Adjustable external Dacron annuloplasty in aortic valve repair.

In aortic valve repair, whilst performing a Yacoub remodelling operation, the external annuloplasty of the aortic ring plays a very important role. Here we present an adjustable external Dacron annuloplasty as an additional tool, in very selected cases, that can help surgeons to further improve their immediate results thus influencing the long-term ones.

Resection of a cardiac tumour with reconstruction of the atria and the superior vena cava.

Cardiac tumours are very rare and their complete resection, when feasible, remains the only curative treatment. We present the case of a patient who had aortic stenosis. The routine preoperative workup also identified stenosis in the left anterior descending and right coronary arteries, and most importantly, an invasive tumour at the confluence of the superior vena cava-right atrium-left atrium. After discussion by the heart team, and as is usually done in our department for non-complex right coronary lesions, the stenosis was treated by inserting a stent. The patient was operated on for an aortic valve replacement with a concomitant left internal mammary artery to left anterior descending artery coronary artery bypass graft. In addition, the tumour was completely resected surgically. Reconstruction included a patch for the left atrium, another for the right atrium and a Dacron tube for the superior vena cava. Histological analysis confirmed the complete resection of a cardiac hibernoma. Three months after the surgery, the patient is doing well without any symptoms.

Reconstruction of a large pulmonary artery aneurysm using a vascular prosthesis.

A pulmonary artery aneurysm is a rare, heterogeneous disease for which there are currently no surgical guidelines. We present the case of a symptomatic patient presenting with a large aneurysm of the distal pulmonary trunk and left pulmonary artery. The aneurysm was resected through a full median sternotomy under cardiopulmonary bypass and aortic cross-clamping. The reconstruction was performed using a straight vascular prosthesis to connect the proximal pulmonary trunk to the left pulmonary artery with the lateral reimplantation of the right pulmonary artery. We find this surgical technique to be simple, effective, and reproducible by colleagues encountering similar cases.

Randomized controlled trial between conventional versus sutureless bioprostheses for aortic valve replacement: Impact of mini and full sternotomy access at 1-year follow-up.

BACKGROUND: The present study is a sub-analysis of the multicenter, randomized PERSIST-AVR trial (PERceval Sutureless Implant versus Standard Aortic Valve Replacement) comparing the in-hospital and 1-year results of sutureless versus conventional stented bioprostheses in isolated surgical aortic valve replacement (SAVR) within two different surgical approaches: mini-sternotomy (MS) and full-sternotomy (FS). METHODS: A total of 819 patients (per-protocol population) underwent preoperative randomization to sutureless or stented biological valve at 47 centers worldwide. Sub-analysis on isolated SAVR was performed. Results were compared between sutureless and stented within the two different surgical approaches. RESULTS: 285 patients were implanted with Perceval (67% in MS) and 293 with stented valves (65% in MS). Sutureless group showed significantly reduced surgical times both in FS and MS. In-hospital results show no differences between Perceval and stented valves in FS, while a lower incidence of new-onset of atrial fibrillation (3.7% vs 10.8%) with Perceval in MS. After 1-year, use of sutureless valve showed a significant reduction of MACCE (5.2% vs 10.8%), stroke rate (1.0% vs 5.4%), new-onset of atrial fibrillation (4.2% vs 11.4%) and re-hospitalizations (21.8 days vs 47.6 days), compared to stented valves but presented higher rate of pacemaker implantation (11% vs 1.6%). CONCLUSIONS: Sutureless bioprosthesis showed significantly reduced procedural times during isolated SAVR in both surgical approaches. Patients with sutureless valves and MS access showed also better 1-year outcome regarding MACCEs, stroke, re-hospitalization and new-onset atrial fibrillation, but presented a higher rate of permanent pacemaker implantation compared to patients with stented bioprosthesis.

Recent improvement in operative techniques lead to lower pacemaker rate after Perceval implant.

