Does pulmonary endarterectomy improve the clinical conditions of patients with chronic thromboembolic pulmonary disease without pulmonary hypertension?

To verify whether the new hemodynamic definition of pulmonary hypertension (PH) has any implication in treatment of Chronic Thrombo-Embolic Pulmonary Disease (CTEPD) patients without PH, we retrospectively analysed the clinical and functional changes determined by pulmonary endarterectomy (PEA) in 63 CTEPD patients without PH who underwent surgery at our center, comparing those in whom the hemodynamic diagnosis of PH met recent guideline recommendations versus those in whom the diagnosis only met previous hemodynamic thresholds. The results show that the vast majority of CTEPD patients without PH operated at our center would now be defined as chronic thromboembolic pulmonary hypertension (CTEPH) patients. PEA did not result in any improvement in exercise capacity nor in right ventricular function or lung function test in patients with mean pulmonary artery pressure (mPAP) ≤ 20 mm Hg and pulmonary vascular resistance (PVR) ≤ 2 WU; on the contrary, hemodynamic parameters, exercise capacity, right ventricular function and lung function significantly improved in patients with mPAP between 21 and 24 mm Hg.

Results of the European clinical trial of Arrow CorAide left ventricular assist system.

The aim of this study was to evaluate the safety and performance of the Arrow CorAide left ventricular assist system (LVAS) (Arrow International, Reading, PA, USA), a continuous-flow left ventricular assist device, as bridge to transplantation or recovery as well as destination therapy in patients with New York Heart Association (NYHA) class IV heart failure. Twenty-one patients were implanted with the CorAide LVAS between February 2005 and February 2006 in a prospective, multicenter, nonrandomized trial. Seventeen patients (81%) survived to >180 days or to transplantation. The cumulative time on device was 16.58 patient years (range 23-796 days, median 192 days). No intraoperative technical issues were observed at the time of implantation. Of the 21 implants, nine patients died on device, two were converted to other devices, and 10 were transplanted. Three patient deaths were attributed to pump polymer coating delamination. Postmortem device inspection determined delamination of the polymer coating on the pump's internal surface to be the cause of the late hemolysis and sudden fatal pump stops. No embolic or driveline infection event was recorded. The automatic flow control algorithm functioned reliably throughout the trial. Primary performance trial endpoint was achieved with 81% survival to 180 days or transplantation. Delamination of the polymer coating on the internal surface of the pump with resultant hemolysis and pump stops was the sole major device event in this trial. Elimination of the polymer coating and replacement with an amorphous carbon coating has resolved this in preclinical testing, prior to initiation of further clinical testing of this device.

Pulmonary endarterectomy in chronic thromboembolic pulmonary hypertension: Relationship between treated branches and outcome.

BACKGROUND: In patients with chronic thromboembolic pulmonary hypertension (CTEPH) undergoing pulmonary endarterectomy (PEA) it is important to minimize residual obstructions, in order to achieve low postoperative pulmonary vascular resistances and better clinical results. The aim of the study was to test the hypothesis that the greater the number of pulmonary artery branches treated at surgery, the better the hemodynamic and clinical outcome after PEA. METHODS: In 564 consecutive CTEPH patients undergoing PEA the count of the number of treated branches was performed directly on the surgical specimens. Post-operative follow-up visits were scheduled at 3 months and 12 months after surgery including right heart catheterization and modified Bruce test. RESULTS: The population was divided into tertiles based on the number of treated branches: Group 1 (from 4 to 30 treated branches, n = 194 patients); Group 2 (from 31 to 43 treated branches, n = 190 patients); Group 3 (from 44 to 100 treated branches, n = 180 patients). At 3 and at 12 months after PEA, after adjustment for confounders, patients in the highest tertile of treated branches had significantly lower values of pulmonary vascular resistance and higher values of pulmonary arterial compliance as compared to the other two groups (p < 0.002). Hospital mortality was 3% in Group 3, 6% in Group 2 and 10% in Group 1 (overall p = 0.035). CONCLUSIONS: In CTEPH patients undergoing PEA, a higher number of treated pulmonary artery branches is associated with a better hemodynamic and a better clinical outcome at 3 months and 12 months after surgery.

Should we perform heart retransplantation in early graft failure?

