Modified transventricular and transaortic mitral valve edge-to-edge repair mimicking MitraClip overcorrection.

Objective: In the current study, we present our mid-term experience with modified edge-to-edge repair technique through a transventricular and transaortic route in patients requiring left ventricular remodeling or aortic root/valve surgery. Methods: From December 2006 through April 2015, 49 high-risk patients (median age: 69 years; median European System for Cardiac Operative Risk Evaluation II: 11.4 [6.54-14.9]) underwent transventricular (N = 7; 14%) or transaortic (N = 42; 86%) edge-to-edge mitral valve repair. The Alfieri stitch technique was modified by MitraClip type overcorrection and solid buttressing behind the posterior leaflet. Indication was grade 2+ functional mitral valve incompetence and dilated or impaired left ventricle (N = 25; 52%), or grade 3+ (N = 22; 45%) and grade 4+ functional mitral valve regurgitation (N = 2; 4%). Surgical procedure included aortic root surgery in 65%, aortic valve replacement with surgical revascularization in 18%, and Dor-plasty with surgical revascularization in 14%. Results: Intraoperative mortality and early neurologic complications were absent in our series. Ninety-day mortality was 12.2% (N = 6). Median clinical and echocardiographic follow-up-time was 50.7 (21.5-44.1) and 39.2 (33.7-44.1) months, respectively. Median postoperative transvalvular gradient was low (2.72 [1.91-4.22] mm Hg) and did not increase during follow-up (P = .268), although peak gradient rose slightly from 7.41 to 8.12 mm Hg (P = .071). The actuarial reoperation free rate at the index valve was 96.8%. Conclusions: Transventricular or transaortic Alfieri mitral repair mimicking mitral clip overcorrection represents a quick and safe technique in the setting of high-risk patients undergoing left ventricular remodeling or aortic root/valve surgery and can be performed with low risk of creating mitral stenosis at midterm. The technique is straightforward, with reliable identification of the center of the valve leaflets being the limitation.

Mitral Valve Surgery via Upper Ministernotomy: Single-Centre Experience in More than 400 Patients.

Background: Minimally invasive mitral valve (MV) surgery has emerged as an alternative to conventional sternotomy aiming to decrease surgical trauma. The aim of the study was to describe our experience with minimally invasive MV surgery through partial upper sternotomy (PUS) regarding short- and long-term outcomes. Methods: From January 2004 through March 2014, 419 patients with a median age of 58.9 years (interquartile range 18.7; 31.7% females) underwent isolated primary MV surgery using PUS. Myxomatous degenerative MV disease was the predominant pathology (77%). The patients' mean EuroSCORE II risk profile was 3.9 ± 3.6%. Results: Mitral valve repair was performed in 384 patients (91.6%) and replacement in 35 patients (8.4%). Thirty-day mortality was 3.1%. In total, 29 (6.9%) deaths occurred during the follow-up. The overall estimated survival at 1, 5, and 10 years was 93.1 ± 1.3%, 87.1 ± 1.9%, and 81.1 ± 3.4%. Reoperation was necessary in 14 (3.3%) patients. The overall freedom from MV reoperation at 1, 5, and 10 years was 98.2 ± 0.7%, 96.1 ± 1.2%, and 86.7 ± 6.7% and the overall freedom from recurrent MV regurgitation > grade 2 in repaired valves at 1, 5, and 10 years was 98.8 ± 0.6%, 98.8 ± 0.6%, and 94.6 ± 3.3%. Conclusions: Minimally invasive MV surgery via PUS can be performed with particularly good early and late results. Thus, the PUS approach with the use of standard surgical instruments and cannulation techniques can be a valuable option for the MV surgery either in patients contraindicated or not suitable to minithoracotomy.

An Incomplete Form of Shone's Complex With Double Orifice Mitral Valve.

We present the case of an adult male patient with an incomplete form of Shone's complex associated with bicuspid aortic valve and a double orifice mitral valve. Intraoperative inspection of the mitral valve showed double orifice configuration with a small, rudimentary left-sided mitral valve and a large, dominant, right-sided parachute mitral valve with Barlow-type of degeneration. The patient underwent reconstruction of both valves through a minimally invasive incision. At one year echocardiographic control both valves function normally.

