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.

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.

Pulmonary arterial compliance and exercise capacity after pulmonary endarterectomy.

Patients with chronic thromboembolic pulmonary hypertension (CTEPH), despite successful pulmonary endarterectomy (PEA), can continue to suffer from a limitation in exercise capacity. The objective of this study was to assess whether pulmonary arterial compliance is a predictor of exercise capacity after PEA. Right heart haemodynamics, treadmill incremental exercise test, spirometry, carbon monoxide transfer factor, arterial blood gas and echocardiographic examinations were retrospectively analysed in a population of CTEPH patients who underwent PEA at a single centre. Baseline and 3-month haemodynamic data were available in 296 patients; 5-year follow-up data were available in 68 patients. In a multivariable model the following parameters were found to be independent predictors of exercise capacity after surgery: age, sex, pulmonary arterial compliance, tricuspid annular plane excursion, arterial oxygen tension and carbon monoxide transfer factor (p<0.0001); the model showed good discrimination (Harrell's c=0.84) and calibration (shrinkage coefficient=0.91). Poor exercise capacity at 3 months was loosely associated with higher death rate during subsequent survival (Harrell's c=0.61). In conclusion, after successful PEA, reduced pulmonary arterial compliance is an important determinant of exercise capacity in association with the age and sex of the patients, and the extent of recovery of both cardiac and respiratory function. However, exercise capacity does not explain a large proportion of the effect of surgery on subsequent survival.

Should we perform heart retransplantation in early graft failure?

Cardiac retransplantation represents the gold standard treatment for a failing cardiac graft but the decision to offer the patient a second chance is often made difficult by both lack of donors and the ethical issues involved. The aim of this study was to evaluate whether retransplantation is a reasonable option in case of early graft failure. Between November 1985 and June 2008, 922 patients underwent cardiac transplantation at our Institution. Of these, 37 patients (4%) underwent cardiac retransplantation for cardiac failure resulting from early graft failure (n = 11) or late graft failure (acute rejection: n = 2, transplant-related coronary artery disease: n = 24). Survival at 1, 5 and 10 years of patients with retransplantation was 59%, 50% and 40% respectively. An interval between the first and the second transplantation of less than (n = 11, all in early graft failure) or more than (n = 26) 1 month was associated with a 1-year survival of 27% and 73%, and a 5-year survival of 27% and 65% respectively (P = 0.01). The long-term outcome of cardiac retransplantation is comparable with that of primary transplantation only in patients with transplant-related coronary artery disease. Early graft failure is a significant risk factor for survival after cardiac retransplantation and should be considered as an exclusion criteria.

A safe option to perform an apparent difficult redo surgery.

A 50-year-old female operated of Bentall five years before was referred to our hospital for an aneurysm of both right subclavian artery and brachiocephalic trunk associated with a false anastomotic aneurysm on the insertion of the left coronary artery. The procedure was performed under moderate hypothermic circulatory arrest; the false aneurysm was repaired, the brachiocephalic trunk and the subclavian aneurysm were resected, an aorto-carotid and axillary bypass were finally performed. The postoperative course was uneventful. She was discharged to home on postoperative day 7. At six-month follow-up, she was still asymptomatic.

Surgery for infective endocarditis on mitral annulus calcification.

BACKGROUND AND AIM OF THE STUDY: The study aim was to assess the characteristics of bacterial endocarditis complicating mitral annulus calcification, and to evaluate the surgical results. METHODS: Twenty-four patients (mean age 64 years) underwent surgery for mitral insufficiency secondary to mitral endocarditis with annulus calcification (acute, n = 18; healed, n = 6). Surgery was performed as an emergency in seven cases for septic (n = 3) or cardiogenic (n = 4) shock. An aortic prosthesis had previously been placed in three cases. Comorbidities noted included chronic renal insufficiency/dialysis (n = 8), cancer (n = 6), coronary disease (n = 6), and obstructive cardiomyopathy (n = 1). Nine patients suffered an embolic complication, such as stroke (n = 7, of which three had coma), splenic (n = 3), or lower limb (n = 1). The microorganism present was identified as Staphylococcus aureus (n = 9), Streptococcus/ Enterococcus sp. (n = 12), or others (n = 3). The left atrial diameter was 48 mm, the ejection fraction 63%, and the septal thickness 13 mm. RESULTS: The mean severity score of annulus calcifications (range: 1 to 5) was 1.9. The anatomical lesions included: vegetations (n = 16, of which eight were > 10 mm), leaflet perforation (n = 9), chordae rupture (n = 9), aortic abscess (n = 2) and mitral annular abscess (n = 9), and one fistulation into the pericardium. The valve was repaired in 15 cases, and replaced in nine (seven bioprostheses, two mechanical). Associated procedures included aortic valve replacement (n = 7) and coronary artery bypass (n = 3). The in-hospital mortality was 29% (n = 7); all patients who died were operated on during the acute phase. All patients who presented with septic shock or coma died. After a mean follow up of 46 months, six patients had died (overall survival was 46% at 33 months), and 11 were in NYHA class I/II. One recurrence of endocarditis was treated medically. CONCLUSION: Bacterial endocarditis complicating mitral annulus calcification has a poor prognosis due to the frequent comorbidity and severity of the infectious complications. Patients in septic shock or coma do not appear to be suitable candidates for surgery. Valve repair was possible in two-thirds of the present patients; otherwise, a bioprosthetic replacement was the option of choice.

