[Functional tricuspid regurgitation: the increasing clinical importance of the "forgotten valve"]. / L'insufficienza tricuspidale funzionale: un'entità clinica di crescente importanza.

Functional tricuspid regurgitation (FTR) is the most frequent etiology of tricuspid valve pathology in Western countries. In the last years, many investigators have reported evidence in favor of a more aggressive surgical approach to FTR and interest has been growing in the physiopathology and treatment of FTR. The purpose of this editorial is to explore the anatomical basis, pathophysiology, therapeutic approaches and the perspectives of treatment.

Endoscopic mitral and tricuspid valve surgery after previous cardiac surgery.

BACKGROUND: The purpose of this study was to evaluate the feasibility and effectiveness of a right video-assisted approach for atrioventricular valve disease after previous cardiac surgery. METHODS AND RESULTS: Between December 1st 1997 and May 1st 2006, 80 adults (mean age 65+/-12 years; 56% female) underwent reoperative surgery using a video-assisted approach without rib spreading. Previous cardiac operations included mitral valve (39%), CABG (29%), congenital (10%), and other (23%). For 25% of patients, this was at least their third cardiac operation. Mean time to redo surgery was 15+/-12 years. Femoral vessel cannulation and endoaortic clamping were routinely used. Mean preoperative Euroscore was 9.0+/-2.7 (5 to 20) and predicted mortality was 16.0+/-14.2% (4 to 86). Median preoperative NYHA class was II and mean follow-up was 25+/-22 months. Lung adhesions necessitated sternotomy in 4 cases and cannulation problems in another patient. Total operative mortality was 3.8% (n=3), O/E for mortality being 0.24. Procedures were mitral valve repair (45%; n=36), replacement (50%; n=40) and tricuspid valve replacement (5%; n=4). Additional procedures were performed in 44% (n=35). Mean aortic crossclamp and procedure time were 92+/-37 and 267+/-64 minutes. Mean postoperative blood loss was 815+/-1083 mL. Postoperative morbidity included 2 strokes (2.5%). Mean hospital stay was 10.7+/-6.7 days. Survival at 1 and 4 years was 93.6+/-2.8% and 85.6+/-6.4%. There was 1 late reoperation at 5 years. Median NYHA class at follow-up was II. When comparing, all but 1 patient (98.8%) preferred their minimally invasive approach when considering perioperative pain, postoperative rehabilitation, and final esthetic result. CONCLUSIONS: Video-assisted minimal access correction of atrioventricular valve disease after previous cardiac surgery is not only feasible but had lower than predicted mortality and strong patient satisfaction. It should therefore be used more frequently in today's practice.

Tight perioperative glucose control is associated with a reduction in renal impairment and renal failure in non-diabetic cardiac surgical patients.

INTRODUCTION: Acute renal failure after cardiac surgery increases in-hospital mortality. We evaluated the effect of intra- and postoperative tight control of blood glucose levels on renal function after cardiac surgery based on the Risk, Injury, Failure, Loss, and End-stage kidney failure (RIFLE) criteria, and on the need for acute postoperative dialysis. METHODS: We retrospectively analyzed two groups of consecutive patients undergoing cardiac surgery with cardiopulmonary bypass between August 2004 and June 2006. In the first group, no tight glycemic control was implemented (Control, n = 305). Insulin therapy was initiated at blood glucose levels > 150 mg/dL. In the group with tight glycemic control (Insulin, n = 745), intra- and postoperative blood glucose levels were targeted between 80 to 110 mg/dL, using the Aalst Glycemia Insulin Protocol. Postoperative renal impairment or failure was evaluated with the RIFLE score, based on serum creatinine, glomerular filtration rate and/or urinary output. We used the Cleveland Clinic Severity Score to compare the predicted vs observed incidence of acute postoperative dialysis between groups. RESULTS: Mean blood glucose levels in the Insulin group were lower compared to the Control group from rewarming on cardiopulmonary bypass onwards until ICU discharge (p < 0.0001). Median ICU stay was 2 days in both groups. In non-diabetics, strict perioperative blood glucose control was associated with a reduced incidence of renal impairment (p = 0.01) and failure (p = 0.02) scoring according to RIFLE criteria, as well as a reduced incidence of acute postoperative dialysis (from 3.9% in Control to 0.7% in Insulin; p < 0.01). The 30-day mortality was lower in the Insulin than in the Control group (1.2% vs 3.6%; p = 0.02), representing a 70% decrease in non-diabetics (p < 0.05) and 56.1% in diabetics (not significant). The observed overall incidence of acute postoperative dialysis was adequately predicted by the Cleveland Clinic Severity Score in the Control group (p = 0.6), but was lower than predicted in the Insulin group (1.2% vs 3%, p = 0.03). CONCLUSIONS: In non-diabetic patients, tight perioperative blood glucose control is associated with a significant reduction in postoperative renal impairment and failure after cardiac surgery according to the RIFLE criteria. In non-diabetics, tight blood glucose control was associated with a decreased need for postoperative dialysis, as well as 30-day mortality, despite of a relatively short ICU stay.

