log EuroSCORE was 4.9 ± 5.1. Mean aortic crossclamp time (cardiopulmonary bypass time) was 82 ± 25 minutes (130 ± 40 minutes). Mitral valve repair techniques were neochordal replacement with the loop technique in 68.2% of patients, chordal transfer in 14.7%, anterior mitral leaflet resection in 7.1%, and edge-to-edge repair in 5.9%. Thirty-day mortality was 1.8%. Kaplan-Meier estimates showed 86.7% ± 3.2% survival and 95.7% ± 1.6% freedom from mitral valve reoperation at 5 years. CONCLUSIONS: This large series demonstrates good results for anterior mitral leaflet repair with the minimally invasive approach.

Isolated reoperative minimally invasive tricuspid valve operations.

BACKGROUND: Tricuspid valve (TV) regurgitation has recently been identified as a major risk factor for long-term mortality. Isolated reoperative tricuspid valve repair/replacement (TVR/r) carries an excessively high operative risk. Currently, isolated TVR/r with minimally invasive access through a right lateral thoracotomy is being used increasingly in our institution to treat progressive TV pathologic processes after previous cardiac operations. We analyzed our early and midterm results with reoperative TVR/r in this unique patient cohort. METHODS: Forty-eight consecutive patients underwent isolated TV operations after previous cardiac operations with minimally invasive access through a right lateral thoracotomy at our institution between September 2000 and December 2011. Previous cardiac operations included 26 patients (54.2%) with mitral valve replacement/repair, 18 patients (37.5%) with an aortic valve replacement, 10 patients (20.4%) with a TVR/r, and 8 patients (16.7%) with coronary artery bypass grafting. Operations were performed electively in 79% of patients (n=38). Mean patient age was 63.8±13.4 years, with an average log EuroSCORE of 13.9%±11.3%; 67% of patients were women. Follow-up was 94% complete, with a mean duration of 2.8±2.3 years. RESULTS: Thirty-day mortality for patients undergoing elective surgery was zero. For all patients early mortality was 4.2%. Five-year survival for patients after elective reoperative TVR/r through minimally invasive access was 72.2%±10.0%, and 5-year freedom from TV-related reoperations was 88.1%±6.7%, respectively. CONCLUSIONS: Minimally invasive access through a right thoracotomy provides a safe option for reoperative TVR and offers excellent early outcome, particularly in elective cases. Surgical intervention should be performed earlier rather than later.

Postoperative outcome of isolated tricuspid valve operation using arrested-heart or beating-heart technique.

BACKGROUND: Tricuspid valve (TV) operations can be done with either a beating-heart or arrested-heart technique. We herein report the postoperative outcome of patients with isolated TV operations performed with a beating heart or arrested heart, having a closer look at echocardiographic results after TV repair, postoperative incidence of pacemaker implantations, neurologic complications, survival, and freedom from TV-related reoperation. METHODS: We present a retrospective analysis of 105 patients who underwent isolated TV operations with a beating-heart (n=63) or arrested-heart technique (n=42). Mean patient age was 61.2±15.1 years. Male patients were 41.9% of the total, and the average log EuroSCORE was 12.4%±11.4%. Redo operations made up 51.4% of the total. Follow-up was 95% complete, with a mean duration of 32.0±32.6 months. RESULTS: Overall operative mortality was 8.6%. Five-year survival was 68.8%±7.1% versus 66.3%±9.1% for patients with beating-heart versus arrested-heart operations (p=0.9). During follow-up, 7 patients underwent TV reoperations, resulting in a 5-year event-free survival rate of 90.1%±5.9% for patients with beating-heart and 84.0%±6.7% for patients with arrested-heart operations. There was no significant difference regarding postoperative echocardiographic results after TV repair, postoperative pacemaker implantations, or neurologic outcome. CONCLUSIONS: Although both cohorts were very heterogeneous and difficult to compare, our results show that both surgical strategies for TV repair have good results regarding postoperative survival, neurologic complications, and postoperative indications for a pacemaker. TV repair with the beating-heart technique has excellent results and can be safely accomplished in a minimally invasive manner.

Increased risk of dehiscence after tricuspid valve repair with rigid annuloplasty rings.

