Minimum-incision transsubclavian transcatheter aortic valve replacement with balloon-expandable valve for dialysis patients.

BACKGROUND: Dialysis patients undergoing transcatheter aortic valve replacement (TAVR) face increased risk and have poorer outcomes than non-dialysis patients. Moreover, TAVR in dialysis patients using an alternative approach is considered extremely risky and little is known about the outcomes. We routinely perform minimum-incision transsubclavian TAVR (MITS-TAVR), which is contraindicated for transfemoral (TF) TAVR. This study aimed to evaluate the outcomes of MITS-TAVR compared with those of TF-TAVR in dialysis patients. METHODS: This single-center, observational study included 79 consecutive dialysis patients who underwent MITS-TAVR (MITS group, n = 22) or TF-TAVR (TF group, n = 57) under regional anesthesia. RESULTS: The rates of peripheral artery disease (MITS vs. TF, 72.7 % vs. 26.3 %; p < 0.01), shaggy aortas (MITS vs. TF, 63.6 % vs. 5.26 %; p < 0.01), and tortuous aortas (MITS vs. TF, 13.6 % vs. 1.75 %; p = 0.031) were significantly higher in the MITS group. The 30-day mortality was 2.53 % and comparable between the two groups (MITS vs. TF, 4.54 % vs. 1.75 %; p = 0.479). In the MITS group, 14 patients had ipsilateral dialysis fistulas, and three patients had patent in situ ipsilateral internal thoracic artery grafts; however, no vascular complications were observed. Kaplan-Meier survival curves for the two groups showed no significant difference in the survival rate (at 2 years; MITS vs. TF, 77.3 % vs. 68.8 %; p = 0.840) and freedom from cardiovascular mortality (at 2 years; MITS vs. TF, 90.9 % vs. 96.5 %; p = 0.898). The multivariable Cox proportional hazard model also indicated that survival in the MITS group was not significantly different from that in the TF group (hazard ratio 1.48; 95 % confidence interval, 0.77-2.85, p = 0.244). The patency rate of ipsilateral dialysis fistula was 100 % during follow-up. CONCLUSION: The outcome of MITS-TAVR was comparable to that of TF-TAVR in dialysis patients, despite the higher risk of patient characteristics.

Impact of left atrium plication on chronic heart failure with atrial functional mitral regurgitation.

Purpose: We hypothesized that a giant left atrium may oppress  the posterior left ventricle and aggravate diastolic dysfunction and heart failure. We evaluated the effect of left atrial plication (LAP) on atrial functional mitral regurgitation. Methods: We retrospectively reviewed patients who underwent LAP for atrial functional mitral regurgitation at our institution between January 2017 and December 2021. Early outcomes, follow-up echocardiography data, and heart failure indicators were compared. Results: Eighteen patients were divided into two groups: LAP + (n = 9) or LAP- (n = 9). There were no significant differences in patient characteristics and preoperative echocardiographic parameters, except for the preoperative New York Heart Association classification. Operative (505.7 [standard deviation: 100.0] minutes vs. 382.9 [standard deviation: 58.1] minutes, P = .0055) and cardiopulmonary bypass times (335.6 [standard deviation: 50.4] minutes vs. 246.9 [standard deviation: 62.7] minutes, P = .0044) were significantly longer in the LAP + group. No in-hospital mortalities were observed in both groups. The postoperative left atrial volume was significantly reduced in the LAP + group, and mitral regurgitation was controlled at less than mild levels in both groups. At follow-up, the left ventricular end-diastolic volume was reduced significantly in the LAP + group. Brain natriuretic peptide, cardiothoracic ratio, and the New York Heart Association classification were improved in the LAP + group. Conclusions: Additional left atrial plication contributes to the control of atrial functional mitral regurgitation and heart failure at a later stage. A careful long-term follow-up is needed as re-expansion of the left atrium is possible. Supplementary Information: The online version contains supplementary material available at 10.1007/s12055-023-01569-6.

Long-term outcomes of left ventricular posterior wall plication for ischemic mitral regurgitation.

