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BACKGROUND: Takotsubo syndrome is, by definition, a reversible form of acute heart failure. If cardiac output is severely reduced, Takotsubo syndrome can cause cardiogenic shock, and mechanical circulatory support can serve as a bridge to recovery. To date, there are no recommendations on when to use mechanical circulatory support and on which device is particularly effective in this context. Our aim was to determine the best treatment strategy. METHODS: A systematic literature research and analysis of individual patient data was performed in MEDLINE/PubMed according to PRISMA guidelines. Our research considered original works published until 31 July 2023. RESULTS: A total of 93 publications that met the inclusion criteria were identified, providing individual data from 124 patients. Of these, 62 (50%) were treated with veno-arterial extracorporeal life support (va-ECLS), and 44 (35.5%) received a microaxial left ventricular assist device (Impella). Eighteen patients received an Impella CP and twenty-one an Impella 2.5. An intra-aortic balloon pump (IABP) without other devices was used in only 13 patients (10.5%), while other devices (BiVAD or Tandem Heart) were used in 5 patients (4%). The median initial left ventricular ejection fraction was 20%, with no difference between the four device groups except for the IABP group, which was less affected by cardiac output failure (p = 0.015). The overall survival was 86.3%. Compared to the other groups, the time to cardiac recovery was shorter with Impella (p < 0.001). CONCLUSIONS: Though the Impella treatment is new, our analysis may show a significant benefit of Impella compared to other MCS strategies for cardiogenic shock in Takotsubo syndrome.
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Objective: The use of transcatheter mitral valve repair (TMVr) devices is increasing in elderly and high-risk patients. However, the increasing number of patients with recurrent mitral regurgitation (MR) has confronted surgeons with the issue of how to explant the devices and whether the mitral valve should be repaired or replaced. The aim of the study is to summarize our clinical experience with the explantation of different TMVr devices and to provide alternative surgical techniques that can be performed in different clinical scenarios. Methods: A simulator system including a dummy valve representing native valves was used to create video documentation and to develop alternative surgical methods for clip explantation. Moreover, the clip explantation techniques were shown in 2 patients undergoing minimally-invasive mitral valve repair after a failed TMVr. Results: Alternative explantation techniques were described for each TMVr device; 2 techniques for MitraClip and 3 techniques for PASCAL (Precision Transcatheter Valve Repair System), which may be adjusted for each individual according to the underlying valve pathology and the degree of device encapsulation. The patients were discharged without residual MR and remained MR free at the follow-up. Conclusions: Transcatheter edge-to-edge repair devices can be surgically explanted without damaging the MV leaflets. Removal of each device may require a different technique tailored to the degree of device encapsulation and valve pathology. Increasing experience may facilitate repair in patients with recurrent MR after TMVr.
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OBJECTIVES: Annuloplasty rings are routinely used in mitral valve repair (MVr). However, accurate annuloplasty ring size selection is essential to obtain a favourable outcome. Moreover, ring sizing can be challenging in some patients and is highly influenced by surgeons' experience. This study investigated the utility of three-dimensional mitral valve (3D-MV) reconstruction models to predict annuloplasty ring size for MVr. METHODS: A total of 150 patients undergoing minimally invasive MVr with annuloplasty ring due to Carpentier type II pathology and who were discharged with none/trace residual mitral regurgitation were included. 3D-MV reconstruction models were created with a semi-automated software package (4D MV Analysis) to quantitate mitral valve geometry. To predict the ring size, univariable and multivariable linear regression analyses were performed. RESULTS: Between 3D-MV reconstruction values and implanted ring sizes, the highest correlation coefficients were provided by commissural width (CW) (0.839; P < 0.001), intertrigonal distance (ITD) (0.796; P < 0.001), annulus area (0.782; P < 0.001), anterior mitral leaflet area (0.767; P < 0.001), anterior-posterior diameter (0.679; P < 0.001) and anterior mitral leaflet length (0.515; P < 0.001). In multivariable regression analysis, only CW and ITD were found to be independent predictors of annuloplasty ring size (R2 = 0.743; P < 0.001). The highest level of agreement was achieved with CW and ITD, and 76.6% of patients received a ring with no >1 ring size difference from the predicted ring sizes. CONCLUSIONS: 3D-MV reconstruction models can support surgeons in the decision-making process for annuloplasty ring sizing. The present study may be a first step towards accurate annuloplasty ring size prediction using multimodal machine learning decision support.