OBJECTIVES: Surgical management of tricuspid valve regurgitation mainly consists of tricuspid valve annuloplasty, usually performed with implantation of a rigid ring or a flexible band. METHODS: We performed a retrospective analysis on 820 patients who underwent tricuspid valve repair between March 2002 and July 2009 with either a flexible Cosgrove-Edwards band (n = 415; Edwards Lifesciences LLC, Irvine, Calif) or a rigid Carpentier-Edwards Classic annuloplasty ring (n = 405; Edwards Lifesciences). Mean patient age was 69.2 ± 9.5 years, 54.1% were female, and average logistic EuroSCORE was 13.3% ± 12.5%. Concomitant procedures were performed in 94.6% of patients (mitral valve surgery, 80.6%; aortic valve surgery, 28.2%; coronary artery bypass grafting, 24.5%; atrial fibrillation ablation, 44.5%). One fifth of the operations were reoperative procedures. Follow-up was 94% complete, with mean duration of 21.0 ± 19.0 months. RESULTS: Thirty-day mortality was 10.1% (Cosgrove-Edwards, 11.9%; Carpentier-Edwards, 8.4%), and 5-year survival was 62.4% (Carpentier-Edwards, 64.7%; Cosgrove-Edwards, 60.3%). Postoperative echocardiography showed significant improvement in tricuspid valve function, with reduction in tricuspid regurgitation grade from 2.3 ± 0.7 to 0.7 ± 0.7, and no differences between groups. Use of a Carpentier-Edwards ring, however, was associated with significantly higher risk of dehiscence (Carpentier-Edwards, 8.7%; Cosgrove-Edwards, 0.9%; P < .001), almost exclusively at the septal leaflet portion of the annulus. Multivariate analysis identified annuloplasty type as independently predicting ring dehiscence (odds ratio, 10.7; 95% confidence interval, 3.2-36.5; P < .001). Patients with annuloplasty dehiscence had more residual tricuspid regurgitation on predischarge echocardiography than did patients without dehiscence (1.4 ± 0.63 vs 0.7 ± 0.6; P < .001). Ten patients underwent reoperation for recurrent tricuspid regurgitation, 4 with ring dehiscence. Five-year freedom from reoperation was 95.3% (Cosgrove-Edwards, 97.7%; Carpentier-Edwards, 92.3%). CONCLUSIONS: Although both rigid and flexible systems provide acceptable early tricuspid valve repair results, use of a rigid ring increases risk of subsequent ring dehiscence.

Minimally invasive versus sternotomy approach for mitral valve surgery in patients greater than 70 years old: a propensity-matched comparison.

BACKGROUND: The goal of this study was to compare the outcome after mitral valve surgery through either standard sternotomy or right lateral minithoracotomy in elderly patients with higher perioperative risk. METHODS: All 1,027 elderly patients (>70 years) who received isolated mitral valve surgery (± tricuspid valve repair) between August 1999 and July 2009 were analyzed for outcome differences due to surgical approach using propensity score matching. The etiology of mitral valve disease was degenerative (83%), endocarditis (6%), rheumatic (10%), and acute ischemic (<1%). Isolated stenosis was rare (3%); most patients had mitral valve regurgitation (72%) or combined mitral valve disease (25%). RESULTS: The minimally invasive approach led to longer duration of surgery (186 ± 61 vs 169 ± 59 minutes, p = 0.01), cardiopulmonary bypass time (142 ± 54 vs 102 ± 45 minutes, p = 0.0001), and cross-clamp time (74 ± 44 vs 64 ± 28 minutes, p = 0.015). There were no differences between the matched groups in 30-day mortality (7.7% vs 6.3%, p = 0.82), combined major adverse cardiac and cerebrovascular events (11.2% vs 12.6%, p = 0.86), or other postoperative outcome. Only the number of postoperative arrhythmias and pacemaker implants was higher in the sternotomy group (65.7% vs 50.3%, p = 0.023 and 18.9% vs 10.5%, p = 0.059). Long-term survival was 66% ± 5.6% vs 56 ± 5.5% at 5 years and 35% ± 12% vs 40% ± 7.9% at 8 years, and did not show significant differences. CONCLUSIONS: Minimally invasive mitral valve surgery through a right lateral minithoracotomy is at least as good and safe as the standard sternotomy approach in elderly patients.

Hybrid debranching technique for aortic arch replacement.

We present the case of a 64-year-old female with a multisegmental thoracic aortic aneurysm extending from the sinu-tubular junction to the mid-descending aorta. The patient was treated by a combined vascular and endovascular approach containing an ascending aortic replacement, rerouting of the supraaortic branches by autologous double transposition followed by endovascular stent-graft placement.

Valve-in-a-valve concept for transcatheter minimally invasive repeat xenograft implantation.

OBJECTIVES: This study sought to evaluate the feasibility of minimally invasive transapical repeat valve-in-a-valve (VinV) implantation. BACKGROUND: Reoperative heart valve replacement for degenerated xenografts is associated with an increased surgical risk. METHODS: Conventional Carpentier Edwards porcine aortic (n = 5) and mitral (n = 2) valve prostheses were implanted in 7 pigs. Transapical VinV implantation of a pericardial xenograft fixed within a 23-mm stainless steel, balloon expandable stent (Cribier Edwards, Edwards Lifesciences, Irvine, California) was then performed under fluoroscopic and echocardiographic visualization on the beating heart with ventricular unloading via cardiopulmonary bypass and rapid ventricular pacing. RESULTS: Valve deployment was successfully performed in all cases. The radiopaque marking within the stent of the conventional aortic or mitral xenograft allowed for optimal positioning of the stent-delivered valve. All valves were firmly positioned without any migration. There were neither paravalvular nor transvalvular leaks, and good hemodynamic function was observed in all cases. All coronary arteries remained patent. Positioning and function were confirmed by autopsy in all animals. CONCLUSIONS: The VinV concept is promising for minimally invasive beating heart repeat aortic or mitral valve replacement, using a stent-fixed sutureless prosthesis.