ABSTRACT
OBJECTIVE: Transventricular beating-heart mitral valve repair (TBMVR) with artificial chordae implantation is a technique to treat mitral valve prolapse. Two-dimensional (2D) echocardiography completed with simultaneous biplane view during surgeon finger pushing on the left ventricular (LV) wall (finger test [FT]) is currently used to localize the desired LV access, on the inferior-lateral wall, between the papillary muscles (PMs). We aimed to compare a new three-dimensional (3D) method with conventional FT in terms of safety and better localization of LV access. METHODS: During TBMVR, conventional FT was completed using 3D transesophageal echocardiography by placing the sample box in the bicommissural view of the LV, including the PMs and the apex. The 3D volume was subsequently edited to visualize the LV from above (surgical view) to localize the bulge of the operator's finger pushing on the LV. We asked the first operator, the second operator, and the cardiac surgery fellow, separately, to evaluate the location of their finger pushing, both with the 2D method and the 3D method, to estimate the interoperator concordance. RESULTS: From 2019 to 2021, 42 TBMVRs were performed without complications related to access using FT completed with the 3D method. Regarding the choice of the right and safe entry site, the operator's agreement was higher using 3D rendering compared with conventional FT (mean agreement 0.59 ± 0.29 for 2D vs 0.83 ± 0.20 for 3D), while full operator agreement was 10 of 42 for 2D and 23 of 42 for 3D (P = 0.004). CONCLUSIONS: Three-dimensional FT is easy to perform and facilitates surgeons choosing the best access for TBMVR in term of anatomical localization and safety.
Subject(s)
Echocardiography, Three-Dimensional , Mitral Valve Insufficiency , Mitral Valve Prolapse , Humans , Mitral Valve Insufficiency/surgery , Echocardiography , Mitral Valve Prolapse/surgery , Echocardiography, Transesophageal/methods , Echocardiography, Three-Dimensional/methodsABSTRACT
BACKGROUND: Mean age of patients with valves diseases is significantly increasing, and, in the near future, cardiac surgeons will have to deal with a considerable number of patients aged more than 80 years. The remarkable results gained by the minimally invasive approach have encouraged its application in more complex and fragile patients, such as older people. This study aimed to identify the rate of early mortality and major complications, and independent predictors for mid-term mortality in octogenarians undergoing minimally invasive valve surgery. METHODS: Octogenarian patients undergoing right mini-thoracotomy mitral and/or tricuspid valve surgery between 2006 and 2020 were included. Primary endpoint was to identify independent predictors for mid-term mortality, and secondary endpoints were operative morality, stroke, independent predictors for early composite outcome, and quality of life at follow-up. RESULTS: Analysis was performed on 130 patients. Stroke occurred in one patient (0.8%), while operative mortality was 6% (eight patients). One-year and five-year survival were 86% and 64%, respectively. Logistic regression identified age and creatinine level as independent predictors of mid-term mortality, survival analysis showed that age ≥ 84 years and creatinine level ≥ 1.22 mg/dL were the cut-off points for worst prognosis. Female gender and hypertension were found to be independent predictors of early composite outcome. CONCLUSIONS: Results of the present study show that age alone should not be considered a contraindication for minimally invasive valve surgery. Identifying patients who are most likely to have survival and functional benefits after surgery is decisive to achieve optimal health outcomes and prevent futile procedures.
ABSTRACT
The NeoChord procedure is an echo-guided trans-ventricular beating-heart mitral valve repair technique to treat degenerative mitral regurgitation (MR) due to prolapse and/or flail. The aim of this study is to analyze echocardiographic images to find pre-operative parameters to predict procedural success (≤moderate MR) at 3-year follow-up. Seventy-two consecutive patients with severe MR underwent the NeoChord procedure between 2015 and 2021. MV pre-operative morphological parameters were assessed using 3D transesophageal echocardiography with dedicated software (QLAB, Philips). Three patients died during their hospitalization. The remaining 69 patients were retrospectively analyzed. At follow-up, MR > moderate was found in 17 patients (24.6%). In the univariate analysis, end-systolic annulus area (12.5 ± 2.5 vs. 14.1 ± 2.6 cm2; p = 0.038), end-systolic annulus circumference (13.2 ± 1.2 vs. 14 ± 1.3 cm; p = 0.042), indexed left atrial volume (59 ± 17 vs. 76 ± 7 mL/m2; p = 0.041), and AF (25% vs. 53%; p = 0.042) were lower in the 52 patients with ≤ MR compared to those with > moderate MR. Annular dysfunction parameters were the best predictors of procedural success: 3D early-systolic annulus area (AUC 0.74; p = 0.004), 3D early-systolic annulus circumference (AUC 0.75; p = 0.003), and 3D annulus area fractional change (AUC 0.73; p = 0.035). Patient selection relying on 3D dynamic and static MA dimensions may improve the maintenance of procedural success at follow-up.
ABSTRACT
Background: Perfusion strategies and aortic clamping techniques for right mini-thoracotomy mitral valve (MV) surgery have evolved over time and remarkable short- and long-term results have been reported. However, some concerns have raised about the adequacy of myocardial protection during the minimally invasive approach, particularly with the endo-aortic clamp (EAC). Aim of this study was to compare the efficacy, in terms of myocardial preservation, of the EAC with the trans-thoracic aortic clamp (TTC) in patients undergoing right mini-thoracotomy MV surgery. Methods: A single center, prospective observational study was performed on patients undergoing right mini-thoracotomy MV surgery with retrograde arterial perfusion and EAC or TTC. A propensity matched analysis was performed to compare the two groups. Primary outcome was the comparison between cardiac troponin T levels measured at different time-points after surgery. Results: Eighty EAC patients were compared with 37 TTC patients. No cases of myocardial infarction or low cardiac-output syndrome were overall reported. No differences were recorded in terms of stroke, peri-operative mortality, and in the release of myocardial markers, lactates levels and need for inotropic support at different time-points after surgery. CK-MB peak levels were significantly lower in the EAC group. Conclusion: Despite concerns arising about the EAC, this prospective study shows equivalence in terms of myocardial preservation of the EAC compared with the TTC in patients undergoing right mini-thoracotomy MV surgery.
