Initial clinical experience with VersaCross transseptal system for transcatheter mitral valve repair.

OBJECTIVES: The aim of this study is to describe the initial experience with versacross transseptal (TS) system for transseptal puncture for the transcatheter mitral valve repair using the MitraClip device. BACKGROUND: Transeptal puncture is a key step in transcatheter mitral valve repair (MVR) and the use of the VersaCross system comprised of a sheath, a dilator and a radiofrequency wire has not been previously described. METHODS: Prospective single center study of consecutive patients undergoing transcatheter mitral valve repair with the MitraClip device were included. Targeted TS puncture was performed under transesophageal echocardiographic (TEE) guidance. Baseline demographics, procedural characteristics, and major adverse procedural events were collected. RESULTS: Twenty-five consecutive patients underwent transseptal puncture using the VersaCross TS system. Transseptal puncture was successful in 100% of patients. The mean time for TS puncture was 3 3 ± 1.6 min with no major adverse procedural events. The mean time from insertion of the VersaCross system to insertion of the MitraClip guide catheter was 3.8 ± 3.0 minutes. CONCLUSION: The VersaCross TS system was successful in all patients for MitraClip procedure with no adverse procedural events and may be associated with increased procedural efficiency.

Venoarterial Extracorporeal Membrane Oxygenation Support for Severe Pericardial Decompression Syndrome: A Case Report.

OBJECTIVES: We report a case of a man with tamponade decompression syndrome following pericardial drainage. DATA SOURCES: ICU - Montreal Heart Institute. STUDY SELECTION: Case report. DATA EXTRACTION: Clinical and surgical records. DATA SYNTHESIS: None. CONCLUSIONS: Our case adds further concerns in supporting a patient with tamponade decompression syndrome, including mechanical circulatory support, due to the reversible nature of this condition.

The Department of Surgery of the Université de Montréal, 70th anniversary.

SUMMARY: The Department of Surgery of the Université de Montréal was officially chartered in 1961, but the structure had been in place since since 1951. The department grew as a fusion of hospital-based surgery training programs from the largest French-speaking hospitals in Montreal. Currently 448 professors (135 women and 313 men) teach in the department. The research activity, both clinical and applied, is in strong progression. The Department of Surgery is the largest French and bilingual training centre in Canada and North America. In 2021 the department will celebrate its 70th anniversary. As members, we should be proud of the work achieved by our predecessors and by the current rank of professors, teachers and researchers. The department strives to promote the essential role of and highlight the rewards and benefits of academic surgery.

Rate Control versus Rhythm Control for Atrial Fibrillation after Cardiac Surgery.

BACKGROUND: Atrial fibrillation after cardiac surgery is associated with increased rates of death, complications, and hospitalizations. In patients with postoperative atrial fibrillation who are in stable condition, the best initial treatment strategy--heart-rate control or rhythm control--remains controversial. METHODS: Patients with new-onset postoperative atrial fibrillation were randomly assigned to undergo either rate control or rhythm control. The primary end point was the total number of days of hospitalization within 60 days after randomization, as assessed by the Wilcoxon rank-sum test. RESULTS: Postoperative atrial fibrillation occurred in 695 of the 2109 patients (33.0%) who were enrolled preoperatively; of these patients, 523 underwent randomization. The total numbers of hospital days in the rate-control group and the rhythm-control group were similar (median, 5.1 days and 5.0 days, respectively; P=0.76). There were no significant between-group differences in the rates of death (P=0.64) or overall serious adverse events (24.8 per 100 patient-months in the rate-control group and 26.4 per 100 patient-months in the rhythm-control group, P=0.61), including thromboembolic and bleeding events. About 25% of the patients in each group deviated from the assigned therapy, mainly because of drug ineffectiveness (in the rate-control group) or amiodarone side effects or adverse drug reactions (in the rhythm-control group). At 60 days, 93.8% of the patients in the rate-control group and 97.9% of those in the rhythm-control group had had a stable heart rhythm without atrial fibrillation for the previous 30 days (P=0.02), and 84.2% and 86.9%, respectively, had been free from atrial fibrillation from discharge to 60 days (P=0.41). CONCLUSIONS: Strategies for rate control and rhythm control to treat postoperative atrial fibrillation were associated with equal numbers of days of hospitalization, similar complication rates, and similarly low rates of persistent atrial fibrillation 60 days after onset. Neither treatment strategy showed a net clinical advantage over the other. (Funded by the National Institutes of Health and the Canadian Institutes of Health Research; ClinicalTrials.gov number, NCT02132767.).