Aortic Valve Repair for Aortic Insufficiency or Dilatation: Technical Evolution and Long-term Outcomes.

BACKGROUND: Aortic valve repair (AVR) is an attractive alternative to valve replacement for the treatment of aortic valve insufficiency. Here we report on the midterm outcomes after AVR for aortic valve insufficiency with an emphasis on durability of repair. METHODS: Between 1996 and 2017, 560 consecutive patients (mean age, 57 ± 16 years) underwent various AVR procedures on tricuspid (n = 415, 74%) and bicuspid (n = 145, 26%) aortic valves. In 313 patients (56%) the David procedure was performed, whereas in 247 patients (44%) cusp repair without aortic root procedure was conducted. Concomitant procedures were coronary artery bypass grafting in 82 patients (15%) and mitral valve repair in 47 patients (8%). Clinical and echocardiographic follow-up was complete in 97% of patients. Mean follow-up was 6.3 ± 4.6 years. RESULTS: Thirty-day mortality was 1.4% (n = 8). Late mortality was observed in 132 patients with cardiovascular events accounting for mortality in 13 patients: Survival at 10 years was 70%. Reoperation on the aortic valve was performed on 39 patients for recurrent insufficiency, isolated in 25, or combined with valve stenosis in 5 patients; endocarditis accounted for reoperation in 9 patients (0.2% per patient-year). Freedom from reoperation was 88% at 10 years. Cumulative linearized incidence of all valve-related complications was 2% per patient per year. CONCLUSIONS: AVR for insufficiency is a durable procedure with low valve-related morbidity and mortality in the midterm.

Propensity-matched comparison between minimally invasive and conventional sternotomy in aortic valve resuspension.

OBJECTIVES: The aim of the study was to compare the results of David procedure through conventional or minimally invasive approach. METHODS: A propensity-matched comparison in patients undergoing a minimally invasive (partial upper sternotomy, n = 103) or complete sternotomy (n = 103) David procedure from 1991 to 2016 was performed. Patients were 57 ± 14 years old on average in both groups. The David technique was modified by generating a neosinus (P < 0.01) in 99 (96%) patients (minimally invasive group) and in 42 (41%) patients (complete sternotomy group), respectively. The average follow-up time was 3 ± 2 years (minimally invasive group) and 8 ± 4 years (complete sternotomy group). RESULTS: There was only 1 in-hospital death (in the full sternotomy group, P = 0.5). The applied quantity of packed red blood cells (pRBC) was significantly higher in the complete sternotomy group (3.4 ± 4 vs 1 ± 0.5, P < 0.01). There were no late deaths in the minimally invasive group but 14 died during a longer follow-up period in the full sternotomy group (P < 0.01). Freedom from reoperation or aortic valve insufficiency ≥2° was 95% vs 93% (minimally invasive versus complete sternotomy group) at 5 years and 95% vs 79% at 10 years (P < 0.01). CONCLUSIONS: The minimally invasive aortic valve reimplantation procedure for selected patients with aortic root aneurysm and aortic valve incompetence is a durable procedure with minor valve-related morbidity and mortality at the mid-term follow-up. The intra- and perioperative application of pRBC was significantly lower in the minimally invasive group. However, comparison of long-term follow-up data in both groups is necessary to evaluate valve function.

Midterm Results of a Minimally Invasive Approach in David Procedure.