OBJECTIVES: Our goal was to compare pacemaker rate usage following two different operating techniques for implanting the Perceval aortic valve replacement. METHODS: In this retrospective, single-centre study, we studied patients with isolated or concomitant Perceval aortic valve replacement operated on first between April 2013 and January 2016, following traditional operating techniques, with patients operated on between January 2016 and December 2020, after the adoption of a modified protocol based on different annulus sizing, higher positioning of the valve and no ballooning after valve deployment was adopted. The operations were performed by 2 surgeons, and patients were followed-up for a period of 30 days. RESULTS: A total of 286 patients, with a mean age of 77 (4.9) years, had Perceval valves implanted during the study period, of which 79% were isolated aortic valve procedures. Most patients (66.8%) underwent minimally invasive procedures. Cross-clamp time was 55.1 (17.6) min. The overall postoperative pacemaker insertion rate was 8.4%, which decreased decisively after the 2016 change in the implant protocol (16% vs 5.6%; P = 0.005), adjusted odds ratio of 0.31 (95% confidence interval: 0.13-0.74, P = 0.012). Univariable and multivariable analysis showed that larger valve size (P = 0.01) and ballooning (P = 0.002) were associated with higher risk of implanting a pacemaker. Postoperative 30-day mortality was of 4.5%. CONCLUSIONS: Improvement in the operating techniques for implanting the Perceval valve may decrease the rate of pacemakers implanted postoperatively. Although further studies are needed to confirm these results, such a risk reduction may lead to wider use of Perceval valves in the future, potentially benefiting patients who are suitable candidates for minimally invasive surgery.

Hemodynamic Performance of Sutureless vs. Conventional Bioprostheses for Aortic Valve Replacement: The 1-Year Core-Lab Results of the Randomized PERSIST-AVR Trial.

OBJECTIVE: Sutureless aortic valves are an effective option for aortic valve replacement (AVR) showing non-inferiority to standard stented aortic valves for major cardiovascular and cerebral events at 1-year. We report the 1-year hemodynamic performance of the sutureless prostheses compared with standard aortic valves, assessed by a dedicated echocardiographic core lab. METHODS: Perceval Sutureless Implant vs. Standard Aortic Valve Replacement (PERSIST-AVR) is a prospective, randomized, adaptive, open-label trial. Patients undergoing AVR, as an isolated or combined procedure, were randomized to receive a sutureless [sutureless aortic valve replacement (Su-AVR)] (n = 407) or a stented sutured [surgical AVR (SAVR)] (n = 412) bioprostheses. Site-reported echocardiographic examinations were collected at 1 year. In addition, a subgroup of the trial population (Su-AVR n = 71, SAVR = 82) had a complete echocardiographic examination independently assessed by a Core Lab (MedStar Health Research Institute, Washington D.C., USA) for the evaluation of the hemodynamic performance. RESULTS: The site-reported hemodynamic data of stented valves and sutureless valves are stable and comparable during follow-up, showing stable reduction of mean and peak pressure gradients through one-year follow-up (mean: 12.1 ± 6.2 vs. 11.5 ± 4.6 mmHg; peak: 21.3 ± 11.4 vs. 22.0 ± 8.9 mmHg). These results at 1-year are confirmed in the subgroup by the core-lab assessed echocardiogram with an average mean and peak gradient of 12.8 ± 5.7 and 21.5 ± 9.1 mmHg for Su-AVR, and 13.4 ± 7.7 and 23.0 ± 13.0 mmHg for SAVR. The valve effective orifice area was 1.3 ± 0.4 and 1.4 ± 0.4 cm2 at 1-year for Su-AVR and SAVR. These improvements are observed across all valve sizes. At 1-year evaluation, 91.3% (n = 42) of patients in Su-AVR and 82.3% in SAVR (n = 51) groups were free from paravalvular leak (PVL). The rate of mild PVL was 4.3% (n = 2) in Su-AVR and 12.9% (n = 8) in the SAVR group. A similar trend is observed for central leak occurrence in both core-lab assessed echo groups. CONCLUSION: At 1-year of follow-up of a PERSIST-AVR patient sub-group, the study showed comparable hemodynamic performance in the sutureless and the stented-valve groups, confirmed by independent echo core lab. Perceval sutureless prosthesis provides optimal sealing at the annulus with equivalent PVL and central regurgitation extent rates compared to sutured valves. Sutureless valves are therefore a reliable and essential technology within the modern therapeutic possibilities to treat aortic valve disease.

