Plasma Exosome Hemoglobin Released During Surgery Is Associated With Cardiac Injury in Animal Model.

BACKGROUND: Patients with valvular heart disease require cardiopulmonary bypass and cardiac arrest. Here, we test the hypothesis that exosomal hemoglobin formed during cardiopulmonary bypass mediates acute cardiac injury in humans and in an animal model system. METHODS: Plasma exosomes were collected from arterial blood at baseline and 30 minutes after aortic cross-clamp release in 20 patients with primary mitral regurgitation and 7 with aortic stenosis. These exosomes were injected into Sprague-Dawley rats and studied at multiple times up to 30 days. Tissue was examined by hematoxylin and eosin stain, immunohistochemistry, transmission electron microscopy, and brain natriuretic peptide. RESULTS: Troponin I levels increased from 36 ± 88 ng/L to 3622 ± 3054 ng/L and correlated with exosome hemoglobin content (Spearman r = 0.7136, < .0001, n = 24). Injection of exosomes isolated 30 minutes after cross-clamp release into Sprague-Dawley rats resulted in cardiomyocyte myofibrillar loss at 3 days. Transmission electron microscopy demonstrated accumulation of electron dense particles of ferritin within cardiomyocytes, in the interstitial space, and within exosomes. At 21 days after injection, there was myofibrillar and myosin breakdown, interstitial fibrosis, elevated brain natriuretic peptide, and left ventricle diastolic dysfunction measured by echocardiography/Doppler. Pericardial fluid exosomal hemoglobin content is fourfold higher than simultaneous plasma exosome hemoglobin, suggesting a cardiac source of exosomal hemoglobin. CONCLUSIONS: Red blood cell and cardiac-derived exosomal hemoglobin may be involved in myocardial injury during cardiopulmonary bypass in patients with valvular heart disease.

Rescue of False Lumen Frozen Elephant Trunk Deployment Intraoperatively.

Endovascular devices have become increasingly available, which has led to an increase in use of frozen elephant trunk stents for extended repair during type A aortic dissection. Frozen elephant trunk deployment is usually done under direct visualization of both the true and false lumen but rarely, the endograft can inadvertently end in the false lumen. This can lead to false lumen pressurization and end-organ malperfusion. Herein we describe a novel intraoperative rescue technique for misplaced frozen elephant trunk into the false lumen, easily executed in a standard operating room using transesophageal echocardiography and intravascular ultrasound guidance.

Left Anterior Thoracotomy Minimally Invasive Aortic Valve Replacement Following Left Pneumonectomy.

We report the case of a 59-year-old man referred for aortic valve replacement for severe, symptomatic aortic insufficiency who underwent a minimally invasive left anterior thoracotomy aortic valve replacement. This approach was facilitated by his history of a left pneumonectomy for lung cancer 7 years prior to presentation, which resulted in a significant left mediastinal shift. The cannulation strategy and exposure were analogous to what would be expected from a standard right anterior thoracotomy minimally invasive aortic valve replacement. The minimally invasive approach allowed for early extubation and mobilization in a patient with moderate baseline pulmonary dysfunction.

Robotic mitral valve repair in a type B hemophiliac.

Hemophilia B is a rare X-linked recessive disorder that places surgical patients at an increased risk of bleeding. Patients with hemophilia are now achieving near-normal life expectancies and therefore the number of these patients requiring cardiac surgery due to the development of age-related cardiovascular disease may increase. We present the case of a young male with hemophilia B who was diagnosed with severe symptomatic mitral regurgitation and underwent successful robotic mitral valve repair. To our knowledge, this is the first report of a patient with hemophilia B who underwent robotic mitral valve repair.

Total Endovascular Arch Repair Using Needle Fenestration and Extracorporeal Membrane Oxygenation.

There remains a clinical need for endovascular repair of the ascending aorta and the aortic arch in patients who are prohibitively high risk for open surgical repair. Herein we present a case of a total endovascular arch repair by means of a novel technique for graft fenestration using a trans-septal needle with extracorporeal membrane oxygenation support. Although the use of trans-septal needle fenestration use has been described, the use in arch fenestrations has not. We present this case as an example of techniques that may be useful in the expanding landscape of endovascular ascending and arch repair.

Contemporary suprasternal transcatheter aortic valve replacement: A multicenter experience using a simple, reliable alternative access approach.

