Repair of mitral prolapse: comparison of thoracoscopic minimally invasive and conventional approaches.

OBJECTIVES: Surgical repair remains the best treatment for severe primary mitral regurgitation (MR). Minimally invasive mitral valve surgery is being increasingly performed, but there is a lack of solid evidence comparing thoracoscopic with conventional surgery. Our objective was to compare outcomes of both approaches for repair of leaflet prolapse. METHODS: All consecutive patients undergoing surgery for severe MR due to mitral prolapse from 2012 to 2020 were evaluated according to the approach used. Freedom from mortality, reoperation and recurrent severe MR were evaluated by Kaplan-Meier method. Differences in baseline characteristics were adjusted with propensity score-matched analysis (1:1, nearest neighbour). RESULTS: Three hundred patients met inclusion criteria and were divided into thoracoscopic (N = 188) and conventional (sternotomy; N = 112) groups. Unmatched patients in the thoracoscopic group were younger and had lower body mass index, New York Heart Association class and EuroSCORE II preoperatively. After matching, thoracoscopic group presented significantly shorter mechanical ventilation (9 vs 15 h), shorter intensive care unit stay (41 vs 65 h) and higher postoperative haemoglobin levels (11 vs 10.2 mg/dl) despite longer bypass and cross-clamp times (+30 and +17 min). There were no differences in mortality or MR grade at discharge between groups nor differences in survival, repair failures and reinterventions during follow-up. CONCLUSIONS: Minimally invasive mitral repair can be performed in the majority of patients with mitral prolapse, without compromising outcomes, repair rate or durability, while providing shorter mechanical ventilation and intensive care unit stay and less blood loss.

Outcomes of Septal Myectomy beyond 65 Years, with and without Concomitant Procedures.

INTRODUCTION AND OBJECTIVES: Septal myectomy remains the first septal reduction therapy for hypertrophic obstructive cardiomyopathy in young patients and those requiring concomitant procedures. Its role in advanced ages is questioned due to perceived increased risk. We assess the outcomes of surgical relief of obstruction in patients beyond 65 years old. METHODS: A single-center retrospective review of patients ≥ 65 years old undergoing septal myectomy through median sternotomy between April 2015 and February 2020. RESULTS: We identified 52 patients. Mean age was 71.8 ± 4.9 years; 36 (69.2%) were females. All were symptomatic. Mean highest LVOT gradient was 90 ± 39 mmHg. All patients had systolic anterior motion (SAM) of the mitral valve and 36 (69.2%) ≥ moderate mitral regurgitation. Additional LVOT interventions beyond myectomy were performed in 34 (65.4%). At least one other cardiac concomitant procedure was performed 44 (84.6%). No perioperative mortality in elective surgery occurred. One patient (1.9%) developed atrio-ventricular block. Postoperative mean gradient was 4.3 ± 1.9 mmHg, with 46 (88.4%) achieving complete resolution of obstruction. Mitral regurgitation was reduced to grade ≤ I in 46 (88.5%). Mean follow-up time was 2.3 ± 1.2 years and 82% of patients were in NYHA I. Survival at 2 years was 98%. CONCLUSION: Septal myectomy in the elderly is a safe and effective operation despite the need for concomitant procedures. LVOT interventions beyond septal myectomy to relieve obstruction are common in this advanced cohort of hypertrophic cardiomyopathy patients. This operation carried at experienced centers seems an unmatched therapeutic option.

Biventricular fibroma resection in an adult.

Cardiac fibromas are the second most common primary cardiac tumors in childhood. They only rarely present in adults. They are mainly located in the free wall of the ventricles and attached to the interventricular septum. Despite their benign pathology, fibromas in some locations can cause significant complications. This video tutorial illustrates the resection of a septo-apical cardiac fibroma in an asymptomatic 26-year-old woman, diagnosed with transthoracic echocardiography and cardiac magnetic resonance imaging after an abnormal ECG on an occupational medical examination. Surgery was performed through a median sternotomy using cardiopulmonary bypass. A nodular intramyocardial mass was found at the left ventricular apex and resection was carried out. After removing the fibroma, a defect was found at the apex affecting both ventricles. The defects were closed using a direct suture of 4-0 polypropylene "U" stitches reinforced with a Teflon patch to exclude the ventricular cavity.  Pathology confirmed the diagnosis of benign cardiac fibroma with tumor-free surgical margins. The patient recovered uneventfully and was discharged on postoperative day 5. The outpatient follow-up cMRI 10 months after surgery showed no signs of tumor recurrence and normal biventricular function.

