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Mitral annular calcification (MAC) complicates the management of mitral valve (MV) disease, regardless of its etiology. Strategies to address MV surgery in MAC include two main options with their own pros and cons; respect and resect strategy. Here, we present a case of minimally-invasive MV repair with partial annuloplasty in the management of noncircumferential MAC with respect to strategy. This technique may be an alternative option for rescuing high-risk patients without extensive decalcification.
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Calcinose , Doenças das Valvas Cardíacas , Implante de Prótese de Valva Cardíaca , Anuloplastia da Valva Mitral , Insuficiência da Valva Mitral , Valva Aórtica/cirurgia , Calcinose/diagnóstico por imagem , Calcinose/etiologia , Calcinose/cirurgia , Doenças das Valvas Cardíacas/cirurgia , Implante de Prótese de Valva Cardíaca/métodos , Humanos , Valva Mitral/diagnóstico por imagem , Valva Mitral/cirurgia , Anuloplastia da Valva Mitral/métodos , Insuficiência da Valva Mitral/diagnóstico por imagem , Insuficiência da Valva Mitral/etiologia , Insuficiência da Valva Mitral/cirurgia , Resultado do TratamentoRESUMO
Transcatheter aortic valve replacement (TAVR) has already received the green light for high-, intermediate- and low-risk profiles and is an alternative for all patients regardless of age. It is clear that there has been a push towards the use of TAVR in younger and younger patients (<65 years), which has never been formally tested in randomized controlled trials but seems inevitable as TAVR technology makes steady progress. Lifetime management as a concept will set the tone in the field of the structural heart. Some subjects in this scenario arise, including the importance of optimized prosthetic hemodynamics for lifetime care; surgical procedures in the aortic root; management of structural valve degeneration with valve-in-valve procedures (TAVR-in-surgical aortic valve replacement [SAVR] and TAVR-in-TAVR) and redo SAVR; commissural alignment and cusp overlap for TAVR; the rise in the number of surgical procedures for TAVR explantation; and the renewed interest in the Ross procedure. This article reviews all these issues which will become commonplace during heart team meetings and preoperative conversations with patients in the coming years.
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Valvopatia Aórtica , Estenose da Valva Aórtica , Implante de Prótese de Valva Cardíaca , Estenose da Valva Aórtica/cirurgia , Humanos , Fatores de Risco , Resultado do TratamentoRESUMO
Transcatheter mitral valve implantation (TMVI) has emerged as a less invasive approach potentially surmounting some of the current hurdles associated with transcatheter edge-to-edge repair and high-risk mitral valve surgery. In this review, we aimed to outline the main scenarios in the TMVI field, highlight current and upcoming devices, and describe challenges and clinical results. Finally, we briefly discuss the future perspectives for this emerging field and how TMVI might further advance the field of transcatheter treatments of mitral valve disease.
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Implante de Prótese de Valva Cardíaca , Próteses Valvulares Cardíacas , Insuficiência da Valva Mitral , Cateterismo Cardíaco/métodos , Implante de Prótese de Valva Cardíaca/métodos , Humanos , Valva Mitral/cirurgia , Insuficiência da Valva Mitral/cirurgia , Resultado do TratamentoRESUMO
Composite replacement of the aortic root and aortic valve is a valid surgical strategy in a case of annuloaortic ectasia. However, valve-sparing root replacement procedures have become the gold standard in cases with a morphologically intact or at least repairable aortic valve, and offer several advantages compared to conventional replacement techniques. Above all, the David procedure has become established as a well-known valve-sparing root replacement strategy with excellent short- and long-term outcomes, and it has been further applied to additional patient populations with characteristics like a bicuspid aortic valve or in the setting of acute type A aortic dissection. This narrative review offers an overview of the indications as well as the surgical steps of the T. David V procedure, and highlights important key points regarding the surgical feasibility and criteria of patient selection for valve-sparing root replacement.
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Over the past few decades, the field of minimally invasive cardiac surgery has significantly broadened. Novel surgical and endovascular techniques have been developed for the treatment of aortic valve pathologies. Surgical aortic valve replacement (SAVR) through a right antero-lateral (mini-)thoracotomy (RALT) has gained approval due to its limited postoperative trauma, faster rehabilitation and sufficient pain control. Nevertheless, SAVR RALT has not been adopted by a significant proportion of cardiac surgeons, due, in part, to its technical complexity and steep learning curve. In this review, we discuss the data for minimally invasive aortic valve surgery and describe our operative technique for SAVR RALT.