Purpose: To evaluate the early and long-term outcomes of left ventricular posterior wall plication for ischemic mitral regurgitation. Methods: Patients with ischemic mitral regurgitation who underwent left ventricular posterior wall plication via right-sided left atriotomy at our institution between 2010 and 2020 were retrospectively reviewed. Cases with normal cardiac function, left ventricular end-systolic diameter < 50 mm, and left ventriculotomy approach were excluded. Results: The mean follow-up period was 5.3 years [standard deviation (SD) = 3.5], with a maximum of 10 years. Among the 21 patients enrolled, 9 had New York Heart Association (NYHA) class ≥ III. Three patients required preoperative inotrope support, while two preoperative ventilator support. The mean left ventricular ejection fraction was 31.4% (SD: 8.6), and 16 patients had mitral regurgitation grade ≥ III. All patients underwent coronary artery bypass grafting and mitral annuloplasty. Concomitant surgeries included 11 chordae cutting and 3 tricuspid annuloplasties. One in-hospital death occurred due to sepsis. At the follow-up, echocardiographic data showed significant improvement in cardiac dilation and function and good control of mitral regurgitation. The serum brain natriuretic peptide level was significantly reduced, and 85% of patients improved to NYHA class I. Four deaths occurred later due to sudden, unknown causes. The 5- and 8-year survival rates were 60.2% and 46.8%, respectively, and the 5- and 8-year hospitalization rates due to heart failure were 14.9% and 21.3%, respectively. Conclusion: The long-term outcomes of left ventricular posterior wall plication were satisfactory for controlling heart failure and improving survival rate and patient prognosis. Supplementary Information: The online version contains supplementary material available at 10.1007/s12055-023-01527-2.

Proximal dislocation of a sutureless Perceval valve after the second aortic valve replacement.

Sutureless aortic valve replacement is a widely used technique that facilitates short cross-clamping time and has excellent hemodynamic outcomes. However, it is associated with paravalvular leakage or migration risk. We report a surgical case using a sutureless aortic valve replacement in a 74-year-old male patient with a history of previous aortic valve replacement. He underwent redo aortic valve replacement with the Perceval valve (Corcym Canada Corp, Vancouver, Canada), which got dislocated with moderate-to-severe aortic paravalvular leakage at 3 months after implantation. Our observations suggested that redo aortic valve replacement using a sutureless aortic valve can cause valve dislocation as it might be difficult to clearly remove calcification and excess tissue and implant the valve to crimp on the annulus precisely. This report also highlights the challenges of performing repeat aortic valve replacement after explanting the Perceval valve, which includes the aortotomy height and annulus identification. Although the Perceval valve can help improve patient prognosis, careful implantation and thorough follow-up examinations are warranted.

Noncommunicating acute type A aortic dissection in elderly patients: Surgery versus medical management.

OBJECTIVES: Our goal was to evaluate the surgical and conservative outcomes of acute type A aortic dissection with a thrombosed false lumen of the ascending aorta in elderly patients. METHODS: Patients older than 75 years with acute type A aortic dissection admitted to our hospital from October 2011 to December 2020 were reviewed retrospectively, including those with the noncommunicating type without malperfusion and low physical capacity prehospitalization. RESULTS: Sixty-six patients were enrolled consecutively in the medical (M, n = 30) and surgical (S, n = 36) groups. The ascending aorta was the most replaced section in the S group (78%). Groups did not differ significantly in hospital deaths and in intensive care unit and hospital stays. Two patients (7%) underwent surgery and 3 (10%) underwent redissection in the M group. No significant difference existed between the groups in the decline of physical performance during hospitalization. Seven patients in the M group (24%) had aorta-related events in the late period as opposed to none in the S group (P=0.003). Survival rates after 4 years were 78.3% and 71.4% in the S and M groups, respectively (P=0.154). The cumulative incidence of overall reintervention due to an aortic event was significantly higher in the M group; however, the 2 groups did not differ significantly in overall aorta-related deaths. CONCLUSIONS: Surgical outcomes of noncommunicating acute type A aortic dissection in elderly patients were favorable. There was no significant difference in maintaining physical function at discharge, and the medical group had a significantly higher overall aortic event rate than the surgical group.