Myocardial Protection in Minimally Invasive Mitral Valve Surgery: Retrograde Cardioplegia Alone Using Endovascular Coronary Sinus Catheter Compared With Combined Antegrade and Retrograde Cardioplegia.

OBJECTIVE: To compare myocardial protection with retrograde cardioplegia alone with antegrade and retrograde cardioplegia in minimally invasive mitral valve surgery (MIMS). DESIGN: Retrospective study. SETTING: Tertiary care university hospital. PARTICIPANTS: The authors studied 97 MIMS patients using retrograde cardioplegia alone and 118 MIMS patients using antegrade and retrograde cardioplegia. INTERVENTIONS: The data from patients admitted for MIMS using retrograde cardioplegia (MIMS retro) between 2009 to 2012 were compared with the data from patients undergoing MIMS with antegrade and retrograde cardioplegia (MIMS ante-retro) between 2006 and 2010 (control group). Cardioplegia in the MIMS retro group was delivered solely through an endovascular coronary sinus (CS) catheter positioned under echographic and fluoroscopic guidance. Antegrade and retrograde cardioplegia was used in the MIMS ante-retro group. Data regarding myocardial infarction (MI; creatine kinase Mb, troponin T, electrocardiogram), myocardial function, and hemodynamic stability were collected for comparison. MEASUREMENTS AND MAIN RESULTS: Adequate cardioplegia administration (CS pressure >30 mmHg and asystole) was attained in 74.2% of the patients with retrograde cardioplegia alone. In 23.7% of the patients, the addition of an antegrade cardioplegia was necessary. No difference was observed in the incidence of MI (0 MIMS retro v 1 for MIMS ante-retro, p = 0.3623), difficult separation from cardiopulmonary bypass, and postoperative malignant arrhythmia. No difference was found for maximal creatine kinase Mb (39.1 [28.0-49.1] v 37.9 [28.6-50.9]; p = 0.8299) and for maximal troponin T levels (0.39 [0.27-0.70] v 0.47 [0.32-0.79]; p = 0.1231) for MIMS retro and MIMS ante-retro, respectively. However, lactate levels in the MIMS retro group were significantly lower than in the MIMS ante-retro group (2.1 [1.4-3.05] v 2.4 [1.8-3.3], respectively; p = 0.0453). No difference was observed in duration of intensive care unit stay and death. MIMS retro patients had a shorter hospital stay (7.0 [6.0-8.0] v 8.0 [7.0-9.0] days; p = 0.0003). CONCLUSION: Retrograde cardioplegia administration alone provided comparable myocardial protection to antegrade and retrograde cardioplegia during MIMS, but was not sufficient to achieve asystole in one-fifth of patients.

Myocardial Protection in Mitral Valve Surgery: Comparison Between Minimally Invasive Approach and Standard Sternotomy.

OBJECTIVE: To compare antegrade and retrograde cardioplegia administration in minimally invasive mitral valve surgery (MIMS) and open mitral valve surgery (OMS) for myocardial protection. DESIGN: Retrospective study. SETTING: Tertiary care university hospital. PARTICIPANTS: The study comprised 118 patients undergoing MIMS and 118 patients undergoing OMS. INTERVENTIONS: The data of patients admitted for MIMS from 2006 to 2010 were reviewed. Patients undergoing isolated elective OMS from 2004 to 2006 were used as a control group. Cardioplegia in the MIMS group was delivered via the distal port of the endoaortic clamp and an endovascular coronary sinus catheter positioned using echographic and fluoroscopic guidance. Antegrade and retrograde cardioplegia were used in OMS. Data regarding myocardial infarction (MI) (creatine kinase [CK]-MB, troponin T, electrocardiography); myocardial function; and hemodynamic stability were collected. MEASUREMENTS AND MAIN RESULTS: There was no difference in the perioperative MI incidence between both groups (1 in each group, p = 0.96). No statistically significant difference was found for maximal CK-MB (35.9 µg/L [25.1-50.1] v 37.9 µg/L [28.6-50.9]; p = 0.31) or the number of patients with CK-MB levels >50 µg/L (29 v 33; p = 0.55) or CK-MB >100 µg/L (3 v 4; p = 0.70) between the OMS and MIMS groups. However, maximum troponin T levels in the MIMS group were significantly lower (0.47 µg/L [0.32-0.79] v 0.65 µg/L [0.45-0.94]; p = 0.0007). No difference in the incidence of difficult weaning from bypass and intra-aortic balloon pump use between the MIMS and OMS groups was found. CONCLUSIONS: Antegrade and retrograde cardioplegia administration during MIMS and OMS provided comparable myocardial protection.