Surgical treatment of a pulmonary artery aneurysm.

We would like to report a rare case of post-stenotic aneurysm of the pulmonary trunk and its left branch in a 51-year-old man. His cardiac disease, which was first diagnosed at the age of 4, was left untreated because of absence of symptoms and normal physical development. A CT scan, recently performed because of decrease in exercise tolerance and worsening dyspnea, showed a pulmonary artery aneurysm (52 mm x 79 mm). The echocardiography revealed a severe pulmonary commissural stenosis. Through a surgical approach the pulmonary trunk and its left branch were excised and reconstructed using a 30 mm Dacron graft; the right pulmonary branch was then reimplanted on the right side of the tube. The patient's postoperative course was uneventful. He was discharged on the seventh postoperative day and there were no adverse events or complications at 1- and 3-month follow-up.

Mitral annulus calcification: determinants of repair feasibility, early and late surgical outcome.

OBJECTIVE: The aim of this study was to determine the factors influencing the feasibility of valve repair and the surgical outcome in patients with mitral annulus calcification. METHODS: In 124 patients with mitral annulus calcification undergoing surgery, two entities were distinguished: Barlow disease (myxomatous leaflets, n=60) and fibroelastic deficiency (FED) (normal leaflets, n=64). The calcification score was lower (1.9 vs 2.8); the annulus was more dilated (ring 35 vs 32 mm) and ruptured chordae were more frequent (77% vs 37%) in Barlow than in FED (p<0.001). The clinical profile was different: age (60+/-14 vs 73+/-8 years, p<0.001), systemic hypertension (22% vs 70%, p<0.001), chronic renal insufficiency (5% vs 22%, p<0.01), cancer (7% vs 25%, p<0.01). Multifocal atherosclerosis was less frequent in Barlow than in FED: carotid disease (17% vs 54%, p<0.001), aortic atheroma (21% vs 51%, p<0.001) and coronary disease (22% vs 56%, p<0.01). Echocardiography showed two different patterns in Barlow and FED: aortic valve stenosis (1.7% vs 31%), left atrial diameter (54 vs 49 mm), left ventricular end-diastolic diameter (62 vs 54 mm), interventricular septal thickness (11 vs 13 mm), and systolic pulmonary pressure (40 vs 56 mmHg), respectively (p<0.001). Bacterial endocarditis was observed in 24 cases (19%). RESULTS: The surgical technique was a valve repair in 68% and a replacement in 32%. The repair rate depended upon the extent of annulus calcifications (p<0.001) and the type of degenerative disease (95% vs 44% in Barlow and FED p<0.001). In-hospital mortality was 14% (Barlow: 5% vs FED: 23%, p<0.01). The mean follow-up was 50+/-41 months. Overall 5-year year survival was 76% (Barlow: 90% vs FED: 64%, p<0.001) and survival free from cardiac event was 69% at 5 years (Barlow: 87% vs FED: 52%, p<0.001). Five-year survival was higher following repair than replacement (84% vs 64% p<0.001). Chronic renal insufficiency and bacterial endocarditis were two predictors of early and late death (p<0.01). CONCLUSIONS: The aetiopathogeny of the degenerative mitral disease responsible for annulus calcifications corresponded to distinct anatomical, clinical and echographic patterns. It was a main determinant of repair feasibility, early and late surgical outcome.