Left ventricular posterior wall plication for ischemic mitral regurgitation and cardiogenic shock.

Ischemic mitral regurgitation, a known complication of myocardial infarction that results from left ventricular remodeling, causes heart failure and has a poor prognosis. While recent reports have revealed that surgical techniques utilizing a subvalvular or left ventricular approach might be effective in controlling mitral regurgitation, these methods are not yet established. We report the successful surgical management of a 73-year-old man who suffered from severe ischemic mitral regurgitation, experienced cardiogenic shock, and could not be weaned off mechanical support. We performed left ventriculoplasty from within the left ventricle over the mitral valve through a left atriotomy from the right side, along with coronary artery bypass grafting, ring annuloplasty, and basal chordal resection. The mitral regurgitation improved, and he finally could be weaned off mechanical support. Left ventriculoplasty might lead left ventricular reverse remodeling, improve the cardiac ejection efficiency by changing the left ventricular shape from spherical to oval, and secondarily control mitral regurgitation. Furthermore, performing left ventriculoplasty from inside the left ventricle precludes incising through the remaining healthy left ventricular myocardium, regardless of the position of the papillary muscles, and might be more effective in reducing the infarcted area responsible for ischemic mitral regurgitation.

A Hybrid Intervention for Post-infarction Papillary Muscle Rupture with Severe Mitral Regurgitation: A Case Report.

Papillary muscle rupture with severe acute mitral regurgitation is a rare complication of acute myocardial infarction (AMI) that causes pulmonary congestion and cardiogenic shock. Moreover, it has a poor prognosis. Surgical intervention, including revascularization, is indicated; however, surgical mortality remains high. We report the case of an 85-year-old woman with cardiogenic shock from severe acute mitral regurgitation, in whom a hybrid intervention, combining percutaneous coronary intervention with mitral valve replacement via minithoracotomy, was performed after post-infarction papillary muscle rupture. She was discharged in a favorable clinical condition. We describe a novel hybrid intervention for treating a rare complication of AMI, which could minimize surgical invasion in elderly patients, prevent disuse syndrome after the intervention, and improve prognosis. However, mitral valve surgery via minithoracotomy for emergency cases requires technical proficiency, as well as collaboration with other healthcare professionals, and the choice to perform this procedure requires careful consideration.

Mitral Valve Repair for Barlow's Disease with Mitral Annular and Subvalvular Calcification: A Case Report.

Barlow's disease with mitral annular calcification encompassing the subvalvular apparatus, including the valve leaflet and chordae, is extremely rare, and mitral valve repair in such cases is challenging. We report a case of a 60-year-old woman with mitral valve regurgitation that was successfully controlled by resecting the rough zone of P2 and calcifications on the excess leaflet regions and subvalvular apparatus, while retaining the calcification of P3 and implanting artificial chordae and an annuloplasty ring. Mitral valve repair for such cases requires an individualized and compounded surgical strategy for the technique to treat Barlow's disease and manage calcification to control mitral regurgitation.

Surgical repair for systolic anterior motion of anterior mitral leaflet due to mitral annular calcification.

Systolic anterior motion of the anterior mitral leaflet with anterior displacement of the coaptation site of the bi-leaflets due to mitral annular calcification on the posterior side, causing left ventricular outflow tract obstruction, is rare. We report the case of a 72-year-old woman with exertional dyspnea due to systolic anterior motion who underwent surgical repair to decalcify the mitral annular calcification and mitral valve repair. Hence, the systolic anterior motion, mitral valve regurgitation, and symptoms improved significantly. This report illustrates the novelty of surgical technique, the indication, and the limitation of mitral valve repair for such rare cases. A proper understanding of the mechanism in each patient and enhanced techniques for decalcification of posterior mitral annular calcification are needed to treat such complex cases.

Mitral valve repair using the daVinci surgical system after MitraClip failure.