BACKGROUND: The David procedure is a well-known technique in selected patients with aortic root pathology. A minimally invasive approach in heart surgery increases open interest. METHODS: From 1991 to 2015, the David technique was performed in 296 patients in our unit. In 90 cases, operations were performed through partial upper sternotomy. The patient mean age was 57 ± 14 years in the minimally invasive group (n = 90) and 58 ± 14 years in the complete sternotomy group (n = 206; p = 0.2). The neosinus modification was performed in 80 patients (89%) in the minimally invasive group and in 79 patients (38%) in the complete sternotomy group (p < 0.01). Mean follow-up was 3 ± 2 years in the minimally invasive group and 8 ± 4 years in the complete sternotomy group. RESULTS: Thirty-day mortality was zero in the minimally invasive group and was 3% (n = 6) in the complete sternotomy group (p = 0.1). The need for packed red blood cells was significantly lower in the minimally invasive group (1.6 ± 3 U) than in the complete sternotomy group (3.7 ± 6 U; p < 0.01). Thirty late deaths (2% per patient-year) were observed in the complete sternotomy group versus zero in the minimally invasive group (p < 0.01). One patient (0.5% per patient-year) in the minimally invasive group and 12 patients (0.8% per patient-year) in the complete sternotomy group required reoperation in the follow-up period (p = 0.05). CONCLUSIONS: Minimally invasive David technique for patients with ascending aortic aneurysm and aortic valve insufficiency offers a good solution with low perioperative blood transfusion rate. Our midterm results show low valve-related complications and reoperation rate. However, long-term follow-up of the minimally invasive group is necessary.

Triple valve surgery through a less invasive approach: early and mid-term results.

OBJECTIVES: A partial upper sternotomy has become established as a less invasive approach mainly for single and double valve surgery. This report evaluates the clinical outcomes of triple valve surgery performed through a partial upper sternotomy. METHODS: We reviewed the medical records of 37 consecutive patients (28 men, 76%) who underwent triple valve surgery through a partial upper sternotomy between 2005 and 2015. The patients' mean age was 67 ± 17 years; 27 (73%) were in New York Heart Association Class III or IV. Aortic and mitral valve insufficiency was more common than stenosis. Ninety-three percent of surviving patients were followed for a mean period of 58 ± 24 months. RESULTS: Aortic valve procedures consisted of 24 (65%) replacements and 13 (35%) repairs. The mitral valve was repaired in 28 (76%) patients, whereas tricuspid valve repair was feasible in all patients. No conversion to full sternotomy was necessary. Myocardial infarction was not observed. Chest tube drainage was 330 ± 190 ml, and 4 patients required reopening for bleeding (1, 3%) or tamponade (3, 8%). One stroke was observed due to heparin-induced thrombocytopaenia after initial unremarkable neurological recovery. Early mortality included 5 (13.5%) patients. Actuarial survival at 5 years was 52 ± 10%. CONCLUSIONS: A partial upper sternotomy provides adequate exposure to all heart valves. We did not experience technical limitations with this approach. Wound dehiscence, postoperative bleeding, intensive care unit and hospital stay and early deaths were low compared to data from other published series of triple valve surgery through a full median sternotomy. Early and mid-term outcomes were not adversely affected by this less invasive approach.

Long-Term Results Following Pericardial Patch Augmentation for Incompetent Bicuspid Aortic Valves: A Single Center Experience.

BACKGROUND: Many techniques for repair of bicuspid aortic valves have been described and long-term results differ considerably. The current study evaluates our institutional results using the pericardial patch augmentation technique with the aim of increasing coaptation height. METHODS: From November 2002 through April 2015, 103 consecutive patients underwent aortic valve repair using pericardial patch augmentation for incompetent bicuspid aortic valve. Of them 26 were referred with an aortic valve regurgitation grade 1+ or 2+ and were excluded from the current report. The remaining 77 patients with a mean age of 42 ± 14 years and aortic valve regurgitation grade of 3+ or higher were included in this retrospective single-center study. The main step of operative technique is the partial correction of leaflet prolapse by leaflet plication and overcorrection of coaptation height augmenting the fused leaflet with an autologous pericardial patch. In 45 patients (58%) an isolated aortic valve repair was performed. The ascending aorta was dilated in 32 cases (42%), and the following procedures were used for correction: reduction aortoplasty (19 patients), the David procedure (11 patients), and ascending aortic replacement (2 patients). Long-term results were evaluated by echocardiography and standardized questionnaire. Mean follow-up was 4.9 ± 4.6 years. RESULTS: There was no perioperative or 90-day mortality. Survival at 5 and 10 years was 96.1% and 93.5%, respectively. Freedom from reoperation at 5 and 10 years was 94.8% and 93.5%, respectively. At the latest echocardiographic follow-up, 94% of patients had none to trivial aortic regurgitation and 6% showed aortic regurgitation greater than or equal to 2°. Mean aortic gradients were 12.6 ± 9 mm Hg. One patients developed endocarditis 1 year after the procedure. There were no perioperative or long-term major neurologic events. CONCLUSIONS: The pericardial patch augmentation technique provides reliable long-term competence of reconstructed bicuspid aortic valves and results in a low reoperation rate, with other valve related complications being rare.