Does the use of a free internal mammary artery graft on the left anterior descending artery compromise long-term survival?

OBJECTIVES: The aim of the study was to determine if there is a long-term outcomes disadvantage associated with using the internal mammary artery (IMA) as a free graft to the left anterior descending artery (LAD) during coronary artery bypass graft surgery. METHODS: Between 1991 and 2014, 21 876 consecutive patients underwent isolated primary coronary artery bypass graft surgery at our institution. Among these, 238 underwent a free IMA (f-IMA) graft to bypass the LAD. Propensity score matching with bootstrap analysis was performed to produce a cohort of 222 f-IMA patients matched to 222 patients with in situ IMA grafting to the LAD. Early and long-term outcomes including survival, readmission for cardiovascular causes and repeat revascularization up to a maximum of 23 years post-coronary artery bypass graft surgery were compared. Provincial vital statistics and administrative hospital readmission data were used to analyse long-term outcomes. RESULTS: Operative mortality [3.2% f-IMA vs 1.9% in situ IMA; odds ratio = 1.79, 95% confidence interval (CI) = 0.91-3.52] and the majority of postoperative adverse events were not significantly different among matched patients. The risk of late death was not significantly different between the 2 matched groups (hazard ratio = 1.14, 95% CI = 0.92-1.41, P = 0.15). The risk of hospital readmission for cardiovascular reasons was significantly higher in the f-IMA group (54.5% vs 47.3%, odds ratio = 1.4; 95% CI = 1.10-1.72), although repeat revascularization (18.4% vs 13.5%; odds ratio = 1.53, 95% CI = 0.96-2.44) was not significantly different between the matched groups. CONCLUSIONS: Late survival and the need for repeat coronary revascularization were not influenced by using the IMA as a free graft to the LAD. However, there is a small but significant increase in the risk of hospital readmission for cardiac reasons.

Pavia Experience in Reoperative Pulmonary Endarterectomy.

In our experience, we reperformed pulmonary endarterectomy (PEA) in 10 patients who previously underwent a first PEA. We analyzed this cohort of patients to investigate the main causes of recurrence of symptomatic pathology and the clinical and hemodynamic results of redo surgery. Between 1994 and April 2016, 10 of 716 patients were reoperated at our institution. Available postoperative data were analyzed, and a comparison between first and second PEA hemodynamic and clinical results was carried out. In-hospital mortality rate was also evaluated. After reoperation, mean pulmonary arterial pressure decreased from 45?±?9 to 34?±?10?mm Hg, and pulmonary vascular resistance reduced from 932?±?346?dyne*s*cm?5 to 428?±?207?dyne*s*cm?5. Hemodynamic data revealed worthy results of redo PEA, although they are less important than after first PEA. The World Health Organization (WHO) functional class improvement demonstrated satisfactory clinical results. In-hospital mortality of repeat PEA is 40%. Reoperative PEA operative candidacy should be assessed in case of young patients, no other risk factor, and recent medical history of pulmonary hypertension. In the other cases, in-hospital mortality rate is very high and pulmonary hypertension-specific drug therapy or interventional approach should be previously considered.

Surgical Treatment of Constrictive Pericarditis.

Constrictive pericarditis is the final stage of a chronic inflammatory process characterized by fibrous thickening and calcification of the pericardium that impairs diastolic filling, reduces cardiac output, and ultimately leads to heart failure. Transthoracic echocardiography, computed tomography, and cardiac magnetic resonance imaging each can reveal severe diastolic dysfunction and increased pericardial thickness. Cardiac catheterization can help to confirm a diagnosis of diastolic dysfunction secondary to pericardial constriction, and to exclude restrictive cardiomyopathy. Early pericardiectomy with complete decortication (if technically feasible) provides good symptomatic relief and is the treatment of choice for constrictive pericarditis, before severe constriction and myocardial atrophy occur. We describe our surgical approach to constrictive pericarditis, summarize our results in 93 patients, and provide a brief overview of the literature.

Successful Repair of a Bicuspid Pulmonary Autograft Valve Causing Early Insufficiency After a Ross Procedure.

The Ross procedure is an excellent option in terms of long-term outcomes for young patients requiring aortic valve replacement. We report the case of a 49-year-old woman who presented with worsening dyspnea and episodes of presyncope in the context of a patient-prosthesis mismatch, 13 years after mechanical aortic valve replacement. She underwent a Ross procedure despite the pulmonary valve being bicuspid at intraoperative examination. Following implantation, the autograft valve showed an eccentric jet of regurgitation requiring bicuspid valve repair. To our knowledge, this is the first reported case of successful repair of a bicuspid pulmonary autograft valve.

