Case Report: Three-Dimensional Printing Model for Surgical Planning of Left Ventricular Aneurysm: Evolution Toward Tailoring Surgery.

A 59-year-old woman was admitted to the emergency department for heart failure (HF), New York Heart Association (NYHA) IV, showing an anterior, evolved myocardial infarction (MI) with a wide apical left ventricular aneurysm (LVA), ejection fraction (EF) 24%, and global longitudinal strain (GLS) -5. 5% by echo. Cardiac magnetic resonance imaging (MRI) confirmed an apical LVA without thrombus, EF 20%, and a transmural delayed enhancement in the myocardium wall. Coronarography showed a three-vessel disease with occluded proximal left anterior descending (LAD) and proximal right coronary artery (RCA). Based on the cardiac CT scan, we decided to generate a three-dimensional (3D) print model of the heart, for better prediction of residual LV volumes. After LVA surgery plus complete functional revascularization, an optimal agreement was found between predicted and surgical residual LV end-diastolic (24.7 vs. 31.8 ml/m2) and end-systolic (54.1 vs. 69.4 ml/m2) volumes, with an improvement of NYHA class, from IV to I. The patient was discharged uneventfully and at 6- and 12-month follow-up, the NYHA class, and LV volumes were found unchanged. This is a second report describing the use of the 3D print model for the preoperative planning of surgical management of LVA; the first report was described by Jacobs et al. among three patients, one with a malignant tumor and the remaining two patients with LVA. This article focused on the use of the 3D print model to optimize surgical planning and individualize treatment of LVA associated with complete functional revascularization, leading to complete recovery of LV function with a favorable outcome.

Case Report: Lithoplasty-Assisted Trans-Axillary Transcatheter Aortic Valve-in-Valve Implantation.

We present the case of a severely symptomatic patient with a malfunctioning aortic bioprosthesis and severe multidistrict atherosclerosis that was addressed to our unit for transcatheter valve-in-valve implantation. The imaging and clinical assessment that led to the selection of the access route is discussed.

Cardiac Metastasis of Sacral Chordoma.

Chordoma is a rare tumor, usually diagnosed when the disease is advanced. Despite its slow growth, it is locally aggressive and has a poor long-term prognosis. Surgery is the mainstay treatment. Although cardiac metastases are very rare, the heart is frequently involved in systemic neoplastic diseases. This report describes a typical case of metastatic chordoma: the age at first diagnosis, the site of the primary tumor, and the slow growth of the cardiac metastasis were all typical features. Surgical excision of the mass from the right ventricular outflow tract is described together with echocardiographic, radiologic, and histopathologic characteristics of the metastatic chordoma.

Aortic valve replacement using stented or sutureless/rapid deployment prosthesis via either full-sternotomy or a minimally invasive approach: a network meta-analysis.

BACKGROUND: New technologies such as sutureless or rapid deployment prosthetic valves and access via minimally invasive incisions offer alternatives to traditional full-sternotomy aortic valve replacement (SAVR). However, a comprehensive comparison of these surgical techniques along with alternative valve prosthesis has not been completed. METHODS: Electronic databases were searched for studies comparing outcomes for SAVR, minimally invasive AVR (MiAVR), sutureless/rapid-deployment AVR (SuAVR) via full-sternotomy, or minimally invasive SuAVR (MiSuAVR) from their inception until September 2018. Early postoperative outcomes and follow-up data were included in a Bayesian network meta-analysis. RESULTS: Twenty-three studies with 8,718 patients were identified. Compared with standard SAVR, SuAVR had significantly lower incidence of postoperative AF [odds ratio (OR) 0.33, 95% confidence interval (CI): 0.14-0.79, P=0.013] and MiSuAVR greater requirement for postoperative permanent pacemaker (OR 2.27, 95% CI: 1.25-4.14, P=0.008). All sutureless/rapid-deployment procedures had reduced cardiopulmonary bypass and cross-clamp times, by a mean of 25.9 and 25.0 min, respectively. Hospital length of stay (LOS), but not intensive care LOS, was reduced for all groups (MiAVR -1.53 days, MiSuAVR -2.79 days, and SuAVR 3.37 days). A signal towards reduced early mortality, wound infections, and acute kidney injury was noted in both sutureless/rapid-deployment and minimally invasive techniques but did not achieve significance. Sutureless/rapid-deployment procedures had favourable survival and freedom from valve related reoperation, however follow-up times were short and demonstrated significant heterogeneity between intervention groups. CONCLUSIONS: Minimally invasive and sutureless techniques demonstrate equivalent early postoperative outcomes to SAVR and may reduce ventilation time, hospital LOS and postoperative atrial fibrillation (POAF) burden.

A simple method to visualize the bicuspid aortic valve pathology by cardiac computed tomography.