Cardiac retransplantation represents the gold standard treatment for a failing cardiac graft but the decision to offer the patient a second chance is often made difficult by both lack of donors and the ethical issues involved. The aim of this study was to evaluate whether retransplantation is a reasonable option in case of early graft failure. Between November 1985 and June 2008, 922 patients underwent cardiac transplantation at our Institution. Of these, 37 patients (4%) underwent cardiac retransplantation for cardiac failure resulting from early graft failure (n = 11) or late graft failure (acute rejection: n = 2, transplant-related coronary artery disease: n = 24). Survival at 1, 5 and 10 years of patients with retransplantation was 59%, 50% and 40% respectively. An interval between the first and the second transplantation of less than (n = 11, all in early graft failure) or more than (n = 26) 1 month was associated with a 1-year survival of 27% and 73%, and a 5-year survival of 27% and 65% respectively (P = 0.01). The long-term outcome of cardiac retransplantation is comparable with that of primary transplantation only in patients with transplant-related coronary artery disease. Early graft failure is a significant risk factor for survival after cardiac retransplantation and should be considered as an exclusion criteria.

Initial results of clinical trial with a new left ventricular assist device (LVAD) providing synchronous pulsatile flow.

OBJECTIVES: A multicentric European Clinical Study is ongoing to evaluate safety and efficacy of a new pulsatile implantable LVAD (BestBeat), smaller and lighter than similar devices, capable of providing synchronous and counterpulsating flow with respect to the LV of end-stage heart failure patients. Preliminary clinical results are reported. METHODS: The new BestBeat LVAD was used, consisting of an implantable pulsatile blood pump, electromechanically driven by a ball screw mechanism, and a wearable electronic controller and power sources. The clinical trial was conducted at 5 european centers. Adult patients affected by CHF in NYHA Class IV despite optimized medical treatment were enrolled. The primary study endpoint was survival at 90 days. Further study endpoints were maintenance of adequate LVAD pump flow and a minimum rate of adverse events during support. RESULTS: As of June 2008, 6 patients received the implant. Cumulative support time was 3.7 years, median support time 176 days. All patients who completed the study survived except for one, who died after 48 days, due to combined infection and cerebrovascular accident. Another two patients died: one from intracranial bleeding 113 days after implant, and one from septic shock after 123 days. Hemodynamic improvement with CI>2.0 l/min/m2 and recovery of end-organ function expressed by consistent improvement of BUN, creatinine and bilirubin were reached in all patients. No device failure was observed. There was no bleeding requiring re-exploration, no hemolysis and only two device-related infections (both in one patient). Neurologic events were reported, the most serious ones occurring in patients with pre-implant respiratory and kidney failure. Three patients were discharged home. Two patients were successfully transplanted, one after 6 months and one after 13 months on device. CONCLUSIONS: Good performance and efficacy of the device were observed; the endpoints of the study were achieved, and its safety was consistent with expectations. The ongoing study will allow further conclusions to be drawn.

The axillary artery as an alternative site of cannulation for redo port access-assisted minimally invasive mitral valve surgery: early report of 2 cases.

The minimally invasive Heartport (HP)-assisted technique has become first choice option for mitral valve surgery in many centres.The pool of patients potentially treated using HP techniques, however, is still limited by the presence of peripheral vessel disease, expecially in the elderly population. Alternative approaches to using the HP technique safely in such a subset of patients, therefore, should be evaluated. Here, we present our preliminary experience using the axillary artery as an alternative site of cannulation for HP-assisted redo mitral valve surgery in patients with concomitant peripheral vessel disease.

Left ventricular aneurysm resection with port-access surgery: a new mini-invasive surgical approach.

BACKGROUND: In recent years port-access and endovascular extra-corporeal circulation techniques have allowed valvular and coronary operations to be performed by mini-thoracotomy. Experience with the technique suggested application to resection of ventricular aneurysms, which are usually approached through a median sternotomy with the use of traditional cardiopulmonary bypass. METHODS: We performed a left port-access mini-thoracotomy, with 6 to 8 cm skin incisions, in 7 patients undergoing endoventricular pericardial patch repair for anterior left ventricular aneurysm. Cardiopulmonary bypass was effected using the Heartport system. The mean interval between myocardial infarction and operation was 60.4 +/- 57.7 months. Three patients developed sustained ventricular tachicardia. Mean preoperative ejection fraction was 34% +/- 11%. Associated procedures were coronary bypass grafting in 2 patients and cryosurgery in 3 patients. RESULTS: All patients survived to discharge and are alive and well after an average 14.5 months. They are all in NYHA class I-II. Postoperative echocardiograms revealed an average ejection fraction of 48.0% +/- 7.5% (p = 0.006 compared with preoperative value). The 3 patients who had cryosurgery did not demonstrate any recurrence of arrhythmias. CONCLUSIONS: Left ventricular aneurysm can be successfully treated through port-access mini-thoracotomy with endovascular cardiopulmonary bypass, avoiding median sternotomy. This mini-invasive approach allows effective ventricular remodeling. Revascularization and antiarrhythmia surgery can also be done at the same time. In case of severely reduced ventricular function this approach permits fibrillatory arrest without aortic cross-clamping. The results are also good in terms of hospitalization time and long-term survival.