Tamponade Relief by Active Clearance of Chest Tubes.

PURPOSE: Chest tubes are used in every case of cardiac surgery to evacuate shed blood from around the heart and lungs. Chest tubes can become partially or totally occluded, leading to tamponade. The purpose of this article is to discuss a novel method of maintaining chest tube patency in the early recovery after cardiothoracic surgery. DESCRIPTION: The PleuraFlow Active Clearance Technology is a system to prevent chest tube clogging that can be used to help routinely maintain chest tube patency at the bedside in the intensive care unit. EVALUATION: A patient exhibited physiologic tamponade that was confirmed by transthoracic echocardiography. The chest tube was successfully reopened by actively clearing the chest tube using Active Clearance Technology, resulting in resolution of the tamponade. CONCLUSIONS: The present study reports the case of a patient with massive postoperative pericardial effusion with tamponade, successfully managed by active clearance chest tube. Further studies will help define the role for this technology in routine cardiac surgery.

Pulmonary endarterectomy in the elderly: safety, efficacy and risk factors.

AIMS: Pulmonary endarterectomy (PEA) is the treatment of choice for patients with chronic thromboembolic pulmonary hypertension, but there are few data in the literature about the results of this procedure in the elderly. In this study, we aimed to assess whether this type of surgery is effective and well tolerated for the elderly. METHODS: A total of 264 consecutive patients who underwent PEA between January 2008 and December 2012 were reviewed. PEA was performed under cardiopulmonary bypass and hypothermic ventricular fibrillation, with the aorta left unclamped. The population was dichotomized according to age into the following two groups: below 70 years (n = 176, younger patients) and at least 70-year-olds (n = 88, elderly patients). Regression models were used to identify predictors of hospital mortality and postoperative adverse events, and their interaction with age was tested. RESULTS: Hospital mortality was slightly, but not significantly higher in elderly patients (9.1 vs. 5.1%; P = 0.22). Effect modification by history of smoking and preoperative O2 therapy was present. The cumulative survival at 1, 2, and 4 years was 93, 92, and 91% among younger patients; and 88, 86, and 86% among older patients (P = 0.19). Clinical and hemodynamic improvement was similar in the two groups. CONCLUSION: Despite a slightly higher short-term mortality, PEA is feasible and well tolerated for the vast majority of the elderly patients. Clinical and hemodynamic improvements are outstanding, with satisfactory long-term survival rates.

Sutureless Aortic Valve Replacement in the Setting of Triple-Valve Surgery.

Sutureless aortic valve replacement is an emerging alternative to standard aortic valve replacement in high-risk surgical patients. We present our surgical technique for sutureless aortic valve replacement in patients undergoing triple-valve surgery. This procedure has been performed in six patients with excellent clinical and echocardiographic results. Despite some technical concerns, sutureless aortic valve replacement in the setting of triple-valve surgery is simple and reproducible.

Very high repair rate using minimally invasive surgery for the treatment of degenerative mitral insufficiency.

BACKGROUND: Minimally invasive mitral valve surgery (MIMVS) is an established alternative to median sternotomy for mitral valve repair. However, this technique has yet to gain widespread adoption, partly because of concerns that this approach might yield lower repair rates or repairs that are less durable than those performed through a sternotomy. The purpose of this study was to report our inaugural experience with MIMVS, with a focus on mitral valve repair rate and midterm outcomes. METHODS: Between May 2006 and April 2012, minimally invasive mitral valve repair was attempted in 200 consecutive patients with degenerative mitral disease. The approach used was a 4- to 5-cm right anterolateral minithoracotomy with femorofemoral cannulation for cardiopulmonary bypass. Mean follow-up was 2.9 ± 1.8 years, and follow-up was 99% complete. RESULTS: The mitral valve was successfully repaired in all but 2 patients, yielding a repair rate of 99%. Hospital mortality occurred in 2 patients (1%). Intraoperative conversion to sternotomy was necessary in 12 patients (6%), including 1 of the 2 unsuccessful repairs. Mean cardiopulmonary bypass and aortic cross-clamp times were 130.8 ± 41.3 minutes and 104.8 ± 35.6 minutes, respectively. Median hospital stay was 5 days. The 5-year survival and freedom from reoperation were 97.9% ± 1.5% and 98.1% ± 1.3%, respectively. CONCLUSIONS: A very high repair rate can be achieved using MIMVS for the treatment of degenerative mitral regurgitation, including during the learning phase. Midterm survival and freedom from valve-related reoperation are excellent. MIMVS is a safe and effective alternative to mitral valve repair through a sternotomy.

