Extracorporeal life support in mitral papillary muscle rupture: Outcome of multicenter study.

BACKGROUND: Post-acute myocardial infarction papillary muscle rupture (post-AMI PMR) may present variable clinical scenarios and degree of emergency due to result of cardiogenic shock. Veno-arterial extracorporeal life support (V-A ECLS) has been proposed to improve extremely poor pre- or postoperative conditions. Information in this respect is scarce. METHODS: From the CAUTION (meChanical complicAtion of acUte myocardial infarcTion: an InternatiOnal multiceNter cohort study) database (16 different Centers, data from 2001 to 2018), we extracted adult patients who were surgically treated for post-AMI PMR and underwent pre- or/and postoperative V-A ECLS support. The end-points of this study were in-hospital survival and ECLS complications. RESULTS: From a total of 214 post-AMI PMR patients submitted to surgery, V-A ECLS was instituted in 23 (11%) patients. The median age was 61.7 years (range 46-81 years). Preoperatively, ECLS was commenced in 10 patients (43.5%), whereas intra/postoperative in the remaining 13. The most common V-A ECLS indication was post-cardiotomy shock, followed by preoperative cardiogenic shock and cardiac arrest. The median duration of V-A ECLS was 4 days. V-A ECLS complications occurred in more than half of the patients. Overall, in-hospital mortality was 39.2% (9/23), compared to 22% (42/219) for the non-ECLS group. CONCLUSIONS: In post-AMI PMR patients, V-A ECLS was used in almost 10% of the patients either to promote bridge to surgery or as postoperative support. Further investigations are required to better evaluate a potential for increased use and its effects of V-A ECLS in such a context based on the still high perioperative mortality.

A rare case of papillary fibroelastoma involving the tricuspid valve. A single center experience over a period of 22 years (1999-2021).

BACKGROUND AND AIM: Papillary fibroelastoma (PFE) represents only 16% of the benign cardiac tumor and approximately 15% of these are located on the tricuspid valve. MATERIALS AND METHODS: Over a period of 22 years (1999-2021) we observed 75 pts with cardiac tumors at our Center over 9650 pts operated on but only one case of a tricuspid valve PFE in a 69-year-old patient. Trans-thoracic echocardiography demonstrated a mobile mass (20 × 10 mm), adhering to the atrial side of the septal leaflet of the tricuspid valve of unknown origin. In consideration of the mobility of the mass and the consequent high embolic risk, surgical removal was made. The patient underwent surgery through a median sternotomy on CPBP. A 'gelatinous' mass adhering to the tricuspid leaflet was found and completely removed. The postoperative course was uneventful. The pathological diagnosis was PFE. CONCLUSIONS: PFEs of the tricuspid valve are rare entities being in most cases found incidentally. In our experience, the incidence of this tumor in this location is 1/10,000 cases of cardiac surgery. Although most patients are asymptomatic, surgical treatment is nevertheless recommended in consideration of the high embolic risk.

Clinical and Prognostic Role of Noninvasive Hemodynamic Assessment in Left Ventricular Assist Device Carriers.

Persistence of heart failure symptoms or suboptimal hemodynamic is a frequent condition in LVAD carriers, associated with adverse outcome. Invasive hemodynamic optimization was associated with a better outcome. Our group recently validated an echocardiographic protocol to noninvasively assess hemodynamics of LVAD patients. Aim of this prospective study was to investigate its utility in clinical practice and its prognostic role. From February 2016 to February 2019 fifty-five LVAD carriers (HVAD/HM3 34/21; age 61 ± 10 years, 89% males; INTERMACS profile at LVAD implantation ≤3 68%). A two-phased protocol was performed. First, the patient underwent clinical evaluation. Second, an echo-Doppler blinded to clinical data was performed. Clinical and echo-Doppler evaluation both identified patients with "optimal hemodynamic profile" (normal left and right estimated atrial pressures) versus other profiles. clinical evaluation overestimated the presence of an optimal profile compared with echo-Doppler (83% vs. 59%). The presence of overt heart failure identified patients with the highest risk of adverse outcomes (death or hospitalization for HF at 6 months: HR 15, 95% CI, 5.5-39, P < 0.001). An optimal profile by echo-Doppler was associated with a better outcome among patients without overt heart failure (death or hospitalization for HF at 6 months: HR 0.08, 95% CI, 0.01.5-0.64, P < 0.02). After echo-Doppler, the clinician modified treatment in 46 cases (37%). Noninvasive evaluation of hemodynamics by echo-Doppler adds significant prognostic information in LVAD patients without overt HF and is a valuable tool to tailor treatment in the outpatient follow-up of LVAD carriers. Visual abstract: http://links.lww.com/ASAIO/A783.