Effect of mitral valve repair on exercise tolerance in asymptomatic patients with organic mitral regurgitation.

BACKGROUND: The aim of the study was to quantify the changes in cardiopulmonary function after minimally invasive video-assisted mitral valve repair for organic mitral regurgitation (MR) in asymptomatic or minimally symptomatic patients. METHODS: Twenty-six patients (age 54 +/- 11 years) with severe organic MR (regurgitant volume of 94 +/- 37 mL, effective regurgitant orifice [ERO] of 0.73 +/- 0.35 cm2) and mild or no symptoms (New York Heart Association class 1.2 +/- 0.4) underwent exercise echocardiography and cardiopulmonary exercise testing 1 week before and 4 months after uncomplicated video-assisted mitral valve repair. RESULTS: During exercise, left ventricular ejection fraction increased from 68% +/- 7% to 74% +/- 6% (P < .0001), but ERO did not change significantly. Four months after video-assisted mitral valve repair, a significant improvement was observed in peak oxygen uptake (VO2max from 23 +/- 6 to 25 +/- 7 mL x kg(-1) x min(-1), P < .001), peak oxygen pulse (11 +/- 3 to 12 +/- 4 mL per beat, P < .005) as well as in maximal workload (from 143 +/- 49 to 159 +/- 55 W, P < .0001). When only patients without any symptoms (New York Heart Association class I, n = 20) were considered, these changes were even more pronounced (VO2max from 24 +/- 7 to 27 +/- 7 mL x kg(-1) x min(-1), P < .001). Post-operative changes in VO2max correlated with preoperative exercise-induced contractile reserve (r = 0.72, P < .0001), preoperative ERO (r = 0.49, P < .05), and preoperative ejection fraction at rest (r = 0.42, P < .05). CONCLUSION: In patients with severe organic MR but mild or no symptoms, cardiopulmonary performance improves after successful minimally invasive video-assisted mitral valve repair. Improvement is directly related to preoperative left ventricular function and contractile reserve.

Hybrid revascularization strategy: a pilot study on the association of robotically enhanced minimally invasive direct coronary artery bypass surgery and fractional-flow-reserve-guided percutaneous coronary intervention.

BACKGROUND: Robotically enhanced minimally invasive direct coronary artery bypass (RE-MIDCAB) graft of the left internal mammary artery to the left anterior descending coronary artery (LAD) and/or the first diagonal branch might be the least traumatic surgical revascularization approach available so far. When combined with fractional flow reserve (FFR)-guided percutaneous coronary intervention (PCI) in the non-LAD vessels, this "hybrid" strategy takes advantage of the survival benefit conferred by the internal mammary artery graft to the LAD while providing the patients with a truly minimally invasive, functionally complete revascularization. METHODS AND RESULTS: Twenty patients with multivessel disease were selected to undergo combined PCI and RE-MIDCAB because they had a lesion amenable to PCI in the right and/or the left circumflex coronary artery and a lesion in the LAD and/or the first diagonal branch that was considered less than ideal for PCI. PCI was actually performed only when FFR was <0.80 ("provisional PCI"). In 7 stenoses, FFR was >0.80 and the planned PCI was not performed. Surgery was performed before provisional PCI in 6 cases. An angiogram was obtained in all patients before discharge, and a complete clinical follow-up including a stress test was obtained in all patients after a mean of 12 months. There were no significant intraoperative complications, conversions to cardiopulmonary bypass, or reinterventions for bleeding. At early control angiogram, 2 moderate stenoses just proximal to anastomosis were observed, both with normal run-off. After 12 months there were no objective signs of ischemia at stress testing. After an average follow-up of 19+/-10 months there were no deaths, myocardial infarctions, or repeat revascularizations. CONCLUSIONS: A hybrid strategy combining FFR-guided PCI and RE-MIDCAB seems safe and provides selected patients with a functionally complete revascularization with minimal surgical trauma and excellent clinical outcomes.