Del Nido cardioplegia in the setting of minimally invasive aortic valve surgery.

The purpose of this study is to report our experience with del Nido cardioplegia (DNC) in the setting of minimally invasive aortic valve surgery. Forty-six consecutive patients underwent minimally invasive aortic valve replacement (AVR) through a "J" ministernotomy: twenty-five patients received the DNC (Group 1) and 21 patients received standard blood cardioplegia (SBC) (Group 2). The rate of ventricular fibrillation at unclamping was significantly lower in the DNC group (12% vs 52%, p=0.004), as well as postoperative creatinine kinase-MB (CK-MB) values (11.4±5.2 vs 17.7±6.9 µg/L, p=0.004). There were no deaths, myocardial infarctions or major complications in either group. Less postoperative use of intravenous insulin (28% vs 81%, p<0.001) was registered in the DNC group. In conclusion, the DNC is easy to use and safe during minimally invasive AVR, providing a myocardial protection at least equivalent to our SBC, improved surgical efficiency, minimal cost and less blood glucose perturbations.

Experience with the SynCardia total artificial heart in a Canadian centre.

BACKGROUND: The SynCardia total artificial heart (TAH) provides complete circulatory support by replacing both native ventricles. Accepted indications include bridge to transplantation and destination therapy. We review our experience with TAH implantation during a period when axial flow pump became available. METHODS: We retrospectively analyzed the demographics, clinical characteristics and survival of all patients receiving the TAH. RESULTS: From September 2004 to November 2016, 13 patients (12 men, mean age 45 ± 13 yr) received the TAH for refractory cardiogenic shock secondary to idiopathic (56%) or ischemic (17%) cardiomyopathy and to other various causes (33%). Before implantation, mean ejection fraction was 14% ± 4%, 7 (54%) patients had previous cardiac surgery, 4 (31%) were on mechanical ventilation, and 3 (23%) patients were on dialysis. The mean duration of TAH support was 46 ± 40 days. Three (23%) patients died while on support after a mean of 15 days. Actuarial survival on support was 77% ± 12% at 30 days after implantation. Complications on support included stroke (n = 1, 8%), acute respiratory distress syndrome requiring prolonged intubation (n = 5, 38%) and acute renal failure requiring temporary dialysis (n = 5, 38%). Ten (77%) patients survived to be transplanted after a mean of 52 ± 42 days of support. Actuarial survival rates after transplant were 67% ± 16% at 1 month and 56% ± 17% at 1 year after transplantation. CONCLUSION: The TAH provides an alternative with low incidence of neurologic events in extremely fragile and complex patients waiting for heart transplantation. Complex and unusual anatomic conditions explained the current use of TAH.