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BACKGROUND: Minimally invasive approaches to isolated aortic valve replacement (AVR) continue to gain popularity. This study compares outcomes of AVR through right anterolateral thoracotomy (RALT) to those of AVR through full median sternotomy (MS). METHODS: Outcomes of two propensity-matched groups of 85 each, out of 250 patients that underwent isolated AVR through RALT or MS at our two institutions, were compared in a retrospective study. RESULTS: Propensity score matching resulted in 85 matched pairs with balanced preoperative characteristics. Procedure times were significantly shorter in the RALT group (median difference: 13 min [-25 to -0.5]; p = .039), cardiopulmonary bypass times were longer (median difference: 17 min [10-23.5]; p = < .001) and ventilation times shorter (median difference: 259 min [-390 to -122.5]; p = < .001). There was no significant difference in aortic cross-clamp times (median difference: 1.5 min [-3.5 to 6.5]; p = .573). The RALT group had lower rates of perioperative platelet transfusions (odds ratio [OR] = 0.00 [0.00-0.59]; p = .0078) and postoperative pneumonia (OR = 0.10 [0.00-0.70]; p = .012), as well as shorter hospitalization times (median difference: 2.5 days [-4.5 to -1]; p = .005). There were no significant differences regarding paravalvular leakage (p = .25), postoperative stroke (p = 1), postoperative atrial fibrillation (p = .12) or 1-year-mortality (p = 1). CONCLUSIONS: This study found RALT to be an equally safe approach to surgical AVR as MS. Furthermore, RALT showed advantages regarding important aspects of postoperative recovery, especially concerning pulmonary function.
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Implante de Prótese de Valva Cardíaca , Esternotomia , Valva Aórtica/cirurgia , Humanos , Tempo de Internação , Procedimentos Cirúrgicos Minimamente Invasivos , Pontuação de Propensão , Estudos Retrospectivos , Toracotomia , Resultado do TratamentoRESUMO
Implantable left ventricular assist devices (durable LVADs) have dramatically improved mortality and morbidity in patients with advanced heart failure. Originally designed as a bridge or candidacy to heart transplantation, the indications extend toward permanent support and palliation. Modern durable continuous flow LVADs are small, commercially available, and allow for different surgical approaches to a wide range of patients with various cardiac pathologies. We will review different surgical implantation techniques of modern continuous flow LVADs, as well as specific aspects of preoperative patient evaluation and planning.
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Insuficiência Cardíaca , Transplante de Coração , Coração Auxiliar , Insuficiência Cardíaca/cirurgia , Ventrículos do Coração , HumanosRESUMO
The two current strategies for robotic-assisted, surgical myocardial revascularization are minimally invasive direct coronary artery bypass (MIDCAB) and totally endoscopic coronary artery bypass grafting (TECAB). We discuss the rationale underlying the benefits of robotic assistance in surgical myocardial revascularization, and detail the technical steps to safely and effectively perform these two procedures.
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Doença da Artéria Coronariana , Procedimentos Cirúrgicos Robóticos , Ponte de Artéria Coronária , Doença da Artéria Coronariana/cirurgia , Humanos , Revascularização Miocárdica , Resultado do TratamentoRESUMO
Acute type A aortic dissection (ATAAD) is a life-threatening event that requires immediate surgical treatment. Improvements in surgical treatment, graft technology, organ protection and imaging techniques have led to improved clinical outcomes. Individualized treatment concepts have emerged based on more advanced planning tools that allow for a tailored approach even in complex situations such as multi-level malperfusion. This review provides an overview of the current surgical treatment of ATAAD, focusing on new disease classifications, preoperative computed tomography angiography (CTA) assessment, new prosthesis and stent technologies, and organ-protection strategies.
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Dissecção Aórtica , Implante de Prótese Vascular , Doença Aguda , Dissecção Aórtica/diagnóstico por imagem , Dissecção Aórtica/cirurgia , Humanos , Estudos Retrospectivos , Stents , Resultado do TratamentoRESUMO
INTRODUCTION: Extrahepatic portal vein thrombosis (PVT) is the most common cause of portal hypertension (PH), particularly in children. PH-related manifestations include refractory variceal bleeding, splenomegaly and ascites. Albeit more rarely performed, the distal splenorenal shunt (Warren's shunt) has proven to be effective in selectively decompressing the collateral circulation. The aim of our study was to describe our experience with the distal splenorenal shunt and to determine the long-term effect on PH-related side-effects. METHODS: Distal splenorenal shunt operations performed at our institution between 2000 and 2014 were reviewed for: age, male/female ratio, children/adults ratio, body mass index, indications, grade of PVT (Yerdel classification), maximal shunt-flow velocity, shunt patency and thrombosis, re-intervention for variceal bleeding and survival. Complications of PH (esophageal variceal bleeding and ascites) were compared pre- versus post-operatively (last follow-up). Paired student t-test and fisher's exact were applied for pre- versus post-operative comparison. Results are reported as median [range]. RESULTS: Fourteen patients with PVT and refractory complications of PH underwent distal splenorenal shunt surgery. Age was 15 years [4.5-66]. Male/female ratio was 7/7. PVT -grade was 2 [1-4]. Follow-up was 3 [0.5-14]. All shunts were patent (100%) with no shunt thrombosis (0%) at last follow-up. There was no re-intervention for variceal bleeding (0%) and survival at last follow-up was 100%. Occurrence of esophageal variceal bleeding was higher pre-operatively (57%) than postoperatively (0%) (p = .0032) and also the incidence of ascites was higher pre-operatively (79%) than postoperatively (0%) (p < .0001). CONCLUSIONS: Based on our experience, the distal splenorenal shunt can be considered a valuable surgical technique for PVT-induced PH, with excellent post-operative prevention of complications of PH.
