Hybrid multistep approach to mega-aortic syndrome: the Lupiae technique.

OBJECTIVES: Several techniques have been described for the treatment of thoraco-abdominal aneurysms in patients with mega-aortic syndrome (MAS), but the incidence of stroke, spinal cord injury and endoleaks remains significant. We present the mid-term results of a new hybrid, multistep technique to treat patients with MAS. METHODS: From November 2005 to November 2012, 118 patients with MAS underwent surgical repair of thoracic and thoraco-abdominal aneurysms with the Lupiae technique. Fifty-five patients presented chronic aneurysms and 63 patients Type A acute dissections. Eighty-three patients underwent ascending aorta and arch replacement with a multibranched Dacron graft and epiaortic vessels rerouting (thoracic Lupiae procedure). Twenty patients had the thoracic Lupiae procedure plus partial visceral debranching (coeliac trunk and superior mesenteric artery [SMA]) through an upper mini-laparotomy. Fifteen patients had the thoracic Lupiae procedure plus a complete visceral debranching (coeliac trunk, SMA and renal arteries) using a second multibranched Dacron graft to replace the infrarenal aorta. All the patients with chronic aneurysms and 34 of 63 patients with Type A dissections underwent implant of endovascular stent grafts. RESULTS: In-hospital mortality was 8.4%. No patients had stroke or spinal cord injury. The incidence of temporary renal failure was 5.2%. No patients presented endoleaks immediately and at follow-up CT scans. No death or reoperation occurred during the follow-up. CONCLUSIONS: These results evidence that the Lupiae technique is a safe and effective option for the treatment of patients with MAS, achieving the complete exclusion of thoraco-abdominal aneurysms and of the residual false lumen in patients with acute aortic dissections.

Cut-and-transfer technique for ischemic mitral regurgitation and severe tethering of mitral leaflets.

BACKGROUND: Chronic ischemic mitral regurgitation (MR) denotes abnormal function of normal leaflets resulting from left ventricular enlargement. We present the midterm results of a tailored mitral repair technique using a combination of the following subvalvular procedures: (1) detachment and reimplantation of secondary chordae on the free edge of the anterior leaflet ("cut-and-transfer" technique), (2) relocation of the posterior papillary muscle (PPM) closer to the mitral annulus, and (3) infarct plication on the lateral wall of the left ventricle. METHODS: From 2008 to 2011, 49 patients with moderate to severe ischemic MR underwent coronary surgery plus mitral valve repair using the cut-and-transfer and PPM relocation techniques. All the patients received a "true-sized" semirigid complete annuloplasty ring. In 20 patients, a plication of the lateral wall of the left ventricle was performed to reduce the tethering of the mitral leaflets. The mean number of coronary grafts per patient was 3.4 ± 0.4. RESULTS: Hospital mortality was 2%. No patient died during 1-year follow-up and New York Heart Association (NYHA) class improved from 3.4 ± 0.5 to 1.4 ± 0.6 (p < 0.0001). The 1-year echocardiogram showed the following changes from baseline: mitral regurgitation grade (0-4) 2.9 ± 0.4 versus 0.2 ± 0.4 (p < 0.0001), left ventricular end-systolic volume index (mL/m(2)) 52.7 ± 13.1 versus 48.2 ± 10.1 (p = 0.07), left ventricular end-systolic index (mL/m(2)) 92.9 ± 16.5 versus 83.4 ± 15.9 (p <0.005), and ejection fraction (%) 37.8 ± 6.3 versus 44.2 ± 8.1 (p < 0.0001). CONCLUSIONS: Both clinical and echocardiographic results show that reducing the tethering of the mitral leaflets with tailored interventions on subvalvular apparatus without undersizing the mitral annulus can safely and effectively correct chronic ischemic MR.