A 17-year, single-centre experience with the Ross procedure: fulfilling the promise of a durable option without anticoagulation?

OBJECTIVES: For adult patients <60 years with aortic valve disease, the Ross procedure is an attractive alternative to a prosthetic aortic valve. The Ross procedure enables surgeons to achieve a haemodynamically ideal aortic valve replacement. A potential drawback may be long-term durability, which varies considerably between series. METHODS: Between 1996 and 2014, 209 patients (mean age, 43 ± 10 years) underwent an elective Ross procedure in our department. In 78% (n = 161) of patients a bicuspid valve was found. Patients were examined clinically and with echocardiography during the follow-up. The mean follow-up was 7.9 ± 5 years and was 98% complete. RESULTS: The 30-day mortality rate was 2.4% (n = 5). The Kaplan-Meier survival rates at 10 and 15 years were 91 and 85%, respectively. In 17 patients (8.3%) the pulmonary autograft had to be reoperated on: 12 of them could be repaired; only 5 patients finally underwent prosthetic valve replacement. The rate of freedom from reoperation for autograft failure was 93% and that from reoperation or moderate autograft regurgitation was 87% at 10 years. Thromboembolic events occurred in 9 patients (0.54%/patient-year) and were mostly related to atrial fibrillation. Endocarditis involving the pulmonary autograft was observed in 6 patients (0.36%/patient-year). CONCLUSIONS: Pulmonary autograft aortic root replacement to treat patients with severe aortic valve dysfunction is a challenging procedure. The reoperation rate is higher compared with mechanical valve replacement; however, in the majority of patients with reoperations in our series the autograft could be saved. Other valve-related complications are rare.

Long-term results of the David Procedure in patients with acute type A aortic dissection.

INTRODUCTION: The David Procedure may provide an attractive alternative to aortic root replacement in patients with aortic valve insufficiency (AI) even in the emergency setting of an acute type A aortic dissection (AAD). METHODS: From 1996 to 2011 the David Procedure was performed in 23 patients with AAD in our department. Patients' mean age was 49 ± 15 years and 70% (n = 16) were male. Concomitant hemiarch replacement was performed in 19 patients while the remaining 4 patients underwent full arch replacement. Additional leaflet prolapse was corrected by plication in 5 cases. A modification of the classic David technique was performed by creating a pseudosinus in 6 patients (26%) and a neosinus in 9 patients (39%). Mean follow up was 7.7 ± 3 years. RESULTS: Thirty-day mortality was zero. There were 4 late deaths (17%). One patient suffered a perioperative neurologic event (4%). One further patient suffered a late stroke during follow up (0.6%/pt-yr). Three patients (1.7%/pt-yr) required aortic valve reoperation during follow up: in 2 cases leaflet perforation was observed, and one patient had to undergo valve replacement because of endocarditis with severe AI. There were two cases of bleeding events (1.1%/pt-yr) at follow up. The linearized rate for recurrent AI ≥ 2° was 1.1%/pt-yr. DISCUSSION: The David Procedure certainly provides a challenging option to treat selected young patients with AI in the presence of AAD. However, current data suggest that it is safe and feasible. CONCLUSIONS: Long-term valve-related events of the David Procedure applied in emergency cases are rare and aortic valve function remains stable for many years.

Aortic valve reimplantation for aortic root aneurysms: trainer and trainee differences on long-term results.