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Varizes Esofágicas e Gástricas , Hipertensão Portal , Derivação Esplenorrenal Cirúrgica , Adolescente , Adulto , Criança , Varizes Esofágicas e Gástricas/etiologia , Varizes Esofágicas e Gástricas/cirurgia , Feminino , Hemorragia Gastrointestinal/etiologia , Hemorragia Gastrointestinal/cirurgia , Hospitais Universitários , Humanos , Hipertensão Portal/complicações , Hipertensão Portal/cirurgia , MasculinoRESUMO
BACKGROUND: Outflow graft (OG) obstruction is a dangerous complication that may occur for various reasons after left ventricular assist device (LVAD) implantation. CASE SUMMARY: We describe the case of a 51-year-old patient on LVAD support who developed significant OG kinking and external OG obstruction due to a fibrin mass causing severe stenosis. Both the OG kinking and external obstruction were eliminated via a left lateral thoracotomy.
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Fibrina , Oclusão de Enxerto Vascular/etiologia , Oclusão de Enxerto Vascular/cirurgia , Coração Auxiliar/efeitos adversos , Implantação de Prótese/efeitos adversos , Toracotomia/métodos , Trombose/etiologia , Oclusão de Enxerto Vascular/patologia , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do TratamentoRESUMO
Less-invasive techniques for cardiothoracic surgical procedures are designed to limit surgical trauma, but the technical requirements and preoperative planning are more demanding than those for conventional sternotomy. Patient selection, interdisciplinary collaboration, and surgical skills are key factors for procedural success. Aortic valve replacement is frequently performed through an upper hemisternotomy, but the right anterior minithoracotomy represents an even less traumatic, technical advancement. Preoperative assessment of the ascending aorta in relation to the sternum is mandatory to select patients and the intercostal access site. This description of the surgical technique focuses on the specific procedural details including the obligatory planning with computed tomography and our cannulation strategy. We also sought to define the anatomical ascending aorta-sternal relationship, as it is of utmost importance in preoperative computed tomographic planning.
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Doenças das Valvas Cardíacas , Implante de Prótese de Valva Cardíaca , Próteses Valvulares Cardíacas , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/cirurgia , Doenças das Valvas Cardíacas/cirurgia , Humanos , Procedimentos Cirúrgicos Minimamente Invasivos , Toracotomia , Resultado do TratamentoRESUMO
BACKGROUND: Takotsubo syndrome is, by definition, a reversible form of acute heart failure. If cardiac output is severely reduced, Takotsubo syndrome can cause cardiogenic shock, and mechanical circulatory support can serve as a bridge to recovery. To date, there are no recommendations on when to use mechanical circulatory support and on which device is particularly effective in this context. Our aim was to determine the best treatment strategy. METHODS: A systematic literature research and analysis of individual patient data was performed in MEDLINE/PubMed according to PRISMA guidelines. Our research considered original works published until 31 July 2023. RESULTS: A total of 93 publications that met the inclusion criteria were identified, providing individual data from 124 patients. Of these, 62 (50%) were treated with veno-arterial extracorporeal life support (va-ECLS), and 44 (35.5%) received a microaxial left ventricular assist device (Impella). Eighteen patients received an Impella CP and twenty-one an Impella 2.5. An intra-aortic balloon pump (IABP) without other devices was used in only 13 patients (10.5%), while other devices (BiVAD or Tandem Heart) were used in 5 patients (4%). The median initial left ventricular ejection fraction was 20%, with no difference between the four device groups except for the IABP group, which was less affected by cardiac output failure (p = 0.015). The overall survival was 86.3%. Compared to the other groups, the time to cardiac recovery was shorter with Impella (p < 0.001). CONCLUSIONS: Though the Impella treatment is new, our analysis may show a significant benefit of Impella compared to other MCS strategies for cardiogenic shock in Takotsubo syndrome.