CONTEXTE: Le cœur artificiel total (CAT) SynCardia offre un soutien circulatoire complet en remplaçant les 2 ventricules naturels. Parmi ses indications acceptées, mentionnons la transition pré-greffe et l'assistance permanente. Nous passons ici en revue notre expérience en matière d'implantation de CAT à partir de l'avènement des pompes à flux axial. MÉTHODES: Nous avons analysé de manière rétrospective les caractéristiques démographiques et cliniques et la survie de tous les patients ayant reçu un CAT. RÉSULTATS: De septembre 2004 à novembre 2016, 13 patients (12 hommes, âge moyen 45 ± 13 ans) ont reçu le CAT pour un choc cardiogénique réfractaire dû à la cardiomyopathie idiopathique (50 %) ou ischémique (17 %) ou à d'autres causes (33 %). Avant l'implantation, la fraction d'éjection était en moyenne de 14 % ± 4 %, 7 patients (54 %) avaient déjà subi une chirurgie cardiaque, 4 (31 %) étaient sous ventilation mécanique et 3 (23 %) étaient dialysés. La durée moyenne du soutien par CAT a été de 46 ± 40 jours. Trois patients (23 %) sont décédés malgré l'implantation du dispositif après une moyenne d'utilisation de 15 jours. La survie actuarielle pendant l'utilisation du dispositif a été de 77 % ± 12 % 30 jours suivant l'implantation. Les complications ont inclus : accident vasculaire cérébral (n = 1, 8 %), syndrome de détresse respiratoire aigüe nécessitant une intubation prolongée (n = 5, 38 %) et insuffisance rénale aigüe nécessitant une dialyse temporaire (n = 5, 38 %). Dix patients (77 %) ont survécu jusqu'à leur greffe après une moyenne d'utilisation de 52 ± 42 jours. Les taux de survie actuarielle après la greffe ont été de 67 % ± 16 % après 1 mois et de 56 % ± 17 % après 1 an suivant la greffe. CONCLUSION: Le CAT est une solution de rechange qui s'accompagne d'une incidence faible de complications neurologiques chez des patients à l'état extrêmement fragile et complexe en attente d'une greffe cardiaque. Des complications anatomiques inhabituelles ont expliqué l'utilisation du CAT.

Changes in patient characteristics following cardiac transplantation: the Montreal Heart Institute experience.

BACKGROUND: Heart transplantation is no longer considered an experimental operation, but rather a standard treatment; nevertheless the context has changed substantially in recent years owing to donor shortage. The aim of this study was to review the heart transplant experience focusing on very long-term survival (≥ 20 years) and to compare the initial results with the current era. METHODS: From April 1983 through April 1995, 156 consecutive patients underwent heart transplantation. Patients who survived 20 years or longer (group 1) were compared with patients who died within 20 years after surgery (group 2). To compare patient characteristics with the current era, we evaluated our recent 5-year experience (group 3; patients who underwent transplantation between 2010 and 2015), focusing on differences in terms of donor and recipient characteristics. RESULTS: Group 1 (n = 46, 30%) included younger patients (38 ± 11 v. 48 ± 8 yr, p = 0.001), a higher proportion of female recipients (28% v. 8%, p = 0.001) and a lower prevalence of ischemic heart disease (42% v. 65%, p = 0.001) than group 2 (n = 110, 70%). Patients in group 3 (n = 54) were older (52 ± 12 v. 38 ± 11 yr, p = 0.001), sicker (rate of hospital admission at transplantation 48% v. 20%, p = 0.001) and transplanted with organs from older donors (42 ± 15 v. 29 ± 11 yr, p = 0.001) than those in group 1. CONCLUSION: Very long-term survival ( ≥ 20 yr) was observed in 30% of patients transplanted during the first decade of our experience. This outcome will be difficult to duplicate in the current era considering our present population of older and sicker patients transplanted with organs from older donors.

CONTEXTE: De nos jours, la transplantation cardiaque n'est plus considérée comme une intervention expérimentale, mais bien comme une opération standard; mais le contexte a substantiellement changé ces dernières années en raison d'une pénurie de donneurs. Cette étude avait pour but de faire le point sur la situation de la greffe cardiaque, et plus particulièrement sur la survie à très long terme (≥ 20 ans), et de la comparer aux résultats initiaux. MÉTHODES: Entre avril 1983 et avril 1995, 156 patients consécutifs ont subi une greffe cardiaque. Les patients qui ont survécu 20 ans ou plus (groupe 1) ont été comparés aux patients décédés moins de 20 ans après l'intervention (groupe 2). Pour comparer les caractéristiques des premiers patients à celles des cas plus récents, nous avons fait un bilan des 5 années allant de 2010 à 2015 (groupe 3), en portant attention aux différences quant aux caractéristiques des donneurs et des receveurs. RÉSULTATS: Le groupe 1 (n = 46, 30 %) incluait des patients plus jeunes (38 ± 11 ans c. 48 ± 8 ans, p = 0,001), une proportion plus élevée de femmes (28 % c. 8 %, p = 0,001) et la prévalence de maladie cardiaque ischémique y était moindre (42 % c. 65 %, p = 0,001) comparativement au groupe 2 (n = 110, 70 %). Les patients du groupe 3 (n = 54) étaient plus âgés (52 ± 12 ans c. 38 ± 11 ans, p = 0,001), plus malades (taux d'hospitalisation au moment de la transplantation 48 % c. 20 %, p = 0,001) et ont reçu le cœur de donneurs plus âgés (42 ± 15 ans c. 29 ± 11 ans, p = 0,001) que ceux du groupe 1. CONCLUSION: Une survie à très long terme (≥ 20 ans) a été observée chez 30 % des patients ayant reçu leur greffe au cours de la première décennie de notre expérience. Ce résultat sera difficile à reproduire de nos jours étant donné que notre population actuelle est constituée de receveurs plus âgés et plus malades, qui reçoivent le cœur de donneurs plus âgés.