OBJECTIVES: To describe outcomes after suprasternal (SS) transcatheter aortic valve replacement (TAVR) as a new alternative access approach. BACKGROUND: There still remains a cohort of the TAVR population who are not suitable for a transfemoral (TF) approach. SS-TAVR is a safe and effective alternative to TF-TAVR and has now become our preferred alternative access route. METHODS: We retrospectively reviewed all patients from New York Presbyterian Hospital, Columbia University Medical Center and Princeton Baptist Medical Center who underwent SS-TAVR from 2015 to July 2018. A total of 84 patients were included in the study. RESULTS: Technical success was achieved in all cases. Thirty-day survival was 98.8% (n = 83). There were minimal complications. Most notably, there were no transient ischemic attacks or strokes (0%, n = 0). Reexploration for bleeding was 3.6% (n = 3), and major bleeding was 1.7% (n = 1). We also achieved satisfactory results with a mean aortic valve gradient of 6.07 ± 3.79 mmHg and an aortic valve area of 2.21 ± 0.51 cm2 . No patients had anything more than mild paravalvular leak. The mean length of stay (LOS) in the intensive care unit was 1.42 ± 1.23 days, and hospital LOS was 4.20 ± 3.29 days. CONCLUSIONS: SS access for TAVR is an extremely important technique to have in any valve team's alternative access armamentarium. This technique can be safely and reliably reproduced with any standard hybrid operating room setup and no additional equipment, and it can be used with any commercially available valve system. In the current experience, minimal complications and excellent early term results were obtained.

Robot-assisted aortic valve surgery: State of the art and challenges for the future.

Robotic cardiac surgery was FDA-approved in 2002 and since then several different procedures have been performed to facilitate a truly minimally invasive approach. The use of robotics in aortic valve surgery, however, is still in its infancy. In this article, we report our clinical experience and chronological development with robot-assisted aortic valve surgery. This includes a description of how robotic assistance was gradually integrated during right mini-thoracotomy aortic valve replacement, a series of cases in which the robot was docked for parts of the procedure, a single case of a totally endoscopic robot-assisted aortic valve replacement with a stentless valve, and three cases of aortic valve papillary fibroelastoma resections. All of these were performed safely with early postoperative recovery and excellent clinical results. Additionally, we review the latest literature describing robot-assisted aortic valve surgery. Finally, we describe current issues, and challenges for robot-assisted aortic valve surgery.

Usefulness of two- and three-dimensional transesophageal echocardiography in combined mitral valve-in-valve implantation and paraprosthetic leak closure.

We demonstrate the usefulness of two- and live/real time three-dimensional transesophageal echocardiography in a procedure, which combined transcatheter mitral valve-in-valve deployment and paraprosthetic leak closure in the same setting using the less invasive transfemoral approach in an adult patient with bioprosthetic mitral valve degeneration. We also highlight the additive value of three-dimensional echocardiography over the two-dimensional technique.

Minimally Invasive Redo Mitral Valve Replacement Using a Robotic-Assisted Approach.

Minimally invasive, robotic-assisted cardiac surgery has been shown to decrease transfusion rates, decrease wound infection rates, shorten hospital length of stay, and allow for a faster return to full activity compared with traditional sternotomy approaches. However, its application has chiefly been limited to primary, isolated procedures such as primary mitral valve repair or replacement. We describe the first reported use of a robotic surgery platform to perform reoperative mitral valve replacement using a minimally invasive, totally endoscopic, port-access approach.

Minimally Invasive Mitral Valve Surgery I: Patient Selection, Evaluation, and Planning.

Widespread adoption of minimally invasive mitral valve repair and replacement may be fostered by practice consensus and standardization. This expert opinion, first of a 3-part series, outlines current best practices in patient evaluation and selection for minimally invasive mitral valve procedures, and discusses preoperative planning for cannulation and myocardial protection.

Minimally Invasive Mitral Valve Surgery II: Surgical Technique and Postoperative Management.

Techniques for minimally invasive mitral valve repair and replacement continue to evolve. This expert opinion, the second of a 3-part series, outlines current best practices for nonrobotic, minimally invasive mitral valve procedures, and for postoperative care after minimally invasive mitral valve surgery.

Minimally Invasive Mitral Valve Surgery III: Training and Robotic-Assisted Approaches.

Minimally invasive mitral valve operations are increasingly common in the United States, but robotic-assisted approaches have not been widely adopted for a variety of reasons. This expert opinion reviews the state of the art and defines best practices, training, and techniques for developing a successful robotics program.

Application of an Epicardial Left Atrial Appendage Occlusion Device by a Robotic-Assisted, Right Chest Approach.

Closure of the left atrial appendage (LAA) has become a standard part of any mitral valve operation because it is thought to reduce the potential for late thrombus development and for embolic events. To date, surgeons performing robotic mitral valve operations have been limited to an endocardial approach to LAA closure. However, oversewing the orifice of the LAA is time consuming and lengthens the cross-clamp time, and failures to obtain permanent closure have been reported. We describe our technique for an epicardial approach that is safe and efficient and that gives a secure closure of the LAA.

Concurrent Minimally Invasive Aortic Valve Replacement and Coronary Artery Bypass via Limited Right Anterior Thoracotomy.

An 89-year-old man and an 80-year-old woman were treated surgically for critical aortic stenosis secondary to senile calcific aortic disease and high-grade calcified lesions in the ostium of the right coronary artery. Minimally invasive aortic valve replacement and concurrent coronary artery bypass grafting were performed concurrently through a 5-cm right anterior thoracotomy in the second intercostal space. Surgery was uncomplicated in both cases, with no adverse events. Both patients were alive and well at midterm follow-up. Concurrent minimally invasive aortic valve replacement and coronary artery bypass grafting can be performed successfully through a limited right anterior thoracotomy.