PURPOSE: The advantages of aortic valve-preserving surgery are still hampered by a higher rate of reoperations compared to root replacement with valved conduits. This study evaluates whether valve deterioration rate is related to the method or depends on stringent adherence to technical concepts, which might be lost once trainees perform this complex surgery on their own. METHODS: From 1991 to 2011, the David procedure was performed in 209 consecutive patients. Mean age was 57 ± 14 years. The patients were operated either by the senior author or trainees under his supervision (group 1, n = 130) or by surgeons on their own after training by the senior author (group 2, n = 79). Clinical and echocardiography data were evaluated pre- and postoperatively and at follow-up (mean 6.0 ± 4 years). RESULTS: In-hospital mortality was 1.5 % in group 1 and 5 % in group 2 (p = 0.29), and late mortality was 12 % (n = 12 in group 1 and n = 14 in group 2, p = 0.11), three were cardiac related. Nine patients (4.3 %) had to be reoperated; three for endocarditis in group 1, six for structural valve deterioration in group 2 (p = 0.14). The 9-year freedom from reoperation or aortic valve insufficiency (AI) ≥2° was 93 % in group 1 and 78 % in group 2 (p < 0.01). As groups showed differences in preoperative variables, results were compared also in a propensity matched subgroup. Despite no difference in perioperative results, long-term valve competence remained inferior in group 2. CONCLUSIONS: With stringent adherence to technical concepts, structural valve deterioration may virtually be considerably reduced in aortic valve reimplantation. Once performing this operation on their own, trainees-after training by the senior-achieved results as independent surgeons well comparable to published series. As long-term performance seems to depend more on judgment of the geometry achieved intraoperatively than on technical steps, a means of measurement of effective coaptation height with a caliper might facilitate evaluation of perfect repair.

Long-term results of aortic valve resuspension in patients with aortic valve insufficiency and aortic root aneurysm.

OBJECTIVES: 'The David technique' may provide an alternative to conduit implantation in patients with an aneurysm of the ascending aorta and aortic valve insufficiency. METHODS: From 1991 to 2013, the David technique was performed in 249 consecutive patients in our department. The patient mean age was 58 ± 14 years; 71 (29%) were female and 178 (71%) male. A modification of the David technique was performed by creating a pseudosinus in 43 patients (17%) and by creating a neosinus in 123 patients (49%). The mean follow-up was 6 ± 4.5 years. RESULTS: There were six in-hospital (2.4%) and 30 late deaths (2.4%/patient-year). Cardiac-related events were the cause of death in three patients. The Kaplan-Meier estimate for 10 years survival was 77%. Four patients had perioperative neurological events, and only eight neurological events occurred during follow-up (0.6%/patient-year). Ten patients (0.8%/patient-year) required aortic valve replacement; one because of combined aortic valve stenosis and insufficiency and nine because of severe aortic valve insufficiency as a result of leaflet prolapse (n = 3), leaflet perforation (n = 1), abridgement of the right coronary leaflet (n = 1) and because of endocarditis (n = 4). Three cases of bleeding were observed (0.24%/patient-year). Freedom from reoperation or aortic valve insufficiency ≥2° was 80% at 10 years. CONCLUSIONS: Aortic valve sparing to treat patients with an ascending aortic aneurysm with aortic valve insufficiency is a durable procedure. Aortic valve function remains stable for many years. Valve-related complications are rare, and the rate of reoperations is not increased in comparison to conduit root replacement.

Comparison between homografts and Freestyle® bioprosthesis for right ventricular outflow tract replacement in Ross procedures.