Repair of Anterior Mitral Leaflet Prolapse: Comparison of Mid-Term Outcomes with Chordal Transposition and Chordal Replacement Techniques.

BACKGROUND: The repair of anterior mitral leaflet prolapse is known to be challenging. Hence, the study aim was to compare the mid-term results of anterior leaflet prolapse (ALP) using chordal transposition with results obtained using chordal replacement with expanded polytetrafluoroethylene (ePTFE) sutures. METHODS: Between 1999 and 2012, a total of 96 consecutive patients (mean age 62 years) with ALP underwent mitral valve repair at the authors' institution. Surgery involved either chordal transposition from the posterior to the anterior leaflet (n = 67), or chordal replacement using ePTFE sutures (n = 29). Clinical, operative and follow up data were recorded prospectively for each patient. The follow up was 100% complete (mean 3.4 years; range 0 to 12.9 years). RESULTS: Mitral valve repair was accomplished in all patients, with no operative mortality. The durations of cardiopulmonary bypass and aortic cross-clamp were significantly longer in the chordal replacement group. Actuarial overall survival at one, five and 10 years was 95 ± 3%, 87 ± 5% and 82 ± 7% versus 89 ± 6%, 89 ± 6% and 89 ± 6% in the chordal transposition and chordal replacement groups, respectively (p = 0.84). Freedom from reoperation in the two groups at five years was 95 ± 3% and 91 ± 7%, respectively (p = 0.24). The recurrence of moderate or severe mitral regurgitation (MR) (grade ≤2+) and of severe (grade ≤3+) MR was significantly higher in patients who underwent chordal replacement compared to chordal transposition (p = 0.04 and p = 0.01, respectively). CONCLUSIONS: Provided that chordal quality is preserved, chordal transposition is easier and quicker to achieve for ALP repair, and is also durable in the mid term. Chordal replacement offers a satisfying durability even if the recurrence of severe MR appears to be higher. Preferably, both surgical techniques should be mastered to allow valve repair when anatomic conditions prevent chordal transposition.

Morphological and Clinical Findings of Explanted Carpentier-Edwards Perimount Pericardial Valve in the Aortic Position.

BACKGROUND: Freedom from structural valve deterioration (SVD) at 15 years with the Carpentier-Edwards (CE) Perimount pericardial valve in the aortic position was 60% in patients aged <60 years compared to 90% and 99% in patients aged 60-70 years and >70 years, respectively. The study aim was to focus on the causes of SVD requiring valve explant according to three different age groups: <60 years, 60-70 years, and >70 years. The short- and longterm clinical results of the patient cohort, followed for 25 years, are presented. METHODS: A retrospective review was made of 89 patients among 2,405 who had undergone elective aortic valve replacement (AVR) with CE pericardial valves between November 1981 and March 2011, and in whom the prosthesis explant was secondary to degeneration of the valve. RESULTS: Patients aged >70 years experienced more late complications such as endocarditis (p = 0.02) and mortality (p = 0.02). Following surgery for prosthesis explant and replacement, 39 of the 89 patients (44%) died. The average time to postoperative mortality in that population was 2.8 ± 3.6 years. On combining all causes of SVD, earlier dysfunction was noted in patients aged >60 years, and late dysfunction in patients aged <60 years (p = 0.003). However, there was no significant difference between groups in the process of degeneration (either calcification, pannus, tear, thrombus, endocarditis) (p = NS). No predictors were found of early and late dysfunction. CONCLUSIONS: Patients aged >60 years in whom a CE Perimount valve was implanted in the aortic position were more prone to early degeneration of their valve and related mortality. However, no predictors were found of early degeneration of the valve in that patient population.