Percutaneous repair of the tricuspid valve using a novel cinching device: acute and chronic experience in a preclinical large animal model.

AIMS: The aim of this study was to evaluate the safety, technical feasibility and performance of a new trans-catheter tricuspid repair system. METHODS AND RESULTS: Thirty-one adult swine underwent implantation of a transcatheter tricuspid remodelling system under general anaesthesia. The steerable transcatheter device was introduced through a 24 Fr femoral sheath into the right femoral vein and delivered to the tricuspid annulus on the beating heart. A fixation element was implanted into the tricuspid annulus. Following implantation, a second delivery system was used to couple the fixation element with a self-expanding nitinol stent. The device was tensioned to reshape the tricuspid valve and increase the coaptation length of the valve leaflets under echo guidance. Finally, the stent was deployed in the inferior vena cava (IVC) to maintain the tension applied. The transcatheter device was successfully implanted in all animals (n=31). Doppler echocardiography prior to sacrifice showed that tricuspid valve function was stable and normal tricuspid leaflet motion was observed. Cinching of the tricuspid annulus resulted in an increase of leaflet coaptation length of 70% (4.5±0.7 mm to 7.78±1.3 mm), an increase in trans-tricuspid peak velocity of 79% (0.38±0.1 m/s to 0.68±0.1 m/s), and a reduction in septolateral tricuspid valve dimension of 30% (35.2±5 mm to 24.8±5 mm). At necropsy, the fixation element was firmly attached to the annulus within a fibrotic tissue, with no coronary lesions observed and no abnormality visible. The stent was fully deployed in the IVC, without displacement or change in the stent shape. CONCLUSIONS: Percutaneous beating heart remodelling of the tricuspid annulus with a cinching device is safe and feasible.

Long-term patency of internal mammary artery bypass grafts: relationship with preoperative severity of the native coronary artery stenosis.

BACKGROUND: Internal mammary artery conduits (IMA) have an excellent long-term patency rate. Nevertheless, graft closure does occur and significantly limits future revascularization options. We sought to investigate the relationship between the long-term patency of IMA with clinical and angiographic parameters. Particularly, the preoperative degree of stenosis of the relevant bypassed coronary vessel was assessed to analyze the importance of chronic competitive flow on the arterial graft closure rate. METHODS AND RESULTS: Consecutive patients in whom occlusion of at least 1 IMA had been documented at angiography (OCC group) were compared with a group of patients with patent IMA grafts (PAT group). The degree of stenosis in the native coronary artery on which the IMA was placed was analyzed by off-line quantitative coronary angiography. Multivariate stepwise logistic regression was used to identify independent clinical and angiographic predictors of occlusion. The OCC group comprised 96 patients (67+/-10 years) with 103 native bypassed arteries analyzed. The PAT group comprised 127 patients (69+/-8 years) with 170 native bypassed arteries analyzed. Both groups were similar except for gender (42% versus 32% female; P=0.04), height (166+/-8 versus 169+/-8 cm; P=0.006), minimum lumen diameter (0.76+/-0.7 versus 0.51+/-0.5; P=0.001), and diameter stenosis of the native artery (73+/-25% versus 84+/-16%; P<0.0001) in OCC versus PAT, respectively. In the multivariate analysis, only percent diameter stenosis was an independent and statistically significant predictor for graft patency. Among IMA placed on coronary arteries with a diameter of stenosis <50% (n=28), the occlusion rate was very high (79%). CONCLUSIONS: The degree of stenosis in the native vessel is a major predictor of internal mammary artery bypass graft patency. The association between nonsignificant stenosis of the native artery and high occlusion rate of the arterial bypass conduit raises concerns about the use of IMA in the treatment of native vessels with only mild or moderate stenosis.