Surgical left ventricle remodeling to treat functional mitral valve regurgitation.

A left ventricular aneurysm complicates an acute myocardial infarction in 4-20% of patients. The loss of the physiological geometry of the ventricle can lead to a dislocation of the papillary muscles with subsequential mitral valve regurgitation. The goal of this case report is to demonstrate that a proper operation to restore the left ventricular anatomy can be a feasible procedure to correct functional mitral regurgitation.

Another step in transcatheter aortic valve implantation: A challenging transcatheter aortic valve implantation procedure in patient with severe peripheral arterial disease.

Approximately 25% of patients undergoing transcatheter aortic valve implantation presents significant peripheral arterial disease. The purpose of this case report was to present a feasible approach for transcatheter heart valve in a patient with peripheral arterial disease where the presence of a subclavian stent jutting in the aortic arch made the delivery system passage a challenging procedure.

Matryoshka procedure for Valve-in-Valve TAVI failure.

Valve-in-valve transcatheter valve implantation (ViV-TAVI) procedures for deteriorated bioprosthesis are an established therapeutic option for high-risk patients. The presence of the fixed sewing ring of the bioprosthesis can hamper appropriate expansion of the TAVI. We present a case of a ViViV-TAVI, as a salvage procedure for acute ViV-TAVI failure.

Surgical treatment for post-infarction papillary muscle rupture: a multicentre study.

OBJECTIVES: Papillary muscle rupture (PMR) is a rare but potentially fatal complication of acute myocardial infarction. The aim of this study was to analyse the patient characteristics and early outcomes of the surgical management of post-infarction PMR from an international multicentre registry. METHODS: Patients underwent surgery for post-infarction PMR between 2001 through 2019 were retrieved from database of the CAUTION study. The primary end point was in-hospital mortality. RESULTS: A total of 214 patients were included with a mean age of 66.9 (standard deviation: 10.5) years. The posteromedial papillary muscle was the most frequent rupture location (71.9%); the rupture was complete in 67.3% of patients. Mitral valve replacement was performed in 82.7% of cases. One hundred twenty-two patients (57%) had concomitant coronary artery bypass grafting. In-hospital mortality was 24.8%. Temporal trends revealed no apparent improvement in in-hospital mortality during the study period. Multivariable analysis showed that preoperative chronic kidney disfunction [odds ratio (OR): 2.62, 95% confidence interval (CI): 1.07-6.45, P = 0.036], cardiac arrest (OR: 3.99, 95% CI: 1.02-15.61, P = 0.046) and cardiopulmonary bypass duration (OR: 1.01, 95% CI: 1.00-1.02, P = 0.04) were independently associated with an increased risk of in-hospital death, whereas concomitant coronary artery bypass grafting was identified as an independent predictor of early survival (OR: 0.38, 95% CI: 0.16-0.92, P = 0.031). CONCLUSIONS: Surgical treatment for post-infarction PMR carries a high in-hospital mortality rate, which did not improve during the study period. Because concomitant coronary artery bypass grafting confers a survival benefit, this additional procedure should be performed, whenever possible, in an attempt to improve the outcome. CLINICAL TRIAL REGISTRATION: clinicaltrials.gov: NCT03848429.

Surgical Treatment of Postinfarction Ventricular Septal Rupture.