Retrospective cohort analysis of 926 tricuspid valve surgeries: clinical and hemodynamic outcomes with propensity score analysis.

BACKGROUND: The objectives were to describe morbidity and mortality after tricuspid valve (TV) surgery, to compare outcomes after repair versus replacement, and to assess risk factors for mortality and tricuspid regurgitation (TR) recurrence. METHODS: A retrospective cohort study including 926 consecutive cases of TV surgery (792 repairs and 134 replacements) performed at the Montreal Heart Institute was conducted. Median follow-up was 4.3 years (4,657 patient-years). Median age was 62 years (interquartile range 53-69 years), and 72% of patients were women. RESULTS: Operative mortality was 14% (128 patients: 1977-1998 20%, 1999-2008 7%, P < .001). Independent risk factors for operative mortality in the 1999 to 2008 period were hypertension (odds ratio [OR] 6.03, P = .02), daily furosemide dose (by 10 mg) (OR 1.06, P = .05), weight (by 10 kg) (OR 0.36, P < .01), and cardiopulmonary bypass time (by 10 minutes) (OR 1.29, P < .001). Ten-year survival was 49% ± 2% and 38 ± 5% in the repair and replacement groups, respectively (P = .012). At discharge, severity of TR was ≥3/4 in 13% and 2% of patients in the repair and replacement groups, respectively (P = .01). Propensity score analysis showed that tricuspid repair was associated with higher rates of TR ≥3/4 at follow-up compared with replacement (hazard ratio 2.15, P = .02). Forty-eight reoperations (7% of patients at risk) were performed during follow-up (repair group, 6%; replacement group, 15%; P = .01). At last follow-up, New York Heart Association functional class was improved compared with baseline in both groups (P < .001). CONCLUSION: Tricuspid valve surgery is associated with substantial early and late mortalities but with significant functional improvement. Replacement is more effective in early and late corrections of regurgitation, but it does not translate into better survival outcomes.

Real-time compared to off-line evaluation of segmental wall motion abnormalities with transesophageal echocardiography using dobutamine stress testing.

OBJECTIVE: To compare real-time (on-line) monitoring of myocardial ischemia with transesophageal echocardiography (TEE) with off-line reviewing during a dobutamine stress test in patients undergoing coronary artery bypass grafting (CABG). DESIGN: Prospective observational study. SETTING: Tertiary care university hospital. PATIENTS: Seventeen patients undergoing CABG. INTERVENTIONS: TEE and electrocardiographic monitoring of myocardial ischemia during dobutamine stress testing. MEASUREMENTS AND MAIN RESULTS: Sixteen of 17 patients developed myocardial ischemia as diagnosed by TEE or electrocardiographic monitoring. On-line and off-line TEE detected myocardial ischemia in 11/17 and 12/17 patients, respectively. In total, 532 myocardial segments were analyzed at baseline and at peak dobutamine dose. The concordance between on-line and off-line assessments of segmental wall motion was poor at baseline and at peak dobutamine dose (κ = 0.28 and 0.29, respectively). The concordance for detecting myocardial ischemia (worsening in regional wall motion by ≥1 class or a biphasic response in any segment) was better between on-line and off-line analysis (κ = 0.60). There was no agreement between ST-segment monitoring and on-line TEE (κ = -0.27) and between 12-lead electrocardiogram and on-line TEE (-0.11). There was no agreement between ST-segment monitoring and off-line TEE (κ = -0.15) and between 12-lead electrocardiogram and off-line TEE (κ = -0.27). CONCLUSIONS: Only a fair agreement exists between on-line and off-line analysis of myocardial ischemia during dobutamine stress testing in patients undergoing CABG. However, TEE misses up to one third of ischemic episodes and the present observations suggest using continuous electrocardiographic methods to complement TEE monitoring.