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BACKGROUND: The "UFO procedure" was initially developed as a surgical option to enlarge the aortic annulus in patients requiring valve replacement. This technique can be employed to treat extensive endocarditis located in the intervalvular fibrous body (IVFB). One of the indications for a "UFO procedure" is massive aortic and mitral valve calcification. It is a challenging surgical procedure with a high risk of intraoperative complications. We present a 76-year-old male patient with massive aortic and mitral valve calcification involving the left atrium, the left ventricle and the left ventricular outflow tract. Both valves exhibited severe stenosis and moderate to severe regurgitation. The left ventricle was hypertrophic and the left ventricular ejection fraction was > 55%. The patient was prediagnosed with persistent atrial fibrillation. The risk of death following heart surgery (EuroSCORE II) was calculated as 9.21%. We successfully performed a so-called "UFO procedure" including replacement of both valves without annular decalcification to avoid atrioventricular dehiscence. We enlarged the IVFB and replaced the non-coronary sinus of Valsalva with doubled bovine pericardium. The left ventricular outflow tract was decalcified. The patient was transferred to a local hospital on the 13th postoperative day. CONCLUSION: Successful surgical treatment to this extent was demonstrated for the first time. Due to the high perioperative mortality, the surgical treatment of patients with this constellation would be refused in most cases. In our patient, the preoperative imaging showed extreme calcification of both valves and the surrounding myocardium. Excellent preoperative planning and a highly experienced surgical team is necessary.
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Fibrilação Atrial , Doenças das Valvas Cardíacas , Implante de Prótese de Valva Cardíaca , Masculino , Humanos , Animais , Bovinos , Idoso , Valva Mitral/cirurgia , Ventrículos do Coração/cirurgia , Volume Sistólico , Fibrilação Atrial/cirurgia , Função Ventricular Esquerda , Doenças das Valvas Cardíacas/cirurgia , Doenças das Valvas Cardíacas/etiologia , Átrios do Coração/cirurgia , Miocárdio , Valva Aórtica/cirurgia , Implante de Prótese de Valva Cardíaca/métodos , Resultado do TratamentoRESUMO
Objective: The use of transcatheter mitral valve repair (TMVr) devices is increasing in elderly and high-risk patients. However, the increasing number of patients with recurrent mitral regurgitation (MR) has confronted surgeons with the issue of how to explant the devices and whether the mitral valve should be repaired or replaced. The aim of the study is to summarize our clinical experience with the explantation of different TMVr devices and to provide alternative surgical techniques that can be performed in different clinical scenarios. Methods: A simulator system including a dummy valve representing native valves was used to create video documentation and to develop alternative surgical methods for clip explantation. Moreover, the clip explantation techniques were shown in 2 patients undergoing minimally-invasive mitral valve repair after a failed TMVr. Results: Alternative explantation techniques were described for each TMVr device; 2 techniques for MitraClip and 3 techniques for PASCAL (Precision Transcatheter Valve Repair System), which may be adjusted for each individual according to the underlying valve pathology and the degree of device encapsulation. The patients were discharged without residual MR and remained MR free at the follow-up. Conclusions: Transcatheter edge-to-edge repair devices can be surgically explanted without damaging the MV leaflets. Removal of each device may require a different technique tailored to the degree of device encapsulation and valve pathology. Increasing experience may facilitate repair in patients with recurrent MR after TMVr.
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OBJECTIVES: Annuloplasty rings are routinely used in mitral valve repair (MVr). However, accurate annuloplasty ring size selection is essential to obtain a favourable outcome. Moreover, ring sizing can be challenging in some patients and is highly influenced by surgeons' experience. This study investigated the utility of three-dimensional mitral valve (3D-MV) reconstruction models to predict annuloplasty ring size for MVr. METHODS: A total of 150 patients undergoing minimally invasive MVr with annuloplasty ring due to Carpentier type II pathology and who were discharged with none/trace residual mitral regurgitation were included. 3D-MV reconstruction models were created with a semi-automated software package (4D MV Analysis) to quantitate mitral valve geometry. To predict the ring size, univariable and multivariable linear regression analyses were performed. RESULTS: Between 3D-MV reconstruction values and implanted ring sizes, the highest correlation coefficients were provided by commissural width (CW) (0.839; P < 0.001), intertrigonal distance (ITD) (0.796; P < 0.001), annulus area (0.782; P < 0.001), anterior mitral leaflet area (0.767; P < 0.001), anterior-posterior diameter (0.679; P < 0.001) and anterior mitral leaflet length (0.515; P < 0.001). In multivariable regression analysis, only CW and ITD were found to be independent predictors of annuloplasty ring size (R2 = 0.743; P < 0.001). The highest level of agreement was achieved with CW and ITD, and 76.6% of patients received a ring with no >1 ring size difference from the predicted ring sizes. CONCLUSIONS: 3D-MV reconstruction models can support surgeons in the decision-making process for annuloplasty ring sizing. The present study may be a first step towards accurate annuloplasty ring size prediction using multimodal machine learning decision support.