OBJECTIVES: Although data from large series indicate the satisfactory performance of bioprosthetic valves in the right ventricular outflow tract (RVOT), replacement of the pulmonary valve in adult patients undergoing the Ross procedure is usually performed with pulmonary allografts. We evaluated the outcomes of homografts vs. bioprosthetic RVOT replacement after the Ross procedure in adults. METHODS: Between 1996 and 2011, a total of 186 adult patients (141 male; mean age 44 ± 10 years) underwent aortic root replacement with a pulmonary autograft. The RVOT was replaced with a homograft in 113 patients and with stentless bioprostheses (Medtronic Freestyle(®)) in 73. Patients were followed for a mean of 6 years (range 1-15 years; 1106 patient years). RESULTS: Twelve patients required reintervention owing to dysfunction of the RVOT replacement, which was caused by endocarditis (n = 4), degeneration (n = 2) or stricture at the proximal suture line (n = 6). For homografts, the incidence of reintervention was 1 in 150 patient years, compared with 1 in 36 patient years for stentless bioprostheses (P = 0.007). The median gradient was 15 mmHg for the homograft group and 24 mmHg for bioprosthesis (P < 0.0001). The incidence of gradients >40 mmHg was 10-fold higher in the bioprosthetic group. CONCLUSIONS: Patients with bioprostheses in the RVOT position after the Ross procedure showed a significantly higher risk of reintervention or pulmonary valve dysfunction. The main problem, early development of a stricture at the proximal suture line, has to be solved to achieve satisfactory bioprosthetic function in the RVOT.

Long-term results and cusp dynamics after aortic valve resuspension for aortic root aneurysms.

BACKGROUND: This study reports our 10-year experience with the David technique and technical modifications to create neosinuses. METHODS: From January 1996 to February 2009, the David procedure was performed in 151 consecutive patients in our department. Mean age was 59 ± 13 years (range, 22 to 78 years). All patients had ascending aortic aneurysm (mean diameter, 6.0 ± 1.1 cm); 59 patients had additional arch aneurysm. Fifty-four patients underwent the standard David procedure, with a pseudosinus created in 42 patients (28%) and neosinuses in 55 patients (36%) by plicating the base and sinotubular junction of the tube graft. Patients were followed up prospectively and had echocardiography studies before discharge and at follow-up. Mean follow-up was 5 years (584 patient-years). RESULTS: There were 6 in-hospital and 16 late deaths. Reexploration for bleeding was necessary in 27 patients (17%). Three patients had perioperative neurologic events, and 2 patients experienced them during follow-up. Five patients required late aortic valve replacement. Cardiovascular events were the cause of late death in 6 patients. Valve gradients were low, with only 2 patients having significant valve incompetence remaining. Echocardiography results showed a more physiologic, reduced velocity of cusp movement in the neosinus group compared with the conventional technique. CONCLUSIONS: Aortic valve resuspension is a durable procedure. Only 4.8% experienced a relevant valve dysfunction. Other valve-related complications were minimal, with three observed neurologic events and one endocarditis. Creation of the neosinus lead to more physiologic leaflet dynamics and facilitated geometric adaptation.

Sutureless Aortic Valve Replacement via Partial Sternotomy.

OBJECTIVE: : For elderly patients with symptomatic aortic valve stenosis, aortic valve replacement with tissue valves is still the treatment of choice. Stentless valves were introduced to clinical practice for better hemodynamic features as compared with stented tissue valves. However, the implantation is more complex and time demanding, especially in minimal invasive aortic valve replacement. We present our clinical data on 22 patients having received a sutureless ATS 3f Enable aortic bioprosthesis via partial upper sternotomy. METHODS: : The procedure was performed using CPB with cardioplegic arrest. After resection of the stenotic aortic valve and debridement of the annulus, the valve was inserted and released. Mean age was 79 years, and mean logistic Euroscore was 13. Subvalvular myectomy was performed in two patients. Prosthetic valve sizes were 19 mm (n = 1), 21 mm (n = 7), 23 mm (n = 6), 25 mm (n = 6), and 27 mm (n = 2). RESULTS: : Implantation of the valve required 10 ± 6 minutes. Cardiopulmonary bypass and aortic crossclamp time were 87 ± 16 and 55 ± 11 minutes, respectively. Early mortality (<90 days) was 9% (2 patients). No paravalvular leakage was detected intraoperatively or in follow-up echocardiography. The mean transvalvular gradients were 9 ± 6 mm Hg at discharge and 8 ± 2 mm Hg at 1-year follow-up. CONCLUSIONS: : Sutureless valve implantation via partial sternotomy is feasible and safe with the ATS 3f Enable bioprosthesis. Reduction of cardiopulmonary bypass and aortic crossclamp time seems possible with increasing experience. Hemodynamic data are very promising with low gradients at discharge and after 12 month. Sutureless valve implantation via minimal invasive access may be an alternative treatment option for elderly patients with high comorbidity.