Subject(s)
Cardiac Surgical Procedures , Heart Valve Prosthesis Implantation , Heart Valve Prosthesis , Mitral Valve Annuloplasty , Mitral Valve Insufficiency , Humans , Mitral Valve/diagnostic imaging , Mitral Valve/surgery , Mitral Valve/pathology , Mitral Valve Insufficiency/diagnostic imaging , Mitral Valve Insufficiency/surgery , Mitral Valve Insufficiency/pathology , Cardiac Surgical Procedures/methods , Tricuspid Valve/surgery , Mitral Valve Annuloplasty/adverse effects , Mitral Valve Annuloplasty/methods , Heart Valve Prosthesis Implantation/methods , Treatment OutcomeABSTRACT
BACKGROUND: The "UFO procedure" was initially developed as a surgical option to enlarge the aortic annulus in patients requiring valve replacement. This technique can be employed to treat extensive endocarditis located in the intervalvular fibrous body (IVFB). One of the indications for a "UFO procedure" is massive aortic and mitral valve calcification. It is a challenging surgical procedure with a high risk of intraoperative complications. We present a 76-year-old male patient with massive aortic and mitral valve calcification involving the left atrium, the left ventricle and the left ventricular outflow tract. Both valves exhibited severe stenosis and moderate to severe regurgitation. The left ventricle was hypertrophic and the left ventricular ejection fraction was > 55%. The patient was prediagnosed with persistent atrial fibrillation. The risk of death following heart surgery (EuroSCORE II) was calculated as 9.21%. We successfully performed a so-called "UFO procedure" including replacement of both valves without annular decalcification to avoid atrioventricular dehiscence. We enlarged the IVFB and replaced the non-coronary sinus of Valsalva with doubled bovine pericardium. The left ventricular outflow tract was decalcified. The patient was transferred to a local hospital on the 13th postoperative day. CONCLUSION: Successful surgical treatment to this extent was demonstrated for the first time. Due to the high perioperative mortality, the surgical treatment of patients with this constellation would be refused in most cases. In our patient, the preoperative imaging showed extreme calcification of both valves and the surrounding myocardium. Excellent preoperative planning and a highly experienced surgical team is necessary.
Subject(s)
Atrial Fibrillation , Heart Valve Diseases , Heart Valve Prosthesis Implantation , Male , Humans , Animals , Cattle , Aged , Mitral Valve/surgery , Heart Ventricles/surgery , Stroke Volume , Atrial Fibrillation/surgery , Ventricular Function, Left , Heart Valve Diseases/surgery , Heart Valve Diseases/etiology , Heart Atria/surgery , Myocardium , Aortic Valve/surgery , Heart Valve Prosthesis Implantation/methods , Treatment OutcomeABSTRACT
OBJECTIVE: Evidence determining the optimal treatment for cardiac tumors is rare. We report our midterm clinical outcome and patient characteristics of our series undergoing atrial tumor removal through a right lateral minithoracotomy (RLMT). METHODS: From 2015 to 2021, 51 patients underwent RLMT for atrial tumor extirpation. Patients receiving concomitant atrioventricular valvular, cryoablation, and/or patent foramen ovale closure surgery were included. Follow-up was performed using standardized questionnaires (mean: 1,041 ± 666 days). Follow-up involved any tumor recurrence, clinical symptoms, and any recurrent arterial embolization. Survival analysis was successfully achieved in all patients. RESULTS: Successful surgical resection was achieved in all patients. Mean cardiopulmonary bypass and cross-clamping times were 75 ± 36 and 41 ± 22 min, respectively. The most common tumor location was the left atrium (n = 42, 82.4%). Mean ventilation time was 12.74 ± 17.23 h, intensive care unit stay ranged from 1 to 1.9 days (median: 1 day). Nineteen patients (37.3%) received concomitant surgery. Histopathological analysis showed 38 myxoma (74.5%), 9 papillary fibroelastoma (17.6%), and 4 thrombus (7.8%). Thirty-day mortality was observed in 1 case (2%). One patient (2%) suffered a stroke postoperatively. No patient had a relapse of cardiac tumor. Three patients (9.7%) showed arterial embolization during follow-up. Thirteen follow-up patients (25.5%) were in New York Heart Association class ≤II. Overall survival was 90.2% at 2 years. CONCLUSIONS: A minimally invasive approach for benign atrial tumor resection is effective, safe, and reproducible. Of the atrial tumors, 74.5% were myxoma and 82% were located in the left atrium. A low 30-day mortality rate with no manifestation of recurrent intracardiac tumor was observed.