Bicuspid aortic valve (BAV) disease is a spectrum of anomalies ranging from mild underdevelopment of a commissure to severe underdevelopment of two interleaflets triangles. Many different classifications of BAV, based on the echocardiographic, surgical or pathological appearance of the valve, and more recently on cardiac CT, have been proposed. We describe a simple technique, based on three-dimensional curved multiplanar reconstruction images, to obtain a pathology-like visualization of the full line of insertion (Hinge) of the aortic valve leaflets and of the interleaflet triangles with cardiac CT. This method could help to obtain a detailed categorization of any specific BAV anatomy based on the degree of underdevelopment (or on the absence) of one interleaflet triangle. Adherence to this concept could help to improve the imaging based analysis of BAV patients undergoing TAVR, and could lead to the adoption of a BAV classification based on the effective pathologic appearance of the valve also for patients undergoing TAVR.

Outcomes of Video-assisted Minimally Invasive Cardiac Myxoma Resection.

BACKGROUND: Myxomas are the most frequent cardiac tumours. Their diagnosis requires prompt removal. In our centre, for valve surgery we use a minimally invasive approach. Here, we report our experience of cardiac myxoma removal through right lateral mini-thoracotomy (RLMT) with particular focus on its feasibility, efficacy and patient safety. METHODS: Between February 2006 and January 2017, 30 consecutive patients (aged 66±12.6years, range 35-83 years) underwent atrial myxoma resection through video-assisted RLMT. Percutaneous venous drainage was performed in all patients and direct cannulation of the ascending aorta was performed in 28 out of 30 (93.3%). The diagnosis of atrial myxoma was confirmed by histology. RESULTS: Complete surgical resection was achieved in all patients. The mean cardiopulmonary bypass (CPB) time was 76.5±40.8minutes and average aortic cross-clamping time was 41.5±29.8minutes. No patient suffered postoperative complications. Five patients (16.7%) received a blood transfusion. Mechanical ventilation ranged from 3 to 51hours (median 6hours), intensive care unit (ICU) stay ranged from 1 to 5days (median 1day). Total hospital length of stay (HLOS) was 5.6±2 days. Home discharge rate was 56.7%. No in-hospital mortality was reported. During follow-up (55.6±32.3 months; range 4-132 months), one tumour recurrence was observed. There were three late non-cardiac deaths. Overall survival was 100%, 85.7% and 85.7% at 1, 5 and 10 years, respectively. CONCLUSIONS: The use of video-assisted RLMT is an effective and reproducible strategy in all patients requiring expedited surgery for left atrial myxoma, independently of coexisting morbidity such as systemic embolisation or previous surgery. This technique leads to complete tumour resection, prompt recovery, early home discharge and high freedom from both symptoms and tumour recurrence.

Massive Hemoptysis from a Pulmonary Artery Pseudoaneurysm during Cardiac Surgery.

Massive hemoptysis is a life-threatening condition usually related to a pathology of the bronchial arteries. Pulmonary artery pseudoaneurysms represent a relatively rare cause of severe airway bleeding, but are associated with a mortality rate of over 50%. A case of massive intraoperative hemoptysis treated with temporary occlusion of the right pulmonary artery and delayed endovascular occlusion of the feeding segmental artery is described.

Increased Gradients After Aortic Valve Replacement With the Perceval Valve: The Role of Oversizing.

BACKGROUND: Significant underexpansion or distortion of valved stents may be associated with altered leaflet function, leading to increased transprosthetic gradients and, possibly, early structural degeneration. We investigated the relationship between a computed tomography measure of the degree of oversizing and the early hemodynamic and clinical outcomes in patients undergoing aortic valve replacement with the Perceval sutureless aortic valve (LivaNova, Saluggia, Italy). METHODS: The degree of oversizing of the implanted prosthesis was calculated as the ratio between the patients' aortic annulus cross-sectional area and the ex vivo cross-sectional area of the implanted prosthesis in 151 Perceval patients who underwent preoperative cardiac computed tomography. This value was then entered in a multivariate analysis to ascertain its role as a predictor of increased postoperative gradient. RESULTS: The operative mortality was 1.3%. Procedural success, defined as having a normally functioning valve in the proper anatomical location, was achieved in 150 patients (99.3%). The mean transprosthetic gradient was 13.4 ± 5.0 mm Hg, and 23 patients (15.2%) showed a gradient of 20 mm Hg or more at discharge or at the 1-month follow-up. The degree of oversizing of the implanted prosthesis was the most important predictor of increased postoperative gradient (odds ratio, 1.264; 95% confidence interval, 1.147 to 1.394; p < 0.0001). Interestingly, other relevant factors (patients' body surface area, prosthesis size) were not associated with increased gradients. CONCLUSIONS: Our study demonstrates that excessive oversizing should be avoided in Perceval patients and suggests that a different sizing algorithm, possibly based on cardiac computed tomography, should be developed. Further studies are needed to optimize the sizing strategy for the Perceval sutureless valve.