Impact of left atrial size reduction and endocardial radiofrequency ablation on continuous atrial fibrillation in patients undergoing concomitant cardiac surgery: three-year results.

BACKGROUND AND AIM OF THE STUDY: The study aim was to evaluate the efficacy of left atrial (LA) size reduction combined with radiofrequency (RF) ablation in the treatment of continuous atrial fibrillation (AF), by comparative analysis of the outcomes of patients undergoing RF ablation with and without LA size reduction. METHODS: A total of 46 patients with continuous AF and cardiac disease underwent cardiac surgery and RF ablation alone (group I, n = 20) or combined with LA size reduction (group II, n = 26). Patients were followed for three years postoperatively, with evaluation of cardiac rhythm, neurological complications, LA size (by echocardiography) and atrial contractility. RESULTS: At three years after surgery, sinus rhythm (SR) was restored in 61.1% and 70% of patients in groups I and II, respectively. Mean LA diameter was reduced from 60 +/- 15 mm to 57 +/- 5 mm in group I, and from 69 +/- 19 mm to 55 +/- 6 mm in group II. The overall three-year survival was 90% in group I, and 88.5% in group II. Three-year freedom from stroke was 88.9% and 86.2% in groups I and II, respectively. Two patients in each group received transvenous permanent pacemaker implantation. Atrial contractility was recovered in all patients with stable SR. CONCLUSION: LA size reduction improves SR conversion rate after RF ablation for continuous AF in patients undergoing concomitant cardiac surgery.

Seven years' experience with suture annuloplasty for mitral valve repair.

OBJECTIVE: Our early experience with the mural annulus shortening suture procedure for mitral valve repair showed superior hemodynamic performance over ring annuloplasty. The aim of this study was to assess the durability of the mural annulus shortening suture procedure and evaluate our 7-year experience regarding valve function, hemodynamic performance, and clinical outcome. METHODS: Between 1996 and 2003, 222 elective consecutive patients (58.1% males; age, 59 +/- 14 years) underwent simple or complex mitral valve repair. Minimal invasive reconstruction was performed in 150 patients. For correction of annular dilatation, we used double-running 2-0 polytetrafluoroethylene sutures to reinforce the posterior circumference of the annulus. Patients were investigated prospectively by means of transthoracic echocardiography before discharge and 1 and 5 years after the operation. The mean follow up was 32 +/- 21 months (range 1-77 months). RESULTS: The operative mortality was 3.1%. Hemodynamic performance at 1 and 5 years showed low mean transvalvular gradients (2.1 +/- 0.9 and 2.0 +/- 0.8 mm Hg, respectively) and a calculated mitral valve orifice area of 3.3 +/- 0.9 cm2 and 3.1 +/- 0.6 cm2, respectively, with progressive annular dilatation from 31.2 +/- 3 mm to 33.9 +/- 4 mm at 1 year and 35.7 +/- 4 mm at 5 years (P < .01). Clinical status improved from New York Heart Association class 3.0 +/- 0.4 to 0.6 +/- 0.8 at 1 year and 0.8 +/- 0.8 at 5 years. Freedom form nontrivial residual mitral regurgitation was 82.3%, freedom from reoperation was 95.1% and actuarial survival was 87.2%, all at 77 months. CONCLUSIONS: The midterm results show satisfactory hemodynamic performance and clinical improvement. Valve competence and reoperation rates are comparable with those of other reports. Durability of the mural annulus shortening suture procedure for mitral valve repair is questioned because progressive annular redilatation occurs.

Pericardial patch augmentation for reconstruction of incompetent bicuspid aortic valves.