Mitral valve surgery can now routinely be performed endoscopically.

BACKGROUND: There is an increasing interest in minimally invasive cardiac surgery. METHODS AND RESULTS: Since February 1, 1997 till April 1, 2002, 306 patients underwent endoscopic mitral valve surgery (226 repair, MVP; 80 replacement, MVR). Predominant valve pathology was degenerative in MVP (83.6%) and rheumatic in MVR (65%). Mean age was 61.5+/-12.9 years. Median preoperative functional class (MVP+MVR) and mitral regurgitation (MVP) were II and 4+. Statistical analysis included Kaplan-Meier and Cox regression methods. Mean follow-up was 19.6+/-17.3 months and complete. The procedure was successfully performed in all but 6 patients. Hospital mortality included 3 patients (1%) and was technology related in one. Postoperative morbidity included aggressive re-exploration (8.5%), new onset atrial fibrillation (17.0%), and pacemaker implantation (2.3%). There were 1 early and 10 late reoperations, 5 of which were because of endocarditis. Freedom from mitral valve reoperation at 4 years was 91+/-3.5%. No risk factors for reoperation could be detected. Echocardiographic follow-up showed a median degree of mitral regurgitation (MVP) of 0 and a small paravalvular leak in four patients (MVR). Ninety-four percent of the patients reported no or mild postoperative pain and 99.3% felt they had an esthetically pleasing scar. Ninety-three percent would choose the same procedure again and 46.1% were back at work within 4 weeks. CONCLUSIONS: Endoscopic mitral valve surgery can be performed safely but definitely requires a learning curve. Good results and a high patient satisfaction are guaranteed. It is now our exclusive approach for isolated atrioventricular valve disease.

Endoscopic mitral valve repair: feasible, reproducible, and durable.

OBJECTIVE: We sought to document the feasibility, safety, and effectiveness of performing mitral valve repair using a totally endoscopic approach. METHODS: Between February 1997 and October 1, 2001, 187 patients underwent totally endoscopic mitral valve repair at our institution. The mean age was 60.7 +/- 13.1 years, and 62% were male. Median preoperative functional class and degree of mitral regurgitation were II and 4, respectively. Data collection included an institutional protocol assessing procedure-related pain, cosmesis, and functional recovery. Statistical analysis included Kaplan-Meier and Cox regression methods. Mean follow-up was 19 +/- 15.2 months and was 100% complete. RESULTS: Associated atrial procedures were performed in 9.1% (n = 17) of the patients. Two patients required intraoperative conversion to sternotomy. Thoracoscopic re-evaluation for suspected bleeding (n = 19) was part of our aggressive postoperative management. One patient required sternotomy for control of bleeding. Hospital mortality included 1 (0.5%) patient and was not technology related. There were 1 early and 6 late reoperations, 4 of which were due to endocarditis. No risk factors for repair failure could be detected. Freedom from mitral valve reoperation at 4 years was 93.3% +/- 2.6%. The median degree of mitral regurgitation at follow-up was 0. Ninety-three percent of the patients were highly satisfied with either no or mild postoperative pain, and 98.4% believed they had an aesthetically pleasing scar. CONCLUSIONS: Totally endoscopic mitral valve repair can be done safely with excellent results and a high degree of patient satisfaction. It is now our exclusive approach for isolated atrioventricular valve disease.

Initial experience with an endoscopic radial artery harvesting technique.