Ascending aortic aneurysms treated by cuneiform resection and end-to-end anastomosis through a ministernotomy.

BACKGROUND: Ascending aortic aneurysms without dilatation of the sinuses of Valsalva are generally handled by resection and replacement with a tubular graft or by tailoring aortoplasty. We propose an alternative treatment with a direct anastomosis of the two stumps of the aorta after complete aneurysm resection through an upper J ministernotomy. PATIENTS AND METHODS: We have applied this procedure to 45 patients. Mean age was 60.2 +/- 12.1 years. Mean aneurysm diameter was 51.0 +/- 8.0 mm. The skin incision averaged 6.5 cm. Two circumferential aortotomies were made: one at the level of the sinotubular junction, the other one just below the innominate artery. The two ends of the aorta were then sutured with a 3-0 Prolene running suture. In 31 cases (61%) aorta-associated valve replacement was carried out. RESULTS: Hospital mortality was 4.4%. Mean CPB and cross-clamp times were 104 +/- 71 and 68 +/- 25 minutes respectively. Mean blood loss was 380 +/- 300 mL. Median ventilation requirement and intensive care unit stay were 17 and 21 hours. Median hospital stay was 7 days. During the follow-up period (23.7 +/- 12.3 months), 1 patient required reoperation and 2 patients died. Event-free survival is 88.4 +/- 5.7 at 44 months. The surviving patients are routinely checked with ultrasonography and angio computed tomography scan. There was a very low redilatation rate (1 patient, 2.3%) and no incidence of pseudoaneurysm. CONCLUSIONS: Complete resection of ascending aortic aneurysms with end-to-end anastomosis through an upper ministernotomy represents a feasible, safe, physiologic and cost-effective minimally invasive surgical option in cases of aneurysms with normal or nearly normal sinotubular junctions.

Traumatic tricuspid valve rupture treated by minimally invasive thoracotomy.

Isolated valvular lesions consequent to non-penetrating trauma are rare. We present a case of a traumatic tricuspid valve rupture in a 51-year-old woman seriously involved in a motor vehicle accident 20 years earlier. She underwent tricuspid valve replacement performed via a minimally invasive thoracotomy in the right fourth intercostal space. The advantages of minimally invasive thoracotomy are discussed.

Acute aortic dissection with intestinal ischemia: what to do first.

PURPOSE: In the case of an acute aortic dissection, a surgical aortic procedure is usually the priority in order to restore the perfusion of vital organs. Afterwards, associated ischemic abdominal visceral lesions can be resected. For particular patients, it could be highly beneficial to perform the abdominal surgery before surgically addressing the aorta. The aim of this paper is to contribute to the therapeutic choice in cases of acute aortic dissection with acute abdomen. CASE REPORT: The case is reported of a 38-year-old patient, affected by an acute aortic dissection (Stanford type A) and peritonitis.Suspecting the necessity for a complex combined surgical procedure, the patient underwent emergency diagnostic laparoscopy, which showed an infarctual necrosis of the distal ileum and right colon. Therefore, he immediately underwent a wide right hemicolectomy. Afterwards, an ascending aortic substitution was performed.The patient was discharged on the 15th post-operative day, and he is doing well, 1 year and 3 months after the operation. CONCLUSION: In the case of an acute aortic dissection with acute abdomen, emergency laparoscopy is a precious surgical technique to identify criteria that can lead to therapeutic decisions, including timing.

Minimally invasive video-assisted approach for left atrial myxoma resection.

Minimally invasive surgery has become the standard approach for several cardiac diseases. We report in the present study our ten-year experience with endoscopic cardiac surgery for left atrial myxoma resection. Between January 1998 and January 2008, 14 patients (median age: 61 years) underwent surgery for left atrial myxoma resection at our institution. The Heartport access system and the video-assistance were systematically employed to provide excellent vision and facilitate surgery. The aortic clamping was obtained with an 'EndoClamp' in 11 cases (using a central or peripheral endoaortic balloon, depending on the site of the arterial cannulation) or transthoracically with the Portaclamp system in two cases and the Chitwood clamp in one case. The average time needed for cross-clamping was 49+/-29 min, with a mean cardiopulmonary bypass (CPB) time of 88+/-57 min. There were no early or late hospital deaths. Mean intensive care unit and hospital stay were three and eight days, respectively. The mean follow-up time was 64 months and there was no evidence of residual or recurrent tumor. There were two late deaths due to acute ischemic stroke. Minimally invasive video-assisted surgery for left atrial myxoma resection is a safe, reproducible and cosmetic operation and can be considered an effective oncologic approach as an alternative to standard sternotomy.