The Evolution of Transcatheter Therapies for Mitral Valve Disease: From Mitral Valvuloplasty to Transcatheter Mitral Valve Replacement.

The prevalence of mitral valve disease has evolved over the past 5 decades from primarily a disease of rheumatic origin to a disease affecting the aging population that encompasses a range of phenotypes from rheumatic mitral stenosis, degenerative mitral regurgitation, and degenerative mitral valve calcification to secondary mitral regurgitation. A reflection on the history of therapy for mitral valve disease is an expedition that follows the birth and development of structural heart intervention from the first percutaneous balloon mitral valvuloplasty to innovative technologies for transcatheter mitral valve repair and replacement. This review will lead you along this journey, pause to acknowledge the feats accomplished, and reflect on the road that lies ahead.

Triple-valve surgery: clinical results of a three-decade experience.

BACKGROUND AND AIM OF THE STUDY: Triple-valve disease is a challenge that surgeons face periodically, yet the clinical benefits of triple-valve surgery, in relation to the high operative risk, are not well known. The study aims were to describe the early and late mortality associated with triple-valve surgery, to assess the risk factors, and describe the long-term outcomes. METHODS: A retrospective analysis of 178 consecutive triple-valve surgeries performed at the Montreal Heart Institute between 1977 and 2008 was performed. The median follow up was 5.0 years (inter-quartile range: 1.6 to 9.4 years). RESULTS: Among 170 patients (122 females, 48 males; mean age 60 +/- 11 years), the preoperative NYHA functional class was > or = III/IV in 93% of cases; 61% of the patients had undergone previous cardiac surgery. The operative mortality was 12% between 1999 and 2008, and 25% between 1977 and 1998 (p = 0.033). Independent risk factors between 1999 and 2008 period included tricuspid regurgitation severity (OR = 13.71; p = 0.03) and the presence of a right intraventricular pacemaker lead (OR = 11.25; p = 0.039). Survival rates at five and 10 years were 61 +/- 4% and 38 +/- 5%, respectively. A lower left ventricular ejection fraction at discharge was associated with a poor late survival, independent of patient age and gender (OR = 0.95; p = 0.035). Twenty-three patients (18%) required reoperation during the follow up period, at which time the NYHA functional class was improved compared to baseline (p < 0.001). CONCLUSION: Although triple-valve surgery is associated with substantial operative mortality, this situation has improved significantly over the years. Currently, survivors experience a significant improvement in their cardiac functional capacity, justifying the continued use of triple-valve procedures, though preferably earlier during the course of the disease.

Sudden Tamponade From Vein Graft Side Branch Avulsion on Removal of Temporary Pacemaker Wires.

Temporary epicardial pacing wires are universally used in cardiac surgery and are associated with very low morbidity and mortality. Although rare, serious complications can occur with pacing wires. We present a case of avulsion of a saphenous vein graft side branch caused by removal of pacing wires and leading to pericardial tamponade. Our case favors the use of silk ties rather than hemoclips for occlusion of saphenous vein side branches and illustrates the importance of the location of pacing wires relative to the grafts at the time of coronary artery bypass surgery.

Use of Mobile-Based Application for Collection of Patient-Reported Outcomes in Cardiac Surgery.

OBJECTIVE: Application-based (app) technology has been studied for patient engagement and collecting patient-reported outcomes (PROs) in several surgical specialties with limited research in cardiac surgery. The aim of study was to determine the effectiveness of app-based technology for collecting PROs, improving the patient experience, and reducing health services utilization in a cardiac surgery center. METHODS: Patients accessed an interactive app via smartphones. Patients were guided from 4 weeks preoperative to 4 weeks postoperative via reminders, tasks, PRO surveys, and evidence-based education. In the postoperative period, patients were engaged with daily health surveys to track warning signs and recovery milestones. Based on the patient's signs and symptoms, the app escalated lower risk issues to self-care education or higher risk issues to the care team (e.g., phone call to a nurse). RESULTS: Sixty-six percent of patients (730 of 1,108) activated their app account. Two hundred seventy-seven patients completed an end-of-program feedback survey, with 94% of patients recommending the app and 98% of patients finding the app was helpful in recovery. Patients also reported using the app to avoid unnecessary health services utilization, with 45% of patients using the app to avoid at least 1 phone call and 28% of patients using the app to avoid at least 1 hospital visit. CONCLUSIONS: App-based technology for patient engagement is an effective modality to enhance the patient experience, better understand the trajectory of recovery, and reduce unnecessary health services utilization in cardiac surgery.