OBJECTIVE: The purpose of the study was to investigate the feasibility of an endoscopic radial artery harvesting technique to improve esthetic results and possibly reduce the incidence of neurologic complications observed with the open method. METHODS: Between July 1, 2002, and October 1, 2003, a total of 54 patients underwent endoscopic radial artery harvesting at our institution. Standard endoscopic equipment and a Harmonic Scalpel (Ethicon Endo-Surgery, Inc, Cincinnati, Ohio) were used. Mean age of the patients was 63 +/- 8.1 years, and 16% were female. All patients underwent a preoperative Allen test and duplex ultrasonography to demonstrate adequate ulnar collateral flow. The nondominant arm was used for radial artery harvesting. Mean clinical follow-up was 13 +/- 4.6 months. RESULTS: The artery was harvested through a 3-cm incision at the wrist and was divided at the elbow either through a small counterincision (n = 16) or endoscopically with the use of clips, Endoloop, and endoscopic scissors (n = 38). Mean harvest time was 42.2 +/- 16.9 minutes but decreased from 85 minutes for the first cases to 25 minutes for the last 5 cases. Mean harvested length was 19.6 +/- 1.7 cm. Harvesting complications included 1 conversion, 2 postoperative hematomas, 1 injury, 8 endoscopically controlled bleedings, and 15 cases of at least some superficial radial nerve paresthesia at 6 weeks (clinically relevant in 4 cases). Selective postoperative angiography revealed 1 occluded graft and 1 stenotic graft requiring percutaneous transluminal coronary angioplasty of the native vessel. Eighty-seven percent of the patients were enthusiastic about this new procedure. CONCLUSIONS: Endoscopic radial artery harvesting is a feasible procedure that requires a definite learning curve. Although nerve paresthesias were not completely eliminated in our experience, the technique provided ample patient satisfaction. Further clinical follow-up is required to determine long-term patency rates.

Combined atrial fibrillation and mitral valve surgery using radiofrequency technology.

Recently, intraoperative radiofrequency ablation of the left atrium combined with mitral valve surgery has become widely used. In our center, 30 patients underwent this combined procedure; median sternotomy was used in 16 patients, and port access was used in 14 patients. At hospital discharge, 18 patients (60%) were no longer in atrial fibrillation, and at 6 months, 19 patients (65%) remained in sinus rhythm. All sinus rhythm patients had a well-defined transmitral A wave detectable by echocardiography. One patient sustained a major stroke. Two patients required pacemaker implantation. Such encouraging preliminary results have triggered worldwide interest in the percutaneous and surgical treatment of atrial fibrillation. However, the excellent long-term results with the classic Cox-Maze III operation have not yet been achieved with these newer approaches. Further basic and clinical research is required before a predictable simple and safe technique can be introduced as a new standard for the surgical treatment of atrial fibrillation in patients with or without structural heart disease.

Surgical treatment of tachyarrhythmias due to postinfarction left ventricular aneurysm with endoaneurysmorrhaphy and cryoablation.

OBJECTIVE: In this study, the efficacy of left ventricular (LV) endoaneurysmorrhaphy and cryoablation without intraoperative electrophysiologic mapping was evaluated in patients with postinfarction LV aneurysm and sustained ventricular tachycardia (VT). METHODS: A prospective study was performed on all patients operated with malignant VT in the presence of a resectable LV aneurysm between July 1990 and February 2001. RESULTS: The study included 31 patients, 20 men and 11 women, with a mean age of 65.5 years (47-84). Monomorphic, polymorphic VT or ventricular fibrillation was present in all patients prospectively, and VT was incessant in 11. Twenty-six patients had an anterior, four patients had an inferior and one patient a posterolateral myocardial wall infarction. All patients had a well-limited ventricular aneurysm. Ten patients had three, eight patients two and 13 patients had single vessel coronary artery disease. Mean preoperative ejection fraction was 34.8 +/- 14.5% (8-62) and mean end-diastolic volume index was 141.5 +/- 51.8 ml/m(2) (57-288). Six patients had mitral regurgitation grade III or IV. All patients underwent extensive cryoablation at the transition zone of scar and viable tissue and LV remodelling with prosthetic patch in 26 patients. Associated procedures were CABG in 19 patients (61%) and mitral valve reconstruction in six patients (19%). Postoperative electrophysiologic study (EPS) revealed freedom from VT induction in 25 patients and inducible VT in five patients. One patient had inducible polymorphic VT. Five patients received an implantable cardioverter defibrillator (ICD) and three patients had a permanent pacemaker implanted. After a mean follow-up of 30 +/- 27 months (6-132) there was one arrhythmia-related death. There was one early hospital readmission for clinical VT and no need for late ICD implantation. CONCLUSIONS: In patients suffering from ventricular arrhythmias in the presence of a complicated postinfarction LV aneurysm, combined 'blind' cryoablation and endoaneurysmorrhaphy offers excellent arrhythmia control and clinical and haemodynamic outcome.