EuroSCORE Performance in Minimally Invasive Cardiac Surgery: Discrimination Ability and External Calibration.

OBJECTIVE: Prediction of operative risk in adults undergoing cardiac surgery remains a challenge. The European System for Cardiac Operative Risk Evaluation (EuroSCORE) is one of the most commonly used in clinical settings. Recently, the new EuroSCORE II was published attempting to improve the accuracy of risk prediction. We sought to assess the predictive value of EuroSCORE or EuroSCORE II in selected field of minimally invasive cardiac surgery. METHODS: Patients who underwent cardiac surgery operation with minimally invasive approach from 2007 to 2013 identified from prospective cardiac surgical database. Additional variables included in EuroSCORE II, but not in original EuroSCORE, were retrospectively collected via electronic health records reviewing. The C-statistic was calculated for the EuroSCORE (additive and logistic) and EuroSCORE II. The Hosmer-Lemeshow test was used to assess model calibration by comparing observed and expected morality in number of risk strata. RESULTS: There were 39 hospitals deaths (1.6%). A total of 2472 patients were identified from the main database. The mean ± SD logistic EuroSCORE was 7.6 ± 8.3, mean ± SD additive EuroSCORE was 6.1 ± 2.7, and mean ± SD EuroSCORE II was 2.9 ± 4.2. EuroSCORE logistic model performed with substantial accuracy of 0.78, EuroSCORE additive performed with accuracy of 0.78, and EuroSCORE II performed as almost perfect 0.82. Model calibration was poor in EuroSCORE II (χ = 17.57, P = 0.02), calibration for logistic EuroSCORE was also poor (χ = 140.58, P < 0.01), and additive model also (χ = 94.95, P < 0.01). The area under the curve was high in all algorithms; logistic EuroSCORE was 0.78 (95% confidence interval = 0.71-0.85), additive EuroSCORE was 0.79 (95% confidence interval = 0.71-0.86), and EuroSCORE II was 0.82 (95% confidence interval = 0.75-0.89). CONCLUSIONS: In overall settings, original EuroSCORE and EuroSCORE II perform poorly in minimally invasive operation conditions. Data suggest that EuroSCORE could not be used for estimating operative risks correctly. New risk score should be explored, developed, and implemented for selective minimally invasive cohorts.

Transapical transcatheter mitral valve-in-valve implantation versus minimally invasive surgery for failed mitral bioprostheses.

OBJECTIVES: The aim of this study was to compare early outcomes and survival of patients undergoing minimally invasive mitral valve replacement through a right anterior minithoracotomy (MIMVR) versus patients undergoing transcatheter transapical mitral valve-in-valve (M-VIV) implantation for a failed mitral bioprostheses. METHODS: From 2005 to 2015, 61 patients with a failed mitral bioprosthesis underwent either MIMVR ( n = 40 patients, 65.6%) or M-VIV implantation ( n = 21, 34.4%) at our institution. The groups were compared in terms of early outcomes and survival rates. Treatment selection bias was controlled by a propensity score and was included along with the comparison variable in the multivariable analyses of outcome. RESULTS: Patients with M-VIV implantation were older ( P = 0.03), had more pulmonary hypertension ( P = 0.02) and a higher EuroSCORE ( P = 0.001). In-hospital mortality was 7.5% ( n = 3) in the MIMVR group and 4.7% ( n = 1) in the M-VIV group [odds ratio (OR) = 2.46; P = 0.512]. Incidence of stroke was 12.5% ( n = 5) in the MIMVR group vs 4.7% ( n = 1) in the M-VIV group (OR = 0.887; P = 0.935). No significant differences were noted in postprocedural complications, even after adjusting the results for the propensity score. M-VIV patients had shorter stays in the intensive care unit and in the hospital ( P = 0.02). In the M-VIV group, 28% ( n = 7) had less than mild paravalvular leakage, whereas no patients had mild paravalvular leakage in the MIMVR group ( P < 0.001). Finally, the 2-year survival rates were 86 ± 1% vs 87 ± 1% in patients undergoing MIMVR compared with those undergoing M-VIV implantation, respectively ( P = 0.1). CONCLUSIONS: In selected patients, M-VIV can be performed safely with results comparable with those of surgical therapy.

Surgical resection of colorectal carcinomas metastatic to the heart.

Colorectal carcinomas metastatic to the heart are rare. We present a case of colonic carcinoma metastatic to the right atrium and discuss the management and prognosis of these rare lesions.