Subject(s)
Atrial Fibrillation , Heart Neoplasms , Myxoma , Humans , Follow-Up Studies , Neoplasm Recurrence, Local/epidemiology , Heart Neoplasms/pathology , Heart Atria/surgery , Heart Atria/pathology , Myxoma/surgery , Treatment Outcome , Minimally Invasive Surgical ProceduresABSTRACT
Coronary artery obstruction is a life-threatening complication of transcatheter aortic valve replacement procedures, and current preventive strategies are suboptimal. The novel ShortCut device splits bioprosthetic valve leaflets that are at risk of causing coronary artery obstruction after transcatheter aortic valve implantation, allowing for normal coronary flow. In this video tutorial, we demonstrate a valve-in-valve transcatheter aortic valve implantation using a dedicated leaflet-splitting device for prevention of coronary artery obstruction in transcatheter aortic valve replacement.
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Transcatheter Aortic Valve Replacement , Humans , Coronary Vessels , CathetersABSTRACT
A continuous-flow left ventricular assist device implant is a well-established therapy for patients with end-stage heart failure. Currently, the HeartMate 3 device is the only commercially available durable left ventricular assist device. Therefore, patients on HeartWare HVAD support who require a pump exchange must have a HeartMate 3 implanted.
Subject(s)
Heart-Assist Devices , HumansABSTRACT
Minimally invasive aortic valve replacement has become a feasible approach to treat various aortic valve pathologies with limited procedural trauma. Several minimally invasive aortic valve replacement approaches with different levels of complexity and technical requirements are currently available.
Subject(s)
Aortic Valve , Minimally Invasive Surgical Procedures , Humans , Aortic Valve/surgeryABSTRACT
OBJECTIVE: Venous drainage is often problematic in minimally invasive cardiac surgery (MICS). Here, we describe our experience with a self-expandable stent cannula designed to optimize venous drainage. METHODS: The smart canula® was used in 58 consecutive patients undergoing MICS for mitral valve disease (n = 40), left atrial myxoma (n = 3), left ventricular outflow tract obstruction (n = 1), and aortic valve replacement via a right anterior minithoracotomy (n = 14) procedures. The venous cannula was placed under transesophageal echocardiography guidance to reach the superior vena cava. Vacuum-assisted venous drainage (between -20 and -35 mm Hg) was used to reach a target flow index of 2.2 L/min/m² at a core temperature of 34 °C using a goal-directed perfusion strategy aimed at a minimum DO2 of 272 mL/min/m2. Cardiopulmonary bypass (CPB) parameters were recorded, and hemolysis-related parameters were analyzed on postoperative days 1 to 7. RESULTS: Mean body surface area and median body mass index were 1.9 ± 0.2 m2 and 25.2 (23.4, 30.2) kg/m2. Mean CPB and median cross-clamping times were 107.7 ± 24.4 min and 64.5 (53, 75.8) min, and median CPB flow during cardioplegic arrest was 4 (3.6, 4.2) L/min (median cardiac index 2.1 [2, 2.2] L/min/m²). Venous drainage was considered sufficient by the surgeon in all cases, and insertion and removal were uncomplicated. Mean SvO2 during CPB was 80.2% ± 5.5%, and median peak lactate was 10 (8, 14) mg/dL, indicating sufficient perfusion. Mean venous negative drainage pressure during cross-clamping was 27.2 ± 12.3 mm Hg. Platelets dropped by 73.6 ± 37.5 K/µL, lactate dehydrogenase rose by 81.5 (44.3, 140.8) U/L, and leukocytes rose by 3.4 (2.2, 7.2) K/µL on postoperative day 1. CONCLUSIONS: The venous smart canula® allows for optimal venous drainage at low negative drainage pressures, facilitating sufficient perfusion in MICS.