Reintervenciones en una Unidad de Cuidados Intensivos de Cirugía Cardiovascular / Surgery in the Cardiovascular Surgical Intensive Care Unit

INTRODUCCIÓN: Analizar las indicaciones, acciones y resultados de las operaciones realizadas en la Unidad de Cuidados Intensivos (UCI) de Cirugía Cardiovascular. MÉTODOS: Análisis retrospectivo de pacientes adultos consecutivos intervenidos en la Unidad de Cuidados Intensivos (UCI). Se incluyeron todas las intervenciones practicadas. Se realizó estadística descriptiva. RESULTADOS: Entre 2008 y 2013 se intervinieron 3379 pacientes adultos consecutivos. Se practicaron en la UCI 124 intervenciones en 109 pacientes, 70 hombres (64,2%) y 39 mujeres (35,8%) con un promedio de edad de 61,6 años (12-80). Ello ha representado un 3,2%. Durante el mismo periodo de tiempo, se intervinieron en quirófano 185 pacientes por taponamiento cardiaco/hemorragia postoperatoria (5,5%). Las intervenciones previas fueron por cardiopatía valvular (34,9%), patología aórtica (22,9%), cardiopatía isquémica (15,6%), valvular/isquémica (12%), valvular/de la aorta (11%) y miscelánea (3,6%). Las indicaciones de intervención fueron hemorragia persistente 54 (43,5%), taponamiento cardiaco 41 (33%), bajo gasto cardiaco 13 (10,5%), parada cardíaca/arritmias 8 (6,5%), insuficiencia respiratoria 6 (4,8%) e isquemia de extremidades 2 (1,7%). Las intervenciones fueron: exploración mediastínica 73 (58,9%), colocación/retirada de ECMO 17 (13,7%), cierre esternal 16 (12,9%), resucitación abierta 9 (7,3%), drenaje subxifoideo 7 (5,6%) y embolectomía femoral 2 (1,6%). La mortalidad fue 33%. Hubo un caso de mediastinitis (0,9%), sin diferencias con la tasa de infecciones profundas en pacientes no intervenidos en UCI. CONCLUSIONES: La intervención en UCI es una alternativa segura y de rescate en subgrupos específicos de pacientes. no incrementa el riesgo de infección, evita el transporte de pacientes inestables y permite ahorrar tiempo en la decisión quirúrgica postoperatoria

BACKGROUND: To analyze the indications, actions and results of the operations performed in the Cardiovascular Surgery Intensive Care Unit. METHODS: Retrospective analysis of consecutive non-selected adult patients operated in the ICU. All operations were included. Descriptive statistics were used. RESULTS: Between 2008 and 2013, 3379 consecutive adult patients were operated upon. A total of 124 operations were performed in the ICU in 109 patients, 70 male (64.2%) and 39 female (35.8%) with a mean age of 61.6 years (12-80). This represented 3.2% of all operations. During the study period, 185 patients (5.5%) were reoperated for postoperative bleeding/tamponade in the operating room. The index interventions were for valvular heart disease (34.9%), aortic disease (22.9%), ischemic heart disease (15.6%), combined valvular/ischemic (12%), valvular/aorta (11%) and miscellaneous (3.6%). The indications for reoperation were persistent bleeding 54 (43.5%), pericardial tamponade 41 (33%), low cardiac output 13 (10.5%), cardiac arrest/arrhythmia 8 (6.5%), respiratory insufficiency 6 (4.8%) and acute ischemic limb 2 (1.7%). Operations performed were: mediastinal exploration 73 (58.9%), implant/removal of ECMO 17 (13.7%), sternal closure 16 (12.9%), open resuscitation 9 (7.3%), subxyphoid drainage 7 (5.6%) and femoral embolectomy 2 (1.6%). Overall mortality was 33%. There was one case of mediastinitis (0,9%), with no difference from patients operated in the regular operating room. CONCLUSIONS: Operations in the ICU represent a safe, life-saving alternative in specific subgroups of patients. The risk of wound infection is not increased, unstable patients are not transferred and there is time savings