PURPOSE: Reoperation rates after repair of bicuspid aortic valves are higher than for mitral valve reconstruction. Secondary changes and small coaptation surface render repair unreliable. Satisfactory results have been reported for patch augmentation for tricuspid aortic valves. We have applied this technique for the repair of bicuspid aortic valves. DESCRIPTION: Our technique retains the bicuspid morphology of the incompetent aortic valve. A strip of glutaraldehyde-fixed pericardium is sutured to the free edge of the fused leaflet. A large coaptation surface is created, and competence of the bicuspid valve is achieved. EVALUATION: Sixteen patients underwent reconstruction of their bicuspid aortic valves by pericardial patch augmentation. There were no intraoperative or postoperative deaths. The degree of aortic regurgitation was none to trivial for all patients at a mean follow-up of 3.1 +/- 3.4 months. Planimetric effective orifice areas ranged above 2 cm2. Mean aortic gradients were 8.2 +/- 4.8 mm Hg, and the mean height of coaptation surface was 14.7 +/- 2.1 mm. CONCLUSIONS: The pericardial patch augmentation technique increases coaptation surface, and thus provides reliable early competence of reconstructed bicuspid aortic valves.

Echocardiographic assessment in minimally invasive mitral valve surgery.

BACKGROUND: Due to limited exposure, removal of intracavitary air and visual assessment of cardiac function during minimally invasive procedures are not always possible. We analysed the utility of intraoperative transesophageal echocardiography (TEE) and postoperative transthoracic echocardiographic (TTE) in minimally invasive mitral valve (MV) procedures. MATERIAL/METHODS: We evaluated data from 163 consecutive patients undergoing isolated minimally invasive MV replacement (n=40) or repair (n=123) via small right anterolateral thoracotomy (121 complex mitral procedures). Cardioplegic arrest was achieved using either endoaortic (n=23) or transthoracic aortic clamp (n=140). In addition to preoperative TTE, TEE was used intraoperatively before and after cardiopulmonary bypass (CPB). Postoperative TTE was performed to monitor valve function at 3 and 12 months, and at 5-year follow-up. RESULTS: Pre-CPB TEE was useful to assess valve dysfunction and assist in placement of the arterial and venous cannulas. During CPB, placement and positioning of the endoclamp were guided effectively in all but 4 patients, in whom recurrent balloon migration necessitated secondary transthoracic aortic clamping. TEE detected one acute retrograde aortic dissection and one circumflex artery occlusion. After 18.7+/-10.6 months follow-up, all patients except three improved symptomatically and had consistently good valve function. CONCLUSIONS: Intraoperative TEE is essential for minimally invasive MV surgery, because it allows immediate control of valve function before and after surgery. It is useful to detect unexpected complications requiring immediate remedy. Postoperative echocardiographic results show that minimally invasive MV surgery is a good alternative to conventional surgery even in complex MV repairs.

Aortic leaflet replacement with the new 3F stentless aortic bioprosthesis.

PURPOSE: Clinical trials with the new 3F stentless aortic bioprosthesis began October 2001, and as one of the first centers to implant this prosthesis in humans, we would like to present our experiences with this new device. DESCRIPTION: The 3F aortic bioprosthesis is a stentless biological heart valve fabricated from three equal leaflets of equine pericardium, assembled in a tubular shape, and implanted in the native aortic root to replace the patient's diseased aortic leaflets. Between January 2002 and August 2002, 24 3F aortic bioprostheses were implanted at our institution. Effective orifice area, mean gradients, and ejection fraction were evaluated by echocardiography at discharge and at 12-month follow-ups after surgery. EVALUATION: At 12-month follow-ups, the 3F bioprosthesis showed a good hemodynamic performance with a significant drop of mean gradients to 10.3 mm Hg, a mean effective orifice area of 1.7 cm2, and a mean ejection fraction of 61.5%. CONCLUSIONS: The clinical performance of the new 3F aortic bioprosthesis is comparable with regular stentless aortic valves. However its unique design facilitates implantation.