Resection of a cardiac tumour with reconstruction of the atria and the superior vena cava.

Cardiac tumours are very rare and their complete resection, when feasible, remains the only curative treatment. We present the case of a patient who had aortic stenosis. The routine preoperative workup also identified stenosis in the left anterior descending and right coronary arteries, and most importantly, an invasive tumour at the confluence of the superior vena cava-right atrium-left atrium. After discussion by the heart team, and as is usually done in our department for non-complex right coronary lesions, the stenosis was treated by inserting a stent. The patient was operated on for an aortic valve replacement with a concomitant left internal mammary artery to left anterior descending artery coronary artery bypass graft. In addition, the tumour was completely resected surgically. Reconstruction included a patch for the left atrium, another for the right atrium and a Dacron tube for the superior vena cava. Histological analysis confirmed the complete resection of a cardiac hibernoma. Three months after the surgery, the patient is doing well without any symptoms.

Reconstruction of a large pulmonary artery aneurysm using a vascular prosthesis.

A pulmonary artery aneurysm is a rare, heterogeneous disease for which there are currently no surgical guidelines. We present the case of a symptomatic patient presenting with a large aneurysm of the distal pulmonary trunk and left pulmonary artery. The aneurysm was resected through a full median sternotomy under cardiopulmonary bypass and aortic cross-clamping. The reconstruction was performed using a straight vascular prosthesis to connect the proximal pulmonary trunk to the left pulmonary artery with the lateral reimplantation of the right pulmonary artery. We find this surgical technique to be simple, effective, and reproducible by colleagues encountering similar cases.

Recent improvement in operative techniques lead to lower pacemaker rate after Perceval implant.

OBJECTIVES: Our goal was to compare pacemaker rate usage following two different operating techniques for implanting the Perceval aortic valve replacement. METHODS: In this retrospective, single-centre study, we studied patients with isolated or concomitant Perceval aortic valve replacement operated on first between April 2013 and January 2016, following traditional operating techniques, with patients operated on between January 2016 and December 2020, after the adoption of a modified protocol based on different annulus sizing, higher positioning of the valve and no ballooning after valve deployment was adopted. The operations were performed by 2 surgeons, and patients were followed-up for a period of 30 days. RESULTS: A total of 286 patients, with a mean age of 77 (4.9) years, had Perceval valves implanted during the study period, of which 79% were isolated aortic valve procedures. Most patients (66.8%) underwent minimally invasive procedures. Cross-clamp time was 55.1 (17.6) min. The overall postoperative pacemaker insertion rate was 8.4%, which decreased decisively after the 2016 change in the implant protocol (16% vs 5.6%; P = 0.005), adjusted odds ratio of 0.31 (95% confidence interval: 0.13-0.74, P = 0.012). Univariable and multivariable analysis showed that larger valve size (P = 0.01) and ballooning (P = 0.002) were associated with higher risk of implanting a pacemaker. Postoperative 30-day mortality was of 4.5%. CONCLUSIONS: Improvement in the operating techniques for implanting the Perceval valve may decrease the rate of pacemakers implanted postoperatively. Although further studies are needed to confirm these results, such a risk reduction may lead to wider use of Perceval valves in the future, potentially benefiting patients who are suitable candidates for minimally invasive surgery.

Right anterior minithoracotomy with total central cannulation.

A right anterior minithoracotomy is gaining wider acceptance among the members of the surgical community for the treatment of isolated aortic valve replacement. Usually, the cardiopulmonary bypass circuit is implanted either totally peripherally or with 1 cannula in a central position and the other in a peripheral one. This procedure has its drawbacks because it adds potential peripheral morbidity during or after the operation. At our center, during the last year, we have developed some tips and tricks in order to establish in most of the patients a total central cardiopulmonary bypass procedure. We explain this technique in our video tutorial. We think that this approach may help other surgical teams to embrace a right anterior minithoracotomy because it is similar to what we do routinely by sternotomy.

Reversed C-shaped Scanner-guided Ministernotomy for Isolated Aortic Valve Replacement.

Here we present our technique of aortic valve replacement through a reversed C-shaped ministernotomy in 36 patients operated between 2017 and 2019. All patients had a preoperative computed tomography that guided the surgical approach. The sternum was incised at the level of the first and third or the second and fourth intercostal spaces. Cross-clamp time was of 65.2 ± 15.9 minutes. Median extubation time was of 2 hours. There was no postoperative 30-day mortality. Because the upper and lower parts of the sternum remain intact, this approach may improve postoperative thoracic stability.