Pacemaker implantation after sutureless or stented valve: results from a controlled randomized trial.

OBJECTIVES: Sutureless aortic valves demonstrated non-inferiority to standard stented valves for major cardiovascular and cerebral events at 1 year after aortic valve replacement. We aim to assess the factors correlating with permanent pacemaker implantation (PPI) in both cohorts. METHODS: PERSIST-AVR is a prospective, randomized, open-label trial. Patients undergoing aortic valve replacement were randomized to receive a sutureless aortic valve replacement (Su-AVR) or stented sutured bioprosthesis (SAVR). Multivariable analysis was performed to identify possible independent risk factors associated with PPI. A logistic regression analysis was performed to estimate the risk of PPI associated to different valve size. RESULTS: The 2 groups (Su-AVR; n = 450, SAVR n = 446) were well balanced in terms of preoperative risk factors. Early PPI rates were 10.4% in the Su-AVR group and 3.1% in the SAVR. PPI prevalence correlated with valve size XL (P = 0.0119) and preoperative conduction disturbances (P = 0.0079) in the Su-AVR group. No predictors were found in the SAVR cohort. Logistic regression analysis showed a significantly higher risk for PPI with size XL compared to each individual sutureless valve sizes [odds ratio (OR) 0.272 vs size S (95%confidence interval 0.07-0.95), 0.334 vs size M (95% CI 0,16-0; 68), 0.408 vs size L (95% CI 0,21-0.81)] but equivalent risk of PPI rates for all other combination of valve sizes. CONCLUSIONS: Su-AVR is associated with higher PPI rate as compared to SAVR. However, the increased PPI rate appears to be size-dependent with significant higher rate only for size XL. The combination of preoperative conduction disorder and a size XL can lead to a higher probability of early PPI in Su-AVR. CLINICAL TRIAL REGISTRATION NUMBER: NCT02673697.

Right anterior minithoracotomy with total central cannulation.

A right anterior minithoracotomy is gaining wider acceptance among the members of the surgical community for the treatment of isolated aortic valve replacement. Usually, the cardiopulmonary bypass circuit is implanted either totally peripherally or with 1 cannula in a central position and the other in a peripheral one. This procedure has its drawbacks because it adds potential peripheral morbidity during or after the operation. At our center, during the last year, we have developed some tips and tricks in order to establish in most of the patients a total central cardiopulmonary bypass procedure. We explain this technique in our video tutorial. We think that this approach may help other surgical teams to embrace a right anterior minithoracotomy because it is similar to what we do routinely by sternotomy.

Prognostic value of aerobic capacity and exercise oxygen pulse in postaortic dissection patients.

BACKGROUND: Although recommendations encourage daily moderate activities in post aortic dissection, very little data exists regarding cardiopulmonary exercise testing (CPET) to personalize those patient's physical rehabilitation and assess their cardiovascular prognosis. DESIGN: We aimed at testing the prognostic insight of CPET regarding aortic and cardiovascular events by exploring a prospective cohort of patients followed-up after acute aortic dissection. METHODS: Patients referred to our department after an acute (type A or B) aortic dissection were prospectively included in a cohort between September 2012 and October 2017. CPET was performed once optimal blood pressure control was obtained. Clinical follow-up was done after CPET for new aortic event and major cardio-vascular events (MCE) not directly related to the aorta. RESULTS: Among the 165 patients who underwent CPET, no adverse event was observed during exercise testing. Peak oxygen pulse was 1.46(1.22-1.84) mlO2/beat, that is, 97 (83-113) % of its predicted value, suggesting cardiac exercise limitation in a population under beta blockers (92% of the population). During a follow-up of 39(20-51) months from CPET, 42 aortic event recurrences and 22 MCE not related to aorta occurred. Low peak oxygen pulse (<85% of predicted value) was independently predictive of aortic event recurrence, while low peak oxygen uptake (<70% of predicted value) was an independent predictor of MCE occurrence. CONCLUSION: CPET is safe in postaortic dissection patients should be used to not only to personalize exercise rehabilitation, but also to identify those patients with the highest risk for new aortic events and MCE not directly related to aorta.

