Use of 3d printing in preoperative planning and training for aortic endovascular repair and aortic valve disease

Abstract Introduction: Three-dimensional (3D) printing has become an affordable tool for assisting heart surgeons in the aorta endovascular field, both in surgical planning, education and training of residents and students. This technique permits the construction of physical prototypes from conventional medical images by converting the anatomical information into computer aided design (CAD) files. Objective: To present the 3D printing feature on developing prototypes leading to improved aortic endovascular surgical planning, as well as transcatheter aortic valve implantation, and mainly enabling training of the surgical procedure to be performed on patient's specific condition. Methods: Six 3D printed real scale prototypes were built representing different aortic diseases, taken from real patients, to simulate the correction of the disease with endoprosthesis deployment. Results: In the hybrid room, the 3D prototypes were examined under fluoroscopy, making it possible to obtain images that clearly delimited the walls of the aorta and its details. The endovascular simulation was then able to be performed, by correctly positioning the endoprosthesis, followed by its deployment. Conclusion: The 3D printing allowed the construction of aortic diseases realistic prototypes, offering a 3D view from the two-dimensional image of computed tomography (CT) angiography, allowing better surgical planning and surgeon training in the specific case beforehand.

Hybrid approach of aortic diseases: zone 1 delivery and volumetric analysis on the descending aorta

Abstract Introduction: Conventional techniques of surgical correction of arch and descending aortic diseases remains as high-risk procedures. Endovascular treatments of abdominal and descending thoracic aorta have lower surgical risk. Evolution of both techniques - open debranching of the arch and endovascular approach of the descending aorta - may extend a less invasive endovascular treatment for a more extensive disease with necessity of proximal landing zone in the arch. Objective: To evaluate descending thoracic aortic remodeling by means of volumetric analysis after hybrid approach of aortic arch debranching and stenting the descending aorta. Methods: Retrospective review of seven consecutive patients treated between September 2014 and August 2016 for diseases of proximal descending aorta (aneurysms and dissections) by hybrid approach to deliver the endograft at zone 1. Computed tomography angiography were analyzed using a specific software to calculate descending thoracic aorta volumes pre- and postoperatively. Results: Follow-up was done in 100% of patients with a median time of 321 days (range, 41-625 days). No deaths or permanent neurological complications were observed. There were no endoleaks or stent migrations. Freedom from reintervention was 100% at 300 days and 66% at 600 days. Median volume reduction was of 45.5 cm3, representing a median volume shrinkage by 9.3%. Conclusion: Hybrid approach of arch and descending thoracic aorta diseases is feasible and leads to a favorable aortic remodeling with significant volume reduction.

Resection of left atrial myxoma in a patient with retrosternal gastric tube: a case report

Abstract The median sternotomy remains the standard approach in cardiovascular surgery but, in some conditions, it can be considered difficult to perform, especially in patients with history of esophagectomy. This case report describes a successful resection of a left atrial myxoma through a right anterolateral thoracotomy approach in a patient with a previous retrosternal gastric tube reconstruction. The decision for the best surgical approach was made after a heart surgery team discussion. Through this surgical access, a safe and excellent exposure of the left atrium was possible, and a complete resection of the myxoma was performed without any injury to the gastric tube.

Does aortic valve repair in valve-sparing aortic root reconstruction compromise the longevity of the procedure?