Robotic repair of sinus venosus atrial septal defect with partial anomalous pulmonary venous return and persistent left superior vena cava.

The presence of partial anomalous pulmonary venous return and/or persistent left superior vena cava (LSVC) is usually viewed as a contraindication for robotic repair of complex atrial septal defects, such as those of the sinus venosus type. Three patients, aged 29, 73, and 23 years, successfully underwent totally endoscopic, robotic-assisted repair of sinus venosus-type atrial septal defect with partial anomalous pulmonary venous return and persistent LSVC. Two different techniques--direct cannulation or placement of a sump sucker--were successfully used to manage venous return from the persistent LSVC.

Concomitant robotic mitral and tricuspid valve repair: technique and early experience.

BACKGROUND: Robotic mitral valve repair has been successfully performed since the late 1990s, but concomitant robotic tricuspid repair has not yet been widely adopted. We report our first 5 years' experience with concomitant robotic mitral-tricuspid valve repair. METHODS: Records were reviewed for all patients who underwent concomitant robotic mitral-tricuspid valve repair in a single practice. Cardiopulmonary bypass was performed with femoral cannulation, antegrade and retrograde cardioplegia, and aortic cross-clamping by balloon occlusion. Access was through 5 ports. Tricuspid repair techniques included De Vega, modified De Vega with annuloplasty band, and annuloplasty band with interrupted suture repair. RESULTS: From August 2006 to December 2011, 50 patients underwent concomitant robotic mitral-tricuspid valve repair. The mean age was 73.4±9.3 years, and all patients had mitral or tricuspid regurgitation grades of 2+ or greater preoperatively. Cross-clamp and cardiopulmonary bypass times decreased significantly with surgeon experience. There were no conversions to sternotomy and one conversion to mitral valve replacement. Six patients required reexploration for bleeding or hemothorax, most of them early in the series. There were no infections, no intraoperative strokes, and no new-onset acute renal failure requiring dialysis. Two postoperative strokes resolved completely. Two patients experienced nitinol clip fracture and mitral ring dehiscence requiring reoperation. There were 2 early deaths. All patients had regurgitation grades of less than 2 at follow-up (p < 0.001). CONCLUSIONS: Combined robotic mitral-tricuspid valve repair can be performed safely and reproducibly, with acceptable early results. Long-term follow-up will be needed to establish this as an alternative to traditional sternotomy approaches.

St Jude Medical Epic porcine bioprosthesis: results of the regulatory evaluation.

BACKGROUND: The St Jude Medical Epic heart valve (St Jude Medical, Inc, St Paul, Minn) is a tricomposite glutaraldehyde-preserved porcine bioprosthesis. The St Jude Medical Biocor porcine bioprosthesis is the precursor valve to the St Jude Medical Epic valve. The Epic valve is identical to the Biocor valve except that it is treated with Linx AC ethanol-based calcium mitigation therapy. METHODS: The St Jude Medical Epic valve was implanted in 761 patients (mean age 73.9 ± 9.2 years) between 2003 and 2006 in the US Food and Drug Administration regulatory study in 22 investigational centers. The position distribution was 557 aortic valve replacements, 175 mitral valve replacements, and 29 double valve replacements. Concomitant coronary artery bypass grafting was performed in 50.8% of patients undergoing aortic valve replacement and 36.6% of those undergoing mitral valve replacement. RESULTS: The early mortality was 3.6% in aortic and 2.3% in mitral valve replacement. The follow-up was 1675.5 patient-years with a mean of 2.2 ± 1.2 years/patient. Late mortality was 5.2%/patient-year in aortic and 6.6%/patient-year in mitral valve replacement. The late major thromboembolism rate was 0.98%/patient-year for aortic and 2.6%/patient-year for mitral valve replacement. There were 19 reoperations, including 2 for structural valve deterioration, 1 for thrombosis, 9 for nonstructural dysfunction, and 7 for prosthetic valve endocarditis. The actuarial freedom from reoperation owing to structural valve deterioration for aortic valve replacement at 4 years for age 60 years or less was 93.3% ± 6.4%; for ages 61 to 70 years, 98.1% ± 1.9%; and for older than 70 years, 100% (P = .0006 > 70 vs ≤ 60 years). There were no events of structural deterioration with mitral valve replacement. The actuarial freedom from major thromboembolism for all patients at 4 years was 93.6% ± 1.0%. The 2 cases of structural valve deterioration occurred in aortic valves that became perforated without calcification causing aortic regurgitation. CONCLUSIONS: The performance of the St Jude Medical Epic porcine bioprosthesis is satisfactory at 4 years for both aortic and mitral valve replacement. This study establishes the early clinical performance including durability of this porcine bioprosthesis.