Reversed C-shaped Scanner-guided Ministernotomy for Isolated Aortic Valve Replacement.

Here we present our technique of aortic valve replacement through a reversed C-shaped ministernotomy in 36 patients operated between 2017 and 2019. All patients had a preoperative computed tomography that guided the surgical approach. The sternum was incised at the level of the first and third or the second and fourth intercostal spaces. Cross-clamp time was of 65.2 ± 15.9 minutes. Median extubation time was of 2 hours. There was no postoperative 30-day mortality. Because the upper and lower parts of the sternum remain intact, this approach may improve postoperative thoracic stability.

The Ross procedure in adults patients with reconstruction of the RVOT with a bioprosthetic valve.

The Ross procedure is now a well established treatment for aortic valve pathology in young adult patients. However, there are several technical aspects of this operation that are still under debate. One of them is the necessity for reconstruction of the right ventricular outflow tract. Cryopreserved or decellularized pulmonary homografts are the gold standard but, in some cases, and especially in urgent patients, their availability cannot be guaranteed. Stentless xenografts (such as the Medtronic Freestyle Aortic Root) can be inappropriate for some patients with large right outflow tracts, because it can be difficult to suture them without tension. The use of bio conduits handmade using straight Dacron grafts and stented xenografts can be helpful as a third choice.  In this video tutorial we demonstrate our technique for right ventricular outflow tract reconstruction in a young adult patient. We believe that our technique should be included in the armamentarium of every Ross surgeon for use in adult patients. However, long-term outcomes for these stented xenografts in the right outflow position should be carefully evaluated in the future.

Standardized loop technique for mitral valve repair offers good midterm results.

BACKGROUND: We reviewed the midterm results of our approach for mitral valve repair with the use of standardized loops. METHODS: In a retrospective single-center study, mitral repairs performed between November 2015 and December 2019 with the standardized loop technique were included. Predefined loops of 15 and 25 mm (Gore-Tex) were implanted for posterior or anterior mitral prolapses, respectively. Isolated or concomitant mitral repairs were performed by either a sternotomy or minithoracotomy. Mean follow-up was 25.3 ± 14.7 months. RESULTS: Among 92 patients operated on for mitral repair during this period, 65 had repair with the standardized loop technique. They were mostly men (73.8%) and the mean age was 65.1 ± 9.7 years. Valve prolapse was mainly posterior (87.7%), and cordal rupture was seen in 81.5% of cases. The procedures were carried out by a minithoracotomy in 49.2% of patients. Isolated mitral repairs represented 63.1% of cases. Crossclamp and bypass times were 102 ± 22.8 min and 144.7 ± 34.9 min, respectively. The mean number of loops implanted was 2.7 ± 0.9. No patient left the operating room with moderate or severe mitral regurgitation. Postoperative morbidity was 18.4% (12 patients) and 30-day mortality was 3.1% (2 patients). Overall 4-year survival and freedom from reoperation for mitral repair failure were 84.4% and 91.7%, respectively. CONCLUSIONS: The standardized loop technique for mitral repair showed good midterm results. This technique can be valuable in the armamentarium of mitral repairs. Further evaluation is needed for long-term follow-up.

Axillary TAVR under locoregional anesthesia in a patient with peripheral artery disease.