Optimizing Timing of Valve Intervention in Patients With Asymptomatic Severe Valvular Heart Disease.

The management of valvular heart disease has changed dramatically over the past decade with advances in cardiac imaging, the use of novel biomarkers, and the development of transcatheter valve repair and replacement technology. International society guidelines have kept pace to provide recommendations for diagnosis, follow-up, and timing of intervention. The most challenging patient cohort for clinicians are patients with asymptomatic severe disease in whom the optimal timing of intervention can be ill-defined. It is a fine balance between the risks of early intervention on asymptomatic patients and improving patient outcomes by preventing long-term cardiac complications. The key in optimal patient management is gathering the necessary information on patient risk and combining that with the risk, efficacy, and durability of valve interventions to arrive at the appropriate timing for intervention. This group of patients will be the focus of this review as we delve into the natural history, recommended follow-up, and indications for intervention in patients with degenerative aortic and mitral valve disease.

Quality of life following heart valve replacement in the elderly.

BACKGROUND AND AIM OF THE STUDY: The purpose of this investigation was to evaluate both long-term functional status and quality of life (QoL) following valvular replacement surgery in octogenarians. The influence of gender and discharge location was also examined. METHODS: A total of 133 patients (age range: 80-89 years) who underwent surgical valve replacement between January 2003 and December 2006 was identified. Two questionnaires evaluating QoL (SF-12v2 and MLHFQ), as well as a demographic questionnaire, were sent to these patients. RESULTS: The response rate was 64.4%. Among the participants, the mean NYHA functional class improved from 2.7 to 1.4 after surgery. Men showed results similar to those of the age-matched general Canadian population on the mental and physical component scales of the SF-12v2. The data on women were similar to those of the general population on the physical component scale, but their scores were significantly lower on the mental component scale of the SF-12v2. Further analysis of the results comparing discharge location for each gender revealed that women discharged to a convalescence resource had significantly better QoL scores than those discharged to home with regards to the physical component scale of the SF-12v2, the total score of the MLHFQ, and the physical dimension score of the MLHFQ. CONCLUSION: Patients aged > or = 80 years benefit from heart valve replacement surgery in terms of both QoL and functional status. Women may be at increased risk of a decline in their emotional well-being and, postoperatively, may benefit more from convalescence than from discharge to home.

The endovascular coronary sinus catheter in minimally invasive mitral and tricuspid valve surgery: a case series.

OBJECTIVES: To determine the safety and efficacy of a standardized approach to the use of an endovascular coronary sinus (CS) catheter during minimally invasive cardiac surgery. DESIGN: Case series. SETTING: University hospital. PARTICIPANTS: Patients undergoing mitral and/or tricuspid valve surgery using a minimally invasive cardiac surgery approach. INTERVENTIONS: An endovascular CS catheter was placed to enable the administration of retrograde cardioplegia using transesophageal echocardiography (TEE), fluoroscopy, and CS pressure measurements. MEASUREMENTS AND MAIN RESULTS: Data were collected from 96 patient records. A total of 95 (99.0%) endovascular coronary sinus catheters were positioned. The mean time to insert the catheter into the sinus ostium under TEE guidance was 6.3 ± 8.4 minutes. Confirmation of adequate positioning with fluoroscopy took an average of 9.1 ± 10.6 minutes for a mean total procedure time of 16.1 ± 14.1 minutes. Successful positioning, as defined by the ability to generate a perfusion pressure in the CS greater than 30 mmHg during surgery, was achieved in 87.5% of cases. During positioning, ventricularization of the CS pressure curve was observed in 86.0% of cases. The presence of ventricularization was associated with an increase in positioning success (odds ratio = 15.8; 95% confidence interval, 3.713-67.239). One patient developed extravasation of contrast agent after CS catheter placement, without evidence of CS rupture. CONCLUSIONS: Endovascular CS catheter insertion can be performed with a high rate of success for positioning and a low complication rate. During positioning, obtaining ventricularization is associated with an increased success rate.