Subject(s)
Cannula , Cardiac Surgical Procedures , Humans , Vena Cava, Superior/surgery , Cardiac Surgical Procedures/methods , Catheterization , Minimally Invasive Surgical Procedures/methods , Cardiopulmonary Bypass/methodsABSTRACT
The introduction of the transcatheter aortic valve implantation procedure has revolutionized the standards of care in patients with aortic valve pathologies and has significantly increased the quality of the medical treatment provided. The durability and constant technical improvements in the modern transcatheter aortic valve implantation procedure have broadened the indications towards younger patient groups with low-risk profiles. Therefore, transcatheter aortic valve implantation now represents an effective alternative for surgical aortic valve replacement in a large number of cases. Currently, various technical methods for the transcatheter aortic valve implantation procedure are available. The contemporary transcatheter aortic valve implantation procedure focuses on optimization of postoperative results and reduction of complications such as paravalvular leakage and permanent pacemaker implantation. Another goal of transcatheter aortic valve implantation is the achievement of a valid lifetime concept with secure coronary access and conditions for future valve-in-valve interventions. In this case report, we demonstrate a standard transfemoral transcatheter aortic valve implantation procedure with a self-expandable supra-annular device, one of the most commonly performed methods.
Subject(s)
Aortic Valve Stenosis , Heart Valve Prosthesis , Transcatheter Aortic Valve Replacement , Humans , Transcatheter Aortic Valve Replacement/methods , Aortic Valve Stenosis/surgery , Treatment Outcome , Aortic Valve/surgeryABSTRACT
OBJECTIVES: Analyses of fast-track (FT) processes demonstrated that low-risk cardiac surgical patients require minimal intensive care, with a low incidence of mortality or morbidity. We investigated perioperative factors and their association with fast-track failure (FTF) in a retrospective cohort study of patients undergoing minimally invasive mitral valve surgery. METHODS: Patients undergoing minimally invasive surgical mitral valve repair for Carpentier type I or type II mitral regurgitation between 2014 and 2020 were included in the study. The definition of FTF consisted of >10 h mechanical ventilation, >24 h intensive care unit stay, reintubation after extubation and re-admission to the intensive care unit. Multivariable logistic regression analysis enabled the identification of factors associated with FTF. RESULTS: In total, 491 patients were included in the study and were analysed. Two hundred and thirty-seven patients (48.3%) failed the FT protocol. Multivariable logistic regression analysis showed that a New York Heart Association classification ≥III [odds ratio (OR) 2.05; 95% confidence interval (CI) 1.38-3.08; P < 0.001], pre-existing chronic kidney disease (OR 2.03; 95% CI 1.14-3.70; P = 0.018), coronary artery disease (OR 1.90; 95% CI 1.13-3.23; P = 0.016), postoperative bleeding requiring surgical revision (OR 8.36; 95% CI 2.81-36.01; P < 0.001) and procedure time (OR 1.01; 95% CI 1.01-1.01; P < 0.001) were independently associated with FTF. CONCLUSIONS: Factors associated with FTF in patients with Carpentier type I and II pathologies undergoing minimally invasive mitral valve repair are a New York Heart Association classification III-IV at baseline, pre-existing chronic kidney disease and coronary artery disease. Postoperative bleeding requiring rethoracotomy and procedure time were also identified as important factors associated with failed FT.