[Surgery in the Cardiovascular Surgical Intensive Care Unit]. / Reintervenciones en una Unidad de Cuidados Intensivos de Cirugía Cardiovascular.

BACKGROUND: To analyze the indications, actions and results of the operations performed in the Cardiovascular Surgery Intensive Care Unit. METHODS: Retrospective analysis of consecutive non-selected adult patients operated in the ICU. All operations were included. Descriptive statistics were used. RESULTS: Between 2008 and 2013, 3379 consecutive adult patients were operated upon. A total of 124 operations were performed in the ICU in 109 patients, 70 male (64.2%) and 39 female (35.8%) with a mean age of 61.6 years (12-80). This represented 3.2% of all operations. During the study period, 185 patients (5.5%) were reoperated for postoperative bleeding/tamponade in the operating room. The index interventions were for valvular heart disease (34.9%), aortic disease (22.9%), ischemic heart disease (15.6%), combined valvular/ischemic (12%), valvular/aorta (11%) and miscellaneous (3.6%). The indications for reoperation were persistent bleeding 54 (43.5%), pericardial tamponade 41 (33%), low cardiac output 13 (10.5%), cardiac arrest/arrhythmia 8 (6.5%), respiratory insufficiency 6 (4.8%) and acute ischemic limb 2 (1.7%). Operations performed were: mediastinal exploration 73 (58.9%), implant/removal of ECMO 17 (13.7%), sternal closure 16 (12.9%), open resuscitation 9 (7.3%), subxyphoid drainage 7 (5.6%) and femoral embolectomy 2 (1.6%). Overall mortality was 33%. There was one case of mediastinitis (0,9%), with no difference from patients operated in the regular operating room. CONCLUSIONS: Operations in the ICU represent a safe, life-saving alternative in specific subgroups of patients. The risk of wound infection is not increased, unstable patients are not transferred and there is time savings.

Eyes wide shut--unusual two stage repair of pectus excavatum and annuloaortic ectasia in a 37 year old marfan patient: case report.

We report about a 37 year old male patient with a pectus excavatum. The patient was in NYHA functional class III. After performed computed tomography the symptoms were thought to be related to the severity of chest deformation. A Ravitch-procedure had been accomplished in a district hospital in 2009. The crack of a metal bar led to a reevaluation 2010, in which surprisingly the presence of an annuloaortic ectasia (root 73×74 mm) in direct neighborhood of the formerly implanted metal-bars was diagnosed. Echocardiography revealed a severe aortic valve regurgitation, the left ventricle was massively dilated presenting a reduced ejection fraction of 45%. A marfan syndrome was suspected and the patient underwent a valve sparing aortic root replacement (David procedure) in our institution with an uneventful postoperative course. A review of the literature in combination with discussion of our case suggests the application of stronger recommendations towards preoperative cardiovascular assessment in patients with pectus excavatum.

Elective cardiac surgery using Celsior or St. Thomas No. 2 solution: a prospective, single-center, randomized pilot study.