Minimally invasive heart-port assisted technique as standard first choice approach for left ventricle endoplasty: a ten-year single-center experience.

BACKGROUND: Although the port-access technique has been shown to be an effective and safe approach for cardiac surgery procedures it has never become routine practice, and it is still limited to few and selected centers. Furthermore, such technique has rarely been applied to treat left ventricle disease. In 1999 we introduced left ventricle aneurysm repair through a left minithoracotomy using the port-access technique. Here we present the results in terms of early and medium-term follow-up using such technique as a routine first choice approach for left ventricle endoplasty. METHODS: From 1999 to date, out of 38 patients undergoing left ventricle endoplasty (+/-associate procedures), mini-left thoracotomy and port-access techniques have been used in 32 patients (84%). All patients underwent endoventricular patch-repair with ventricular reshaping and associated procedures were performed in 8 patients. RESULTS: All patients survived the operation and were discharged from the hospital (30 days mortality 0%). Two patients (6.2%) experienced prolonged mechanical ventilations and 3 patients (9.3%) prolonged intensive care unit stay. Mean follow-up was 40+/-34 months (range, 2 to 105). One patient died during follow-up (cumulative mortality 3.3%). Follow-up revealed an improvement of hemodynamic performances (left ventricular ejection fraction 0.44+/-0.09 compared with 0.34+/-0.09 preoperatively, p=0.004) and improved clinical conditions (New York Heart Association class 1.4+/-0.5 compared with 2.3+/-1 preoperatively, p=0.003). CONCLUSIONS: The port-access technique can be safely applied to perform left ventricle endoplasty through a left minithoracotomy. Such approach allows optimal surgical view and therefore optimal surgical correction. Based on our satisfactory experience we support left minithoracotomy as a valuable alternative approach for left ventricle endoplasty in view of an extended use of minimally invasive techniques.

Port-access minimally invasive surgery for atrial septal defects: a 10-year single-center experience in 166 patients.

OBJECTIVE: We assessed the surgical results and the benefits to the patient of a minimally invasive surgical approach for atrial septal defects. METHODS: Between May 1998 and May 2008, 166 patients (median age, 44 years) had surgery for atrial septal defects in our institution. Of these patients, 118 (71%) had a patent foramen ovale (associated with atrial septal aneurysm in 48 cases), 33 (20%) had a wide ostium secundum defect, 6 (3.6%) had an ostium primum defect, 6 (3.6%) had a sinus venosus defect with abnormal pulmonary vein connection, and 1 (0.6%) had a coronary sinus defect. In 2 cases (1.2%) patients were referred to our department for surgical correction after failure of interventional occluder placement. All patients were operated on via a right minithoracotomy (mean incision, 5.5 + or - 1 cm) in the fourth intercostal space and under cardiopulmonary bypass. RESULTS: The HeartPort access system was used in 106 patients (64%), with an endoaortic clamp (central kit in 50 cases and peripheral kit in 56). In the remaining patients (36%), we preferred the Portaclamp system (37 cases) or the Chitwood clamp (23 cases). Average crossclamp time was 38.4 + or - 22.2 minutes with a mean cardiopulmonary bypass time of 64.9 + or - 34.5 minutes. There was no conversion in classic sternotomy. There were no early or late hospital deaths. Surgical revision was performed in 6 patients for bleeding from the thoracic wall. The mean hospital stay was 5.8 days. At 51 months mean follow-up, 4 patients died of non-cardiac-related causes. CONCLUSIONS: Port-access minimally invasive surgery for atrial septal defects is a safe, less-invasive, reproducible, and cosmetic operation, providing an excellent outcome and an effective correction, and could be now considered the standard approach for this type of patient.

Port-access surgery as elective approach for mitral valve operation in re-do procedures.

BACKGROUND: Re-do mitral valve procedures performed through median sternotomy carry substantial mortality and morbidity. To avoid complications of sternal re-entry and to provide adequate mitral valve exposure, antero-lateral thoracotomy has been suggested by some authors. METHODS: From October 1997 to January 2007, 677 mitral valve operations have been performed in our centre using port-