Subject(s)
Coronary Artery Disease , Heart Valve Prosthesis Implantation , Mitral Valve Insufficiency , Renal Insufficiency, Chronic , Coronary Artery Disease/surgery , Heart Valve Prosthesis Implantation/adverse effects , Heart Valve Prosthesis Implantation/methods , Humans , Length of Stay , Minimally Invasive Surgical Procedures/adverse effects , Minimally Invasive Surgical Procedures/methods , Mitral Valve/surgery , Mitral Valve Insufficiency/etiology , Postoperative Complications/etiology , Retrospective Studies , Treatment OutcomeABSTRACT
This paper presents the first transcatheter management of severe aortic regurgitation in a 77-year-old woman with a criss-cross heart-an extremely rare and complex congenital heart disease. The procedure achieved an elimination of aortic regurgitation and resulted in a remarkable improvement of the patient's physical condition. (Level of Difficulty: Advanced.).
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OBJECTIVES: The standard approach for minimally invasive cardiac surgery (MICS) for repair of the atrioventricular valves is a right lateral minithoracotomy. In this study, we report our experience with a periareolar endoscopic approach, which aims at an optimal cosmetic outcome while preserving optimal clinical outcomes. METHODS: All patients underwent periareolar endoscopic MICS using high-definition three-dimensional endoscopic visualization without additional rib-spreading. Patients presented with degenerative and/or functional mitral regurgitation. Patients undergoing concomitant tricuspid valve surgery, cryo-ablation, patent foramen ovale closure, left atrial appendage occlusion and/or left atrial myxoma extirpation were included. This descriptive article analysed the aesthetic and functional outcome of the periareolar scar using 5 most common and clinimetrically sound scar assessment scales. For statistical analysis of the scar assessment grading scales, box and whisker plots were calculated depicting median, interquartile range and high and low range data points. RESULTS: Median scar assessment scale scores for n = 100 male patients (response rate 100/109; 91.7%) were 2 [1, 4], 7.5 [6, 9], 11 [8, 14], 3 [2, 3] and 10 [9, 11] for the Vancouver scar scale, Manchester scar scale, patient scar assessment scale, Stony brook scar evaluation scale and Dermatology Quality of Life Index scale, respectively. Ninety-seven patients received mitral valve repair, 7 mitral valve replacement, whereas 5 had left atrial myxoma extirpation. Concomitant tricuspid annuloplasty, cryo-ablation, left atrial appendage occlusion and patent foramen ovale closure surgery were performed in 12, 29, 5 and 8 patients, respectively. Median procedure, cardiopulmonary bypass and cross-clamp times were 169.5 [154.3, 189.3], 111.5 [97, 127], and 68.5 [58.8, 81] min, respectively. CONCLUSIONS: Periareolar endoscopic MICS is safe and cosmetically appealing. It is feasible and allows for complex mitral valve repair, mitral valve replacement and concomitant surgery. Data from 5 scar assessment scales suggest that this technique delivers patient-satisfying results regarding functional and cosmetic outcomes.
Subject(s)
Foramen Ovale, Patent , Heart Valve Prosthesis Implantation , Myxoma , Cicatrix/diagnostic imaging , Cicatrix/etiology , Humans , Male , Minimally Invasive Surgical Procedures/methods , Quality of Life , Treatment OutcomeABSTRACT
OBJECTIVES: Although clinical experience with transcatheter mitral valve interventions is rapidly increasing, there is still a lack of evidence regarding surgical treatment options for the management of recurrent mitral regurgitation (MR). This study provides guidance for a minimally invasive surgical approach following failed transcatheter mitral valve repair, which is based on the underlying mitral valve (MV) pathology and the type of intervention. METHODS: A total of 46 patients who underwent minimally invasive MV surgery due to recurrent or residual MR after transcatheter edge-to-edge repair or direct interventional annuloplasty between October 2014 and March 2021 were included. RESULTS: The median age of the patients was 78 [interquartile range, 71-82] years and the EuroSCORE II was 4.41 [interquartile range, 2.66-6.55]. At the index procedure, edge-to-edge repair had been performed in 45 (97.8%) patients and direct annuloplasty in 1 patient. All patients with functional MR at the index procedure (n = 36) underwent MV replacement. Of the patients with degenerative MR (n = 10), 5 patients were eligible for MV repair after removal of the MitraClip. The 1-year survival following surgical treatment was 81.3% and 75.0% in patients with functional and degenerative MR, respectively. No residual MR greater than mild during follow-up was observed in patients who underwent MV repair. CONCLUSIONS: Minimally invasive surgery following failed transcatheter mitral valve repair is feasible and safe, with promising midterm survival. The surgical management should be tailored to the underlying valve pathology at the index procedure, the extent of damage of the MV leaflets and the type of previous intervention.