Cardiac ochronosis: valvular heart disease with dark green discoloration of the leaflets.

We report the case of 67-year-old woman who underwent aortic valve replacement and mitral valve repair due to ochronotic valvular disease (alkaptonuria), which was diagnosed incidentally during cardiac surgery.

Improving mitral valve coaptation with adjustable rings: outcomes from a European multicentre feasibility study with a new-generation adjustable annuloplasty ring system.

OBJECTIVES: To evaluate the performance and safety of an adjustable semi-rigid annuloplasty ring for mitral regurgitation (MR) in a multicentre study. METHODS: Between March 2010 and December 2011, 30 subjects underwent mitral valve (MV) repair using the Cardinal adjustable annuloplasty ring. This device is a semi-rigid ring allowing postimplantation size adjustment, under beating-heart conditions, to optimize leaflet coaptation under echocardiographic guidance. Coaptation length was determined before and after adjustment by transoesophageal echocardiography. RESULTS: The study enrolled 21 (70%) male and 9 (30%) female subjects with a mean age of 64 years. The approach was conventional midline sternotomy or mini-invasive right thoracotomy. Leaflet resection was done in 17 subjects, and chordal repair was used in 13. Concomitant procedures included coronary artery bypass grafting in 2 (7%) subjects, atrial ablation in 4 (13%) and tricuspid repair in 4 (13%). There was 1 (3%) early death unrelated to the study device. Intraoperative ring adjustment was performed in 24 of the 30 subjects. Residual MR was detected prior to adjustment in 6 subjects (4 mild and 2 moderate MR). Following adjustment, 5 subjects had no MR and 1 had trace MR. After adjustment, mean coaptation length improved from 7 ± 3 to 10 ± 3 mm (P < 0.0001). All patients who completed 1-year follow-up had less-than-mild MR, with the exception of 1 patient with ring dehiscence (and resultant 2+ MR) and 1 functional MR patient who developed recurrent 2+ MR due to persistent leaflet tethering. CONCLUSIONS: MV repair with the Cardinal adjustable annuloplasty ring is a reliable technique that enables the adjustment of the ring diameter on a beating heart under echocardiographic control. Such technology allows the optimization of leaflet coaptation, providing minimal residual MR and durable repair.

The growing clinical importance of secondary tricuspid regurgitation.

Functional or secondary tricuspid regurgitation (STR) is the most frequent etiology of tricuspid valve pathology in Western countries. Surgical tricuspid repair has been avoided for years, because of the misconception that tricuspid regurgitation should disappear once the primary left-sided problem is treated; this results in a large number of untreated patients with STR. Over the past few years, many investigators have reported evidence in favor of a more aggressive surgical approach to STR. Consequently, interest has been growing in the physiopathology and treatment of STR. The purpose of this review is to explore the anatomical basis, pathophysiology, therapeutic approach, and future perspectives with regard to the management of STR.

Direct access transcatheter mitral annuloplasty with a sutureless and adjustable device: preclinical experience.

OBJECTIVES: The aim of the study was to evaluate the technical feasibility and performance of a transcatheter mitral annuloplasty system. METHODS: Adult swines (n = 15) underwent left thoracotomy through the 4th-5th intercostal space. A transcatheter device (CardioBand, Valtech-Cardio Ltd) was introduced through an 18F sheath through the left atrium and attached to the annulus between the posterior and anterior commissures using echocardiographic and fluoroscopic guidance, on the beating heart. The sutureless device was implanted using a steerable delivery system to deploy sequential fixation elements. Following implantation, the device length was adjusted on the beating heart to reduce the intercommissural and septolateral dimension, under echocardiographic guidance. Finally, the flexible adjustment tool was withdrawn from the working sheath and the atrial purse-string closed. All but five animals were sacrificed acutely by intent, while the others were sacrificed at 90 days. RESULTS: All animals survived the acute implant. One animal died at the third post-operative day due to bleeding. The annuloplasty system was successfully implanted in all animals. A mean of 12 ± 3 fixation elements were deployed. The band length was reduced up to 20% after implantation in each animal. At necropsy, the location of the implant was within a few millimetres of the annulus (3.5 ± 4 mm). In three animals, fixation elements were implanted inadvertently in the leaflets, but no coronary lesions were observed. All animals survived the acute implant. One animal died on the third post-operative day due to bleeding. In the four long-term survivors, the implanted annuloplasty device showed satisfactory healing and no ring dehiscence. CONCLUSIONS: Transcatheter minimally invasive, beating-heart implantation of an adjustable annuloplasty band is feasible in the animal model. This approach may be an alternative to open surgical procedures in high-risk patients.