OBJECTIVES: The effect of performing aortic valve repair in combination with valve-sparing operation on the length of time for which patients are free from reoperation is unclear. The objective of this study was to determine if the performance of aortic valve repair during valve-sparing operation modified the freedom from reoperation time. METHODS: From January 2003 to July 2014, 78 patients with a mean age of 49±15 years underwent valve-sparing operation. Sixty-eight percent of these patients were male. Twenty-two (28%) aortic valve repair procedures were performed in this patient population. In the aortic valve repair + valve-sparing operation group, 77.3% of patients had moderate/severe aortic insufficiency, while in the valve-sparing operation group, 58.6% of patients had moderate/severe aortic insufficiency (ns = not significant). Additionally, 13.6% of patients in the aortic valve repair + valve-sparing operation group had functional class III/IV, while 14.2% of patients in the valve-sparing operation group had functional class III/IV (ns). RESULTS: The in-hospital and late mortality rates, for the aortic valve repair + valve-sparing operation and valve-sparing operation groups were similar, as they were 4.5% and 3.6%; and 0% and 1.8%, respectively. In the aortic valve repair + valve-sparing operation group, 0% of patients presented moderate/severe aortic insufficiency during late follow-up, while in the valve-sparing operation group, 14.2% of patients presented with moderate/severe aortic insufficiency during this period (ns). In the aortic valve repair + valve-sparing operation group, 5.3% of patients presented with functional class III/IV, while in the valve-sparing operation group, 4.2% of patients presented with functional class III/IV (ns). In the aortic valve repair + valve-sparing operation group, 0% of patients required reoperation, while in the valve-sparing operation group, 3.6% of patients required reoperation over a mean follow-up period of 1621±1156 days (75 patients). CONCLUSION: Valve-sparing operation is a safe and long-lasting procedure and performance of aortic valve repair when necessary does not increase risk of reoperation on the aortic valve.

Novas perspectivas no tratamento cirúrgico da estenose aórtica / New perspectives in the surgical treatment of aortic stenosis

A estenose aórtica degenerativa é a doença valvar adquirida mais comum em adultos, acometendo principalmente os idosos. A cirurgia de substituição da valva aórtica é o tratamento de escolha nos pacientes com estenose aórtica importante sintomática. Seus resultados são reproduzíveis e bem estabelecidos. Porém, cerca de um terço dos pacientes são considerados inoperáveis devido ao risco cirúrgico inaceitável. Em consequência, nos últimos anos, novas alternativas de tratamento intervencionista foram introduzidas na prática clínica, com resultados iniciais favoráveis. Atualmente, as opções englobam a cirurgia de troca da valva aórtica, o implante da valva aórtica transcateter e, mais recentemente, a cirurgia de troca valvar aórtica sem sutura. Técnicas cirúrgicas minimamente invasivas não demonstraram diferença na mortalidade, porém chamam a atenção pelo resultado similar à esternotomia clássica, melhor resultado estético e menor tempo de hospitalização. Além disso, para evitar a utilização de próteses, técnicas de reconstrução valvar têm sido descritas. No implante de valva transcateter, o treinamento de equipe multidisciplinar é mandatório para a criteriosa seleção dos pacientes e da via de acesso. Os acessos transapical e transaórtico evoluíram como opções eficazes e vantajosas nos pacientes não candidatos para a via femoral. A familiaridade dos cirurgiões com essas abordagens tem contribuído para os bons resultados descritos. Um centro que seja capaz de oferecer todas essas alternativas de tratamento poderá selecionar a técnica mais apropriada, considerando a preferência do paciente e avaliando características fundamentais como idade, comorbidades, fragilidade e anatomia. Experiente "Heart Team" será capaz de fazer a escolha mais adequada.

Degenerative aortic stenosis is the most common acquired valvular disease in adults, affecting mainly the elderly. Surgical aortic valve replacement is the treatment of choice in patients with severe symptomatic aortic stenosis. Its results are reproducible and well established. However, about one third of patients are considered inoperable because of unacceptable surgical risk. Therefore, in the past few years, new alternative interventional treatments were introduced in clinical practice, with favorable initial results. Currently, the options include surgical aortic valve replacement, transcatheter aortic valve implantation and more recently, sutureless aortic valve replacement. Minimally invasive surgical techniques showed no difference in mortality, but caIl attention for similar result to the classic sternotomy, better cosmetic effect and shorter length of hospital stay. Furthermore, to avoid the use of prostheses, valve reconstruction techniques have been described. In transcatheter valve implantation, training multidisciplinary team is mandatory for careful selection of patients and access routes. The transapical and transaortic approaches evolved as effective and advantageous options in patients not candidates for transfemoral access. The familiarity of surgeons with these routes has contributed to the good results described. A center that is able to offer ali of these therapeutic alternatives can select the most appropriate technique, considering the patient' s preferences and evaluating crucial characteristics such as age, comorbidities, frailty and anatomy. An experienced "Heart Team" will be able to make the most adequate choice.