Subject(s)
Cardiac Surgical Procedures , Heart Valve Prosthesis Implantation , Mitral Valve Insufficiency , Aged , Aged, 80 and over , Cardiac Catheterization/adverse effects , Cardiac Catheterization/methods , Heart Valve Prosthesis Implantation/adverse effects , Heart Valve Prosthesis Implantation/methods , Humans , Minimally Invasive Surgical Procedures , Mitral Valve/diagnostic imaging , Mitral Valve/surgery , Mitral Valve Insufficiency/diagnostic imaging , Mitral Valve Insufficiency/surgery , Treatment OutcomeABSTRACT
Composite replacement of the aortic root and aortic valve is a valid surgical strategy in a case of annuloaortic ectasia. However, valve-sparing root replacement procedures have become the gold standard in cases with a morphologically intact or at least repairable aortic valve, and offer several advantages compared to conventional replacement techniques. Above all, the David procedure has become established as a well-known valve-sparing root replacement strategy with excellent short- and long-term outcomes, and it has been further applied to additional patient populations with characteristics like a bicuspid aortic valve or in the setting of acute type A aortic dissection. This narrative review offers an overview of the indications as well as the surgical steps of the T. David V procedure, and highlights important key points regarding the surgical feasibility and criteria of patient selection for valve-sparing root replacement.
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Over the past few decades, the field of minimally invasive cardiac surgery has significantly broadened. Novel surgical and endovascular techniques have been developed for the treatment of aortic valve pathologies. Surgical aortic valve replacement (SAVR) through a right antero-lateral (mini-)thoracotomy (RALT) has gained approval due to its limited postoperative trauma, faster rehabilitation and sufficient pain control. Nevertheless, SAVR RALT has not been adopted by a significant proportion of cardiac surgeons, due, in part, to its technical complexity and steep learning curve. In this review, we discuss the data for minimally invasive aortic valve surgery and describe our operative technique for SAVR RALT.
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Mitral annular calcification (MAC) complicates the management of mitral valve (MV) disease, regardless of its etiology. Strategies to address MV surgery in MAC include two main options with their own pros and cons; respect and resect strategy. Here, we present a case of minimally-invasive MV repair with partial annuloplasty in the management of noncircumferential MAC with respect to strategy. This technique may be an alternative option for rescuing high-risk patients without extensive decalcification.
Subject(s)
Calcinosis , Heart Valve Diseases , Heart Valve Prosthesis Implantation , Mitral Valve Annuloplasty , Mitral Valve Insufficiency , Aortic Valve/surgery , Calcinosis/diagnostic imaging , Calcinosis/etiology , Calcinosis/surgery , Heart Valve Diseases/surgery , Heart Valve Prosthesis Implantation/methods , Humans , Mitral Valve/diagnostic imaging , Mitral Valve/surgery , Mitral Valve Annuloplasty/methods , Mitral Valve Insufficiency/diagnostic imaging , Mitral Valve Insufficiency/etiology , Mitral Valve Insufficiency/surgery , Treatment OutcomeABSTRACT
The introduction of transcatheter aortic valve implantation (TAVI) has dramatically improved the treatment of valvular pathologies in high-risk patients. Additionally, transcatheter aortic valve implantation can be successfully applied in patients with deteriorated surgical bioprosthetic valves, representing an attractive alternative to a redo operation. Valve-in-valve transcatheter aortic valve implantations can be especially challenging in patients with a small-diameter prosthesis and patient-prosthesis mismatch. Bioprosthetic valve fracturing or bioprosthetic valve remodeling can be used to increase the valvular opening area and additionally reduce the transvalvular gradients in patients having an aortic valve implant. In this case report, we provide detailed insight and step-by-step guidance for transcatheter aortic valve-in-valve implantation with bioprosthetic valve fracturing/bioprosthetic valve remodeling under cerebral protection in a patient with a deteriorated 19-mm surgically implanted bioprosthesis.