Use of aortic wall patches as leaflet replacement material during aortic valve repair.

Objectives: Aortic valve repair can be limited by inadequate leaflet tissue for proper coaptation. Various kinds of pericardium have been used for cusp augmentation, but most have failed because of tissue degeneration. A more durable leaflet substitute is needed. Methods: In this report, 8 consecutive cases are presented in which autologous ascending aortic tissue was used to augment inadequate native cusps during aortic valve repair. Biologically, aortic wall is a living autologous tissue that could have exceptional durability as a leaflet substitute. Techniques for insertion are described in detail, along with procedural videos. Results: Early surgical outcomes were excellent, with no operative mortalities or complications, and all valves were competent with low valve gradients. Patient follow-up and echocardiograms to a maximum of 8 months' postrepair remain excellent. Conclusions: Because of superior biologic characteristics, aortic wall has the potential to provide a better leaflet substitute during aortic valve repair and to expand patient categories amenable to autologous reconstruction. More experience and follow-up should be generated.

Aortic valve repair for isolated right coronary leaflet prolapse.

Objectives: Isolated right coronary leaflet prolapse is a common cause of nonaneurysmal aortic insufficiency, but can rarely occur in patients with proximal aortic aneurysms. Standardized techniques for routine autologous repair of this disorder are presented. Methods: Most aortic valve leaflet prolapse is isolated to the right coronary leaflet, with hypertension and annular dilatation being contributory. Echocardiographically, a posteriorly eccentric aortic insufficiency jet together with "fracture" of the right leaflet tip are diagnostic. Primary repair includes internal geometric ring annuloplasty to downsize and reshape the annulus, together with central plication of the prolapsing leaflet. Thickened, scarred, or retracted noduli are released using an ultrasonic aspirator. The goal is to achieve equivalent coaptation heights of ≥8 mm for all 3 leaflets. Results: Three videos of 6 cases are provided to illustrate these techniques. In the first, 3 patients are shown with classic isolated right leaflet prolapse. In the second and third videos, alternative pathologies are presented for contrast. Applying the reconstructive approaches of geometric ring annuloplasty, leaflet plication, and ultrasonic nodular release, excellent early and late repair outcomes are obtainable in most patients. Conclusions: The combination of aortic ring annuloplasty, central leaflet plication, and ultrasonic nodular release allows routine and standardized repair of right coronary leaflet prolapse, either isolated or concomitant with aneurysm surgery.

Management of immune dysfunction after adult cardiac surgery.

OBJECTIVE: Pulmonary dysfunction/multiorgan failure syndrome is an important cause of mortality and morbidity after cardiac operations. In this series, results of immune augmentation were assessed in patients experiencing pulmonary dysfunction/multiorgan failure syndrome after cardiac surgery. METHODS: Since 2002, 44 consecutive patients with primary antibiotic-refractory pulmonary dysfunction/multiorgan failure syndrome were treated with intravenous immunoglobulin (0.3 g/kg × 5 days; 1.5 g/kg total dose). Thirty patients had undergone complex valve or aortic surgery, and 14 patients had coronary bypass. Median age was 66 years, and risk profiles were especially high preoperatively. Clinical variables were assessed for 3 days prior (-3) to beginning intravenous immunoglobulin (on day 0) and for 5 days afterward (+5). A postoperative morbidity index was generated as a weighted sum of all relevant clinical variables. By using each patient as his or her own control, the therapeutic effect of intravenous immunoglobulin was assessed with linear regression of postoperative morbidity index over time with a spline and a knot at day 0, coincident with beginning intravenous immunoglobulin. RESULTS: At day 0, all patients were deteriorating clinically and refractory to major antibiotics. Overall morbidity was high, and immunoglobulin-G levels, obtained in the last 14 patients, were consistently low. By using linear regression of postoperative morbidity index over time, intravenous immunoglobulin administration was associated with significant improvement in clinical status (P < .0001). A total of 42 of 44 patients (95%) recovered uneventfully to hospital discharge. No significant complications of intravenous immunoglobulin therapy occurred. CONCLUSIONS: This experience suggests that management of immune dysfunction with intravenous immunoglobulin is safe and effective for treatment of primary pulmonary dysfunction/multiorgan failure syndrome after cardiac surgery. Expanded application seems indicated.

Robotic artificial chordal replacement for repair of mitral valve prolapse.