Pericardiectomy for Constrictive Pericarditis: 20 Years of Experience at the Montreal Heart Institute.

BACKGROUND: The aim of this study was to evaluate our single-center experience with pericardiectomy for constrictive pericarditis. The main objectives of our analysis were long-term survival, clinical outcome, and identification of risk factors. METHODS: Over a 20-year period, 99 consecutive patients underwent pericardiectomy at the Montreal Heart Institute. The indications for operation were idiopathic pericarditis (61%), postsurgical (13%), infectious (15%), postirradiation (2%), and miscellaneous (9%). Associated procedures were performed in 36% of cases. The duration of symptoms was longer than 6 months in 53% of cases, and two thirds of patients were in New York Heart Association class III or IV. RESULTS: Hospital mortality was 9% in the whole series and 7.9% in case of isolated pericardiectomy. The patients operated on within 6 months after the onset of symptoms showed a lower risk of mortality. Conversely, preoperative hepatomegaly and concomitant valvular operation were associated with significantly higher mortality on both univariate and multivariate analysis. In cases of isolated pericardiectomy, the outcome was mainly conditioned by associated comorbidities. The long-term survival was satisfactory, and the functional status at follow-up was improved in most cases. CONCLUSIONS: The clinical outcome of pericardiectomy for constrictive pericarditis is still marked by high operative mortality. Nevertheless, surgical treatment is able to improve the functional class in the majority of late survivors. Preoperative clinical conditions and associated comorbidities are crucial in predicting the risk of mortality, and early operation seems to be the most appropriate choice. The most suitable surgical strategy in cases of associated valvular operation remains to be determined.

Surgical treatment of primary pulmonary artery sarcoma.

OBJECTIVE: Primary pulmonary artery sarcoma is a severe and underdiagnosed disease, with the clinical and surgical approach not clearly established. Only a few individual case reports or small series on this topic have been published. The aim of the present study was to report our surgical experience in this field. METHODS: From March 2004 to December 2012, 13 patients underwent surgery for pulmonary artery sarcoma at our institution. In 7 patients, the sarcoma was unilateral (53.8%), and in 6 (46.2%), the tumor had already extended to both lungs. The surgical strategy evolved over the years, but the 2 techniques used were always the same: pneumonectomy in 5 patients and pulmonary endarterectomy in 8. RESULTS: Two patients died in-hospital, both in the pneumonectomy group. The median length of the intensive care unit and hospital stay was 1 day (range, 1-10) and 14 days (range, 11-17) for the pneumonectomy group and 6 days (range, 3-23) and 19 days (range, 10-32) fort the pulmonary endarterectomy group, respectively. The median survival was 26.8 months after pneumonectomy and 6.6 months after pulmonary endarterectomy. CONCLUSIONS: Primary pulmonary artery sarcoma has a poor prognosis. The surgical strategy at our institution included pneumonectomy, for possible radical resection, and palliative endarterectomy, to reduce symptoms and increase the life expectancy. The correct surgical approach must be evaluated individually, according to the tumor presentation, the presence of pulmonary hypertension, and the patient's clinical condition.

Successful repair of a bicuspid aortic valve with anomalous chordal attachment to the aortic wall.

The congenitally bicuspid aortic valve with anomalous chordal attachment of the fused cusp to the aortic wall is a rare and unappreciated cause of aortic insufficiency. We report the case of a 43-year-old male patient who presented with severe aortic insufficiency caused by this anomaly and in whom surgical aortic valve repair was successfully performed. To our knowledge, this is the first report to describe the successful surgical repair of this rare variant of bicuspid aortic valve.

Minimally invasive video-assisted cardiac surgery: operative techniques, application fields and clinical outcomes.

Minimally invasive video-assisted surgery through a right minithoracotomy has become the standard surgical approach for several cardiac diseases at many major centers worldwide. In this article we review the existing literature on the subject and describe different operative techniques, application fields and clinical outcomes.