Live broadcasting in cardiac surgery does not increase the operative risk.

OBJECTIVE: Live broadcasting of cardiac surgical procedures has an educational intention. There is an ongoing debate whether live surgery increases risk. Aim of this study was to evaluate the outcomes of patients who underwent a cardiac surgical procedure during live broadcasting. METHODS: A total of 250 cardiac operations were performed during 32 live broadcastings at four different clinical sites between 1999 and 2009. Data on patient characteristics, intra-operative procedures and patient short- and long-term outcome were collected and analyzed. All participating centers complied with the rules for the conduct of live surgery developed by the European Association of Cardiovascular and Thoracic Surgery (EACTS) Techno College Committee. RESULTS: Primary educational focus was the mitral valve in 126 cases, aortic valve including transcatheter valve implantations in 34, coronary artery bypass grafting (CABG) in 29, congenital in 26, aortic (ascending, arch, and descending) in 15, atrial fibrillation in 13, and heart failure in seven. Mean EuroSCORE (European System for Cardiac Operative Risk Evaluation) was 8.7 ± 11.5 (range: 0.8-72). Thirty-day mortality was 1.2% (3/250): reasons for death were multi-organ failure in two and respiratory failure in one patient, respectively. Stroke rate was 2.4% (6/250). Five patients (2%) required cardiac re-operations within 30 days. The rate of mitral valve repair was 96% (121) and compares favourably with repair rates presented in national registries. Mean follow-up of all patients was 3.7 ± 2.8 years with an estimated survival of 92% (95% confidence interval (CI): 87-95%) at 5 years. CONCLUSIONS: Based on this large experience there is no evidence for an excess perioperative risk for patients operated under the conditions of live broadcasting.

Beating-heart implantation of adjustable length mitral valve chordae: acute and chronic experience in an animal model.

OBJECTIVE: This study aimed to determine the acute and chronic performance of a new system designed to conduct beating-heart implantation and off-pump adjustment of neochordal length. METHODS: In 14 adult sheep (group A) selected to undergo beating-heart cardiopulmonary bypass, the left atrium was opened through a left thoracotomy. Two or more primary chordae in the A2 region were severed to produce a model of a flail leaflet. A chordal adjustment mechanism (V-Chordal, Valtech Cardio Ltd., Or-Yehuda, Israel) was affixed to the head of the papillary muscle. The system includes two adjustable neochordae. The distal end of the neochordae was sutured to the flail segment without estimating the appropriate length. The neochordal length was adjusted off-pump under real-time echo-guidance. The adjustment tool was removed and the atriotomy was closed with a purse-string suture. Control animals (group B, n=4) were implanted with the conventional neochordae. Animals in both groups were sacrificed 3 months after the procedure. RESULTS: In both groups, prior to repair, mitral regurgitation (MR) was severe in all animals. In group A, following adjustment of neochordae, MR was absent in all animals, with the exception of two animals that had residual 2+ MR irresponsive to neochordae adjustments. In group B, MR was 2+ in two of the four animals following repair. At 3 months, mitral competence was stable in all animals. At necropsy, normal healing of the papillary head and leaflet was observed in both the groups. CONCLUSIONS: The V-Chordal system simplifies the process of neochordal implantation and precise off-pump adjustment of the neochordal length to correct MR occurring due to a flail leaflet. This technology may improve the technical feasibility for adoption of chordal repair during open or minimally invasive surgical procedures.