Importance: Ventricular septal rupture (VSR) is a rare but life-threatening mechanical complication of acute myocardial infarction associated with high mortality despite prompt treatment. Surgery represents the standard of care; however, only small single-center series or national registries are usually available in literature, whereas international multicenter investigations have been poorly carried out, therefore limiting the evidence on this topic. Objectives: To assess the clinical characteristics and early outcomes for patients who received surgery for postinfarction VSR and to identify factors independently associated with mortality. Design, Setting, and Participants: The Mechanical Complications of Acute Myocardial Infarction: an International Multicenter Cohort (CAUTION) Study is a retrospective multicenter international cohort study that includes patients who were treated surgically for mechanical complications of acute myocardial infarction. The study was conducted from January 2001 to December 2019 at 26 different centers worldwide among 475 consecutive patients who underwent surgery for postinfarction VSR. Exposures: Surgical treatment of postinfarction VSR, independent of the technique, alone or combined with other procedures (eg, coronary artery bypass grafting). Main Outcomes and Measures: The primary outcome was early mortality; secondary outcomes were postoperative complications. Results: Of the 475 patients included in the study, 290 (61.1%) were men, with a mean (SD) age of 68.5 (10.1) years. Cardiogenic shock was present in 213 patients (44.8%). Emergent or salvage surgery was performed in 212 cases (44.6%). The early mortality rate was 40.4% (192 patients), and it did not improve during the nearly 20 years considered for the study (median [IQR] yearly mortality, 41.7% [32.6%-50.0%]). Low cardiac output syndrome and multiorgan failure were the most common causes of death (low cardiac output syndrome, 70 [36.5%]; multiorgan failure, 53 [27.6%]). Recurrent VSR occurred in 59 participants (12.4%) but was not associated with mortality. Cardiogenic shock (survived: 95 [33.6%]; died, 118 [61.5%]; P < .001) and early surgery (time to surgery ≥7 days, survived: 105 [57.4%]; died, 47 [35.1%]; P < .001) were associated with lower survival. At multivariate analysis, older age (odds ratio [OR], 1.05; 95% CI, 1.02-1.08; P = .001), preoperative cardiac arrest (OR, 2.71; 95% CI, 1.18-6.27; P = .02) and percutaneous revascularization (OR, 1.63; 95% CI, 1.003-2.65; P = .048), and postoperative need for intra-aortic balloon pump (OR, 2.98; 95% CI, 1.46-6.09; P = .003) and extracorporeal membrane oxygenation (OR, 3.19; 95% CI, 1.30-7.38; P = .01) were independently associated with mortality. Conclusions and Relevance: In this study, surgical repair of postinfarction VSR was associated with a high risk of early mortality; this risk has remained unchanged during the last 2 decades. Delayed surgery seemed associated with better survival. Age, preoperative cardiac arrest and percutaneous revascularization, and postoperative need for intra-aortic balloon pump and extracorporeal membrane oxygenation were independently associated with early mortality. Further prospective studies addressing preoperative and perioperative patient management are warranted to hopefully improve the currently suboptimal outcome.

Surgical Treatment of Post-Infarction Left Ventricular Free-Wall Rupture: A Multicenter Study.

BACKGROUND: Left ventricular free-wall rupture (LVFWR) is an uncommon but serious mechanical complication of acute myocardial infarction. Surgical repair, though challenging, is the only definitive treatment. Given the rarity of this condition, however, results after surgery are still not well established. The aim of this study was to review a multicenter experience with the surgical management of post-infarction LVFWR and analyze the associated early outcomes. METHODS: Using the CAUTION (Mechanical Complications of Acute Myocardial Infarction: an International Multicenter Cohort Study) database, we identified 140 patients who were surgically treated for post-acute myocardial infarction LVFWR in 15 different centers from 2001 to 2018. The main outcome measured was operative mortality. Multivariate analysis was carried out by constructing a logistic regression model to identify predictors of postoperative mortality. RESULTS: The mean age of patients was 69.4 years. The oozing type of LVFWR was observed in 79 patients (56.4%), and the blowout type in 61 (43.6%). Sutured repair was used in the 61.4% of cases. The operative mortality rate was 36.4%. Low cardiac output syndrome was the main cause of perioperative death. Myocardial rerupture after surgery occurred in 10 patients (7.1%). Multivariable analysis revealed that preoperative left ventricular ejection fraction (P < .001), cardiac arrest at presentation (P = .011), female sex (P = .044), and the need for preoperative extracorporeal life support (P = .003) were independent predictors for operative mortality. CONCLUSIONS: Surgical repair of post-infarction LVFWR carries a high operative mortality. Female sex, preoperative left ventricular ejection fraction, cardiac arrest, and extracorporeal life support are predictors of early mortality.

HeartMate 3 left ventricular assist device minimally invasive off-pump implantation.

With advancements in mechanical circulatory support technology, and limitations in donor supply for heart transplantation, the use of left ventricular assist devices (LVADs) has increased significantly in recent years. Multiple studies have shown that minimally invasive cardiac surgery can improve outcomes, with shorter hospital stays, decreased morbidity, faster recovery and ambulation, and lower total hospital costs. The current generation of centrifugal continuous-flow pumps is miniaturized and makes minimally invasive approaches increasingly practicable. Lateral surgical access to the ventricle allows off-pump implantation with minimal risk of blood loss, reducing the risk of air embolism and difficult de-airing. Off-pump implantation reduces hemodilution, systemic inflammatory response syndrome due to extracorporeal circulation, and the negative effects of pulmonary hypertension and right ventricular dysfunction in the perioperative period. Minimally invasive lateral access is encouraged in cases of bridge-to-transplant to avoid the risks associated with resternotomy.  We describe the surgical technique for minimally invasive implantation of the HeartMate 3 (Abbott, USA) left ventricular assist device (LVAD), avoiding sternotomy and cardiopulmonary bypass. Our surgical approach was based on a left minithoracotomy for the LVAD implantation and a right thoracotomy for the outflow graft anastomosis to the ascending aorta.