The Ross procedure in adults patients with reconstruction of the RVOT with a bioprosthetic valve.

The Ross procedure is now a well established treatment for aortic valve pathology in young adult patients. However, there are several technical aspects of this operation that are still under debate. One of them is the necessity for reconstruction of the right ventricular outflow tract. Cryopreserved or decellularized pulmonary homografts are the gold standard but, in some cases, and especially in urgent patients, their availability cannot be guaranteed. Stentless xenografts (such as the Medtronic Freestyle Aortic Root) can be inappropriate for some patients with large right outflow tracts, because it can be difficult to suture them without tension. The use of bio conduits handmade using straight Dacron grafts and stented xenografts can be helpful as a third choice.  In this video tutorial we demonstrate our technique for right ventricular outflow tract reconstruction in a young adult patient. We believe that our technique should be included in the armamentarium of every Ross surgeon for use in adult patients. However, long-term outcomes for these stented xenografts in the right outflow position should be carefully evaluated in the future.

Standardized loop technique for mitral valve repair offers good midterm results.

BACKGROUND: We reviewed the midterm results of our approach for mitral valve repair with the use of standardized loops. METHODS: In a retrospective single-center study, mitral repairs performed between November 2015 and December 2019 with the standardized loop technique were included. Predefined loops of 15 and 25 mm (Gore-Tex) were implanted for posterior or anterior mitral prolapses, respectively. Isolated or concomitant mitral repairs were performed by either a sternotomy or minithoracotomy. Mean follow-up was 25.3 ± 14.7 months. RESULTS: Among 92 patients operated on for mitral repair during this period, 65 had repair with the standardized loop technique. They were mostly men (73.8%) and the mean age was 65.1 ± 9.7 years. Valve prolapse was mainly posterior (87.7%), and cordal rupture was seen in 81.5% of cases. The procedures were carried out by a minithoracotomy in 49.2% of patients. Isolated mitral repairs represented 63.1% of cases. Crossclamp and bypass times were 102 ± 22.8 min and 144.7 ± 34.9 min, respectively. The mean number of loops implanted was 2.7 ± 0.9. No patient left the operating room with moderate or severe mitral regurgitation. Postoperative morbidity was 18.4% (12 patients) and 30-day mortality was 3.1% (2 patients). Overall 4-year survival and freedom from reoperation for mitral repair failure were 84.4% and 91.7%, respectively. CONCLUSIONS: The standardized loop technique for mitral repair showed good midterm results. This technique can be valuable in the armamentarium of mitral repairs. Further evaluation is needed for long-term follow-up.

Axillary TAVR under locoregional anesthesia in a patient with peripheral artery disease.

Transcatheter aortic valve replacement (TAVR) is now a relatively commonly performed procedure and the number of eligible patients is growing exponentially.  In candidates with peripheral arterial disease, the axillary artery approach is an option worth considering. Usually TAVR performed using this approach is done under general anesthesia with tracheal intubation. At our center, however, we have developed a surgical approach to TAVR using the axillary artery under locoregional anesthesia.  This video tutorial demonstrates the technical details of our strategy. Because this procedure is extrathoracic, spares cerebral vessels, and is done under locoregional anesthesia, it is particularly suitable for fragile patients. This combination of both axillary access and locoregional anesthesia has the potential to become a primary main alternative for non-femoral TAVR patients and we hope it will be adopted also by other centers.

Severe Acute Proximal Pulmonary Embolism and COVID-19: A Word of Caution.

Acute pulmonary embolism is an uncharacteristic presentation in patients with coronavirus 2019 (COVID-19). Here we describe the case of a young woman presenting with severe pulmonary embolism, without any associated symptoms of infections. A clot in a patent foramen ovale was noted. Despite emergency surgical embolectomy, her clinical conditions continued to deteriorate. She was put on extracorporeal life support and tested positive for COVID-19. She died of multiorgan failure on day 10. COVID-19 may have a thrombogenic effect, and it may need to be considered in cases of pulmonary embolism and in the absence of any obvious risk factor.

Aortic valve replacement with Edwards INTUITY sutureless bioprosthesis through right anterior minithoracotomy.

Minimally invasive aortic valve replacement through right anterior minithoracotomy has been shown as a reliable and interesting approach. However, the placement of a sutured valve may be challenging and time-consuming in some cases. Sutureless bioprosthesis is an elegant alternative in order to facilitate its placement and to reduce the aortic cross-clamp time. In this video, we report our surgical technique of minimally invasive aortic valve replacement with an Edwards INTUITY sutureless bioprosthesis. Postoperative course was uneventful and the patient was discharged after 6 days.