Exploring the learning curve for minimally invasive sutureless aortic valve replacement.

OBJECTIVE: The study objective was to assess the learning process and quality of care of right minithoracotomy aortic valve replacement with a sutureless bioprosthesis at a single institution. METHODS: We performed an analysis of the first 300 consecutive patients (aged 76 ± 6 years; logistic European System for Cardiac Operative Risk Evaluation 9 ± 6) who underwent sutureless valve implantation via a right minithoracotomy by 6 surgeons at the G. Pasquinucci Heart Hospital between 2011 and 2015. The learning curve was analyzed by dividing the study population into tertiles of 100 patients each. Departmental and individual learning curves were calculated using sequential probability cumulative sum failure analysis. Quality indicators were 2 composite end points reflecting the technical success and 30-day complications. RESULTS: The overall mortality was 0.7% (2 patients). No significant differences were noted in terms of mortality and complications between tertiles. The sutureless valve was implanted successfully in 99% of patients (298/300). Cumulative sum analysis failed to identify any significant learning effects for technical success. Nevertheless, surgeons A, B, and C had a small initial learning curve, and surgeons D, E, and F did not, reflecting a trend toward a positive effect of cumulative institutional experience on the individual learning curve. The 30-day complications analysis revealed a cluster of failures at the beginning of the experience. This cluster prompted an internal audit and modification of the patients' selection process. Consecutively, the procedure returned in control. CONCLUSIONS: Right minithoracotomy sutureless valve implantation can be performed safely without learning curve effects. Cumulative sum analysis is a valuable tool to describe and monitor the learning process. The analysis can identify periods of less than expected performance and alert the team to react.

Transapical Transcatheter Valve-in-Valve Implantation for Failed Mitral Bioprostheses: Gradient, Symptoms, and Functional Status in 18 High-Risk Patients Up to 5 Years.

BACKGROUND: The recourse to mitral valve-in-valve implantation is expected to rise consistently owing to the increasing use of bioprostheses and to the risks related to redo valve replacement. However, there is concern that the excellent early results of mitral valve-in-valve could be nullified by the development of significant gradients. We report our experience with mitral valve-in-valve implantation, with particular emphasis on the midterm follow-up. METHODS: Eighteen patients underwent mitral valve-in-valve implantation at our institution. The mean Society of Thoracic Surgeons score was 10.3. All patients were heavily symptomatic. The mechanisms of bioprosthesis failure were stenosis (3 patients), regurgitation (4 patients) or mixed (11 patients). The mean transprosthetic gradient was 12.8 ± 5.7 mm Hg. All the procedures were transapical. Balloon predilation was never used. RESULTS: In the first patient, the transcatheter valve embolized in the ventricle. The patient died 2 days later of multiorgan failure. There were no other hospital deaths. Four patients died of pneumonia, endocarditis, lung cancer, and stroke at 1, 8, 18, and 46 months, postoperatively. The mean gradient at discharge was 5.1 ± 2.3 mm Hg. At follow-up (median 27 months), all surviving patients were in New York Heart Association functional class II or less. The mean transprosthetic gradient was 7 ± 1.8 mm Hg, and 1 patient had a gradient more than 10 mm Hg. CONCLUSIONS: Mitral valve-in-valve implantation allows good clinical and hemodynamic results. In our series, the appearance of a significant gradient at follow-up was not associated with echocardiographic signs of structural deterioration, and was possibly related to the size of the transcatheter and recipient valve.

Successful percutaneous implantation of symetis ACURATE neo transcatheter aortic bioprosthesis for the treatment of pure aortic regurgitation.

Transcatheter aortic valve implantation (TAVI) was initially developed for the treatment of calcific aortic stenosis. In the recent years, however, TAVI has been used to treat selected patients with pure, severe AR. We report successful transfemoral implantation of a Symetis ACURATE neo bioprosthesis in a severely symptomatic, 87-year-old woman with pure AR and major comorbidities. We decided to use the ACURATE neo bioprosthesis for some of its features appeared to us as potentially useful in the setting of pure AR: the stabilization arches ensure perfect coaxial alignment and extreme stability of the device during deployment, and the "waist" and the skirt were considered useful to obtain a good seal in the absence of significant valvular and annular calcifications. Finally, we decided to use a self-expanding valve to minimize the trauma to the aortic annulus. The procedure was successful and the patient was discharged home on postoperative day 3. At the 3-month control echocardiography, there was no residual AR, and the mean transprosthetic gradient was 3 mm Hg. The current case demonstrates that percutaneous TAVI with the ACURATE neo bioprosthesis may be used to treat pure, isolated AR in selected patients. The device has several interesting features that could make it advantageous in this setting. © 2016 Wiley Periodicals, Inc.