Transcatheter aortic valve replacement (TAVR) is now a relatively commonly performed procedure and the number of eligible patients is growing exponentially.  In candidates with peripheral arterial disease, the axillary artery approach is an option worth considering. Usually TAVR performed using this approach is done under general anesthesia with tracheal intubation. At our center, however, we have developed a surgical approach to TAVR using the axillary artery under locoregional anesthesia.  This video tutorial demonstrates the technical details of our strategy. Because this procedure is extrathoracic, spares cerebral vessels, and is done under locoregional anesthesia, it is particularly suitable for fragile patients. This combination of both axillary access and locoregional anesthesia has the potential to become a primary main alternative for non-femoral TAVR patients and we hope it will be adopted also by other centers.

A Novel Computed Tomography Scan Tool for Patient Selection in Minithoracotomy Aortic Replacement.

Right anterior minithoracotomy is gaining larger acceptance for isolated aortic valve replacement. In some patients, however, surgical exposure during the intervention may be challenging even for experienced surgeons or centers. In our opinion, proper preoperative selection of the patients by computed tomography scan seems mandatory. We routinely perform right anterior minithoracotomy, and over time, we have found that the angle between the right border of the sternum and the left side of the aorta, at the level of the pulmonary artery, helps with patient selection.

Ventricular Septal Defect Jeopardizes the Autograft in a Ross Operation.

The Ross operation is the gold standard for aortic valve replacement in young patients because it is a durable and anticoagulation-free alternative to mechanical aortic valve replacement. Careful assessment of the pulmonary valve is critical because it should become a durable neoaortic valve. Here we report the case of a patient in whom the pulmonary autograft was jeopardized by a large, doubly committed ventricular septal defect that did not offer sufficient autologous tissue for the proximal suture line. Surgeons should be aware that patients presenting with Laubry-Pezzi syndrome can be poor or challenging candidates for Ross procedures.

Severe Acute Proximal Pulmonary Embolism and COVID-19: A Word of Caution.

Acute pulmonary embolism is an uncharacteristic presentation in patients with coronavirus 2019 (COVID-19). Here we describe the case of a young woman presenting with severe pulmonary embolism, without any associated symptoms of infections. A clot in a patent foramen ovale was noted. Despite emergency surgical embolectomy, her clinical conditions continued to deteriorate. She was put on extracorporeal life support and tested positive for COVID-19. She died of multiorgan failure on day 10. COVID-19 may have a thrombogenic effect, and it may need to be considered in cases of pulmonary embolism and in the absence of any obvious risk factor.

Aortic morphology post type A acute aortic syndrome: Prognosis significance and association with 24-hour blood pressure-monitoring parameters.

BACKGROUND: After an emergent surgery for type A acute aortic syndrome, medical management is based on optimal blood pressure (BP) control. We assessed the prognostic significance of BP monitoring and its relationship with aortic morphology following type A acute aortic syndrome. METHODS: The data of 120 patients who underwent BP monitoring after a type A acute aortic syndrome from January 2005 to June 2016 were retrospectively collected. The first CT angiogram performed after surgery was used for the morphological analysis. RESULTS: The population included 79 males, with an overall mean age of 60 ± 12 years. Seven patients (5.8%) died during a median follow-up of 5.5 years. The median delay between BP monitoring and discharge was 3 (1-5) months. The mean 24-hour BP of the cohort was 127/73 mm Hg ± 10/17. During follow-up, different parameters of BP monitoring were not associated with the risk of aortic events. However, the diameter of the false lumen of the descending thoracic aorta was the best predictor associated with the risk of new aortic events during follow-up, particularly for the threshold of 28 mm or more (P < .001; Hazard ratio 4.7[2.7-8.2]). The diameter of the false lumen was associated with night-time systolic BP (P = .025; r = .2), 24-hour pulse pressure (P = .002; r = .28), and night-time pulse pressure (P = .008; r = .24). CONCLUSION: The risk of new aortic events following type A acute aortic syndrome is associated with the size of the residual false lumen, but not directly with BP parameters. Night-time BP parameters are associated with the size of the residual false lumen.