Reports of mitral valve replacement after MitraClip removal have increased; however, surgical re-intervention is risky due to patients' frailty and comorbidities. We report a case of mitral valve repair after MitraClip failure using the daVinci surgical system for a 55-year-old man with many comorbidities and two previous cardiac surgeries. The daVinci surgical system allows detailed handling with high-resolution visualization and endowrist instruments that provide surgeons with clear three-dimensional images and stabilized handling. This procedure enables us to remove the MitraClip precisely while preserving the mitral valve leaflet.

[Hybrid Treatment for Left Internal Thoracic Artery-Pulmonary Artery Fistula with Aneurysm Complicated with Mitral Regurgitation:Report of a Case].

A 78-year-old man with mitral regurgitation incidentally diagnosed with aneurysm of the left internal thoracic artery(LITA) and several internal thoracic artery-pulmonary artery( ITA-PA) fistulas originating from the aneurysm. To prevent rupture of the aneurysm, ITA ligation was performed during surgery for the mitral valve. Because of the complex anatomy surrounding the aneurysm, the main duct of the ITA was ligated at the peripheral and center of the aneurysm, then arterial fistulae were resected as many as possible. Postoperative computed tomography (CT), however, showed patent LITA and contrast material in the aneurysm. Second stage coil embolization procedure was performed with successful results. Intravascular treatment is effective for ITA aneurysms or ITA-PA fistulae because we can clearly visualize and confirm blood flow during operation.

[Successful Surgical Management for Ischemic Heart Failure with Fractional Flow Reserve Derived from Computed Tomography:Report of a Case].

A 71-year-old woman was referred to our hospital for mitral valve repair and coronary artery bypass grafting (CABG). Conventional coronary artery angiography showed stenosis in the right coronary artery (RCA) and two diagonal branches, whereas transthoracic echocardiography (TTE) showed diffuse hypokinesis and mild-to-moderate mitral valve regurgitation. Fractional flow reserve derived from computed tomography (FFRct) demonstrated two additional lesions in the coronary artery at the left anterior descending artery (LAD) and the high lateral (HL) branch. Thus, we decided to perform CABG to RCA, LAD, the second diagonal branch, and HL as well as mitral valve repair. TTE one year after surgery showed trivial mitral regurgitation and progressive improvements in the left ventricular wall motion and the ejection fraction. FFRct is a usuful non-invasive method to identify coronary lesions that cause ischemia.

Surgical management for dual left anterior descending artery with anomalous origin of left coronary artery from pulmonary artery: a case report.

A dual left anterior descending artery with an anomalous origin of the left coronary artery from the pulmonary artery is an extremely rare coronary artery anomaly, with only one case known previously reported. However, that study presented coronary anatomical findings with images and little is known regarding patient outcome following surgical management for this unique condition. We present here the first case report of an affected patient, who underwent off-pump coronary artery bypass grafting and ligation of the coronary anomaly, as well as postoperative course details.

A modified Piehler technique for aberrant origin of left coronary arteries.

A bicuspid aortic valve sometimes coincides with a sinus of Valsalva aneurysm having a coronary artery anomaly. A meticulous aortic root replacement strategy is needed in these cases. In a 64-year-old man, the left coronary arteries (LCA) with an aberrant origin were excised together and reattached to the side hole of a valved conduit via a short Dacron graft. To prevent the formation of an aneurysm at the site, a strip of Dacron graft was sutured from outside between the LCA. The procedure for aortic root replacement with a coronary anomaly needs a case-by-case surgical strategy.

Total endovascular repair of a mycotic thoracic aortic aneurysm in a patient with an aberrant right subclavian artery.

An aberrant right subclavian artery (ARSA) is a rare arterial anomaly. Although a few cases of total endovascular repair for the ARSA aneurysm have been previously reported, anatomical limitations and the possibility of endoleaks remained. In this case, we created 4 holes on the stent graft for each cervical branch, with reference to the preoperative computed tomography findings. This approach might enable us to repair all types of thoracic aortic aneurysms with ARSA with each anatomical feature.