Artificial chordal replacement (ACR) has emerged as a superior method of mitral valve repair with excellent early and late efficacy. It is also ideal to combine with robotic techniques for correction of mitral prolapse, and this article presents a current method of robotic Gore-Tex ACR. Patients with isolated posterior leaflet prolapse are approached with the fourth-generation DaVinci robotic system and endoaortic balloon occlusion. A pledgetted anchor stitch is placed in a papillary muscle, and a 2-o Gore-Tex suture is passed through the anchor pledget. After full annuloplasty ring placement, the Gore-Tex suture is woven into the prolapsing segment and positioned temporarily with robotic forceps. Chordal length is then "adjusted" by lengthening or shortening the temporary knot over 1-cm increments as the valve is tested by injection of cold saline into the ventricle. After achieving good leaflet position and valve competence, the chord is tied permanently. The "adjustable" ACR procedure preserves leaflet surface area and produces a competent valve in the majority of patients. Postoperative transesophageal echo shows a large surface area of coaptation. Patient recovery is facilitated by the minimally invasive approach, while long-term stability of similar open ACR techniques have been excellent with a 2% to 3% failure rate over 10 years of follow-up. Robotic Gore-Tex ACR without leaflet resection is a reproducible procedure that simplifies mitral repair for prolapse. The outcomes observed in early robotic applications have been excellent. It is suggested that most patients with simple prolapse might validly be approached in this manner.

A new mitral valve repair strategy for hypertrophic obstructive cardiomyopathy.

BACKGROUND AND AIM OF THE STUDY: Previously, surgery hypertrophic obstructive cardiomyopathy (HOCM) has consisted primarily of septal myectomy and/or resection of the anterior mitral leaflet with low-profile valve replacement. However, recent studies have shown that the anterior papillary muscle and chordal fan can contribute to obstruction, and also that significant mitral regurgitation (MR) may be encountered. Hence, a surgical procedure was devised to address all components of this disorder. METHODS: A 37-year-old man had a history of heart murmur and NYHA class IV symptoms, despite beta-blocker therapy. Echocardiography showed severe septal hypertrophy, systolic anterior motion (SAM) of the mitral valve, severe MR and a 185 mmHg resting outflow tract gradient. At surgery, the anterior papillary muscle was found to be medially displaced and contributing to outflow obstruction. The anterior papillary muscle and chordae were resected, a 'traditional' septal myectomy was performed, and a full annuloplasty ring placed. The mitral valve was repaired by connecting the left aspect of the leaflets to the posterior papillary muscles, using Gore-Tex artificial chords. RESULTS: The patient recovered uneventfully. Interval echocardiography at one year showed a negligible outflow gradient, relief of SAM and mild residual MR. The patient currently is active, essentially asymptomatic, and not receiving any medical therapy. CONCLUSION: Previous approaches to HOCM have been limited by a small incidence of recurrent outflow gradients, pacemaker requirement, persistent MR or complications of the prosthetic valves. By comprehensively addressing all components of outflow obstruction and mitral dysfunction, this combined procedure may produce better results in certain subsets of HOCM, with the excellent late prognosis of artificial chordal replacement.

Quality assessment of platelet rich plasma during anti-platelet therapy.

Platelet rich plasma (PRP) is being used with increased frequency in many surgical procedures for its known benefits of accelerated surgical wound site healing. Speculations in its efficacy in the presence of anti-platelet therapy have been proposed. To aid in defining a quality platelet rich plasma product in the presence of acetylsalicylic acid (ASA) and Plavix (clopidogrel bisulfate), we investigated three (3) groups (n = 18) of cardiac surgical patients receiving PRP. Platelet function test, platelet concentration, and quantification of growth factors (PDGF-bb and TGF-b1) were evaluated. Results showed no statistical evidence of decreased growth factors delivered to the surgical wound site in the presence of acetylsalicylic acid (ASA) and/or Plavix (clopidogrel bisulfate). Evidence in this pilot study supports the use of PRP for patients receiving Plavix and aspirin therapy without compromising the quantity of specific growth factors delivered to a wound site.

Totally endoscopic robot-assisted transmyocardial laser revascularization.

We describe the first use of totally endoscopic, off-pump, robot-assisted transmyocardial laser revascularization in a 58-year-old man with refractory rest angina who had undergone two prior coronary bypass operations. Preoperative testing revealed reversible ischemia of the left ventricular apex with diffuse coronary atherosclerotic disease not suitable for further treatment by conventional techniques. During surgery a fiberoptic laser delivery system was manipulated using the da Vinci robotic system to create 25 transmural channels in the left ventricular myocardium. Postoperative recovery was rapid and uneventful, with complete relief of anginal symptoms at 30 days.