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Procedimentos Cirúrgicos Cardíacos , Implante de Prótese de Valva Cardíaca , Próteses Valvulares Cardíacas , Anuloplastia da Valva Mitral , Insuficiência da Valva Mitral , Humanos , Valva Mitral/diagnóstico por imagem , Valva Mitral/cirurgia , Valva Mitral/patologia , Insuficiência da Valva Mitral/diagnóstico por imagem , Insuficiência da Valva Mitral/cirurgia , Insuficiência da Valva Mitral/patologia , Procedimentos Cirúrgicos Cardíacos/métodos , Valva Tricúspide/cirurgia , Anuloplastia da Valva Mitral/efeitos adversos , Anuloplastia da Valva Mitral/métodos , Implante de Prótese de Valva Cardíaca/métodos , Resultado do TratamentoRESUMO
OBJECTIVE: Evidence determining the optimal treatment for cardiac tumors is rare. We report our midterm clinical outcome and patient characteristics of our series undergoing atrial tumor removal through a right lateral minithoracotomy (RLMT). METHODS: From 2015 to 2021, 51 patients underwent RLMT for atrial tumor extirpation. Patients receiving concomitant atrioventricular valvular, cryoablation, and/or patent foramen ovale closure surgery were included. Follow-up was performed using standardized questionnaires (mean: 1,041 ± 666 days). Follow-up involved any tumor recurrence, clinical symptoms, and any recurrent arterial embolization. Survival analysis was successfully achieved in all patients. RESULTS: Successful surgical resection was achieved in all patients. Mean cardiopulmonary bypass and cross-clamping times were 75 ± 36 and 41 ± 22 min, respectively. The most common tumor location was the left atrium (n = 42, 82.4%). Mean ventilation time was 12.74 ± 17.23 h, intensive care unit stay ranged from 1 to 1.9 days (median: 1 day). Nineteen patients (37.3%) received concomitant surgery. Histopathological analysis showed 38 myxoma (74.5%), 9 papillary fibroelastoma (17.6%), and 4 thrombus (7.8%). Thirty-day mortality was observed in 1 case (2%). One patient (2%) suffered a stroke postoperatively. No patient had a relapse of cardiac tumor. Three patients (9.7%) showed arterial embolization during follow-up. Thirteen follow-up patients (25.5%) were in New York Heart Association class ≤II. Overall survival was 90.2% at 2 years. CONCLUSIONS: A minimally invasive approach for benign atrial tumor resection is effective, safe, and reproducible. Of the atrial tumors, 74.5% were myxoma and 82% were located in the left atrium. A low 30-day mortality rate with no manifestation of recurrent intracardiac tumor was observed.
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Fibrilação Atrial , Neoplasias Cardíacas , Mixoma , Humanos , Seguimentos , Recidiva Local de Neoplasia/epidemiologia , Neoplasias Cardíacas/patologia , Átrios do Coração/cirurgia , Átrios do Coração/patologia , Mixoma/cirurgia , Resultado do Tratamento , Procedimentos Cirúrgicos Minimamente InvasivosRESUMO
Coronary artery obstruction is a life-threatening complication of transcatheter aortic valve replacement procedures, and current preventive strategies are suboptimal. The novel ShortCut device splits bioprosthetic valve leaflets that are at risk of causing coronary artery obstruction after transcatheter aortic valve implantation, allowing for normal coronary flow. In this video tutorial, we demonstrate a valve-in-valve transcatheter aortic valve implantation using a dedicated leaflet-splitting device for prevention of coronary artery obstruction in transcatheter aortic valve replacement.
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Substituição da Valva Aórtica Transcateter , Humanos , Vasos Coronários , CatéteresRESUMO
A continuous-flow left ventricular assist device implant is a well-established therapy for patients with end-stage heart failure. Currently, the HeartMate 3 device is the only commercially available durable left ventricular assist device. Therefore, patients on HeartWare HVAD support who require a pump exchange must have a HeartMate 3 implanted.