OBJECTIVE: Celsior is a crystalloid solution specifically designed for solid-organ transplantation. Due to its advanced combination of solutes, we wanted to evaluate its safety, efficacy, and possible benefits when used as blood cardioplegia in elective cardiac surgery in a single-center, randomized, controlled clinical trial, comparing its performance with a well-established cardioplegic solution. METHODS: Patients programmed for aortic valve replacement were randomized to receive either St. Thomas No. 2 or Celsior as blood cardioplegia with the same administration protocol. Intraoperative and postoperative variables concerning myocardial protection were registered and compared. RESULTS: A total of 60 patients were enrolled and randomized (Celsior, 30; St. Thomas, 30). There were no significant differences in baseline and preoperative variables. Volume of cardioplegic solution, number of administrations needed and the amount of potassium added were similar in both groups. Patients in the Celsior group showed a higher incidence of spontaneous sinus rhythm after myocardial ischemia (77% vs 40%, p=0.004) and fewer patients required defibrillation (17% vs 43%, p=0.024) for ventricular reperfusion arrhythmias. Postoperatively, there were no significant differences in troponin I release, inotropic and vasopressor drug support, ICU stay, and postoperative evolution. There were no deaths in the study. CONCLUSIONS: Celsior solution used as blood cardioplegia is effective and seems to be safe in elective aortic valve replacement when compared in this pilot study with a standard cardioplegic solution used worldwide. Fast return to sinus rhythm and lower incidence of reperfusion arrhythmias in the Celsior group may reflect a better myocardial protection during cardioplegic arrest. More investigation is needed to elucidate its performance in elective surgery.

Acute limb ischemia due to embolization of biological glue after repair of type A aortic dissection.

OBJECTIVE: We present two cases of type A aortic dissection repaired with the help of biological glue, that were followed by acute limb ischemia due to embolism of glue. METHODS AND RESULTS: A 30-year-old man was diagnosed with aortic dissection from left coronary sinus to right subclavian artery. Under deep hypothermic circulatory arrest (DHCA), distal aortic anastomotic site was reconstructed with injection of Bioglue between dissected layers, and a valve sparing inclusion technique was performed using a straight dacron graft. On postoperative day 14, he presented acute limb ischemia due to femoral artery glue embolism that required surgery. A 76-year-old woman with the diagnosis of type A dissection ending proximal to the celiac trunk was operated under cardiopulmonary bypass and DHCA. The ascending aorta was replaced with a straight dacron tube, with resuspension of aortic valve and reinforcement of proximal and distal anastomosis with Bioglue between the diseased layers. Absence of previously patent radial pulse was detected intraoperatively, solved with humeral thromboembolectomy. CONCLUSIONS: Management of the diseased aortic wall in acute dissections is a surgical challenge for the cardiac surgeon. Despite our group having a positive experience with biological glue in type A aortic dissection, this report reminds us that the use of bioadhesives to reinforce anastomotic sites may be an important tool but it is not free of problems.

Port-Access cardiac surgery: from a learning process to the standard.

BACKGROUND: Port-Access surgery has been one of the most innovative and controversial methods in the spectrum of minimally invasive techniques for cardiac operations and has been widely used for the treatment of several cardiac diseases. The technique was introduced in our center to evaluate its efficacy in reproducing standardized results without an additional risk. METHODS: Endovascular cardiopulmonary bypass (CPB) through femoral access and endoluminal aortic occlusion were used in 129 patients for a variety of surgical procedures, all of which were video-assisted. A minimal (4-6 cm) anterior thoracotomy through the fourth intercostal space was used in all cases as the surgical approach. RESULTS: More than 96% of the planned cases concluded as true Port-Access procedures. Mean CBP and crossclamp times were 87.2 min. +/- 51.2 (range of 10-457) and 54.9 min. +/- 30.6 (range of 10-190), respectively. Hospital mortality for the overall group was 1.5%, and mitral valve surgery had a 2.2% hospital death rate. The incidence of early neurological events was 0.7%. Mean extubation time, ICU stay, and total length of hospital stay were 5 hours +/- 6 hrs. (range of 2-32), 12 hours +/- 11.8 hrs. (range of 5-78), and 7 days +/- 7.03 days (range of 1-72), respectively. CONCLUSIONS: Our experience indicates that the Port- Access technique is safe and permits reproduction of standardized results with the use of a very limited surgical approach. We are convinced that this is a superior procedure for certain types of surgery, including isolated primary or redo mitral surgery, repair of a variety of atrial septal defects (ASDs), and atrial tumors. It is especially useful in high-risk patients, such as elderly patients or those requiring reoperation. Simplification of the procedure is nevertheless desirable in order to further reduce the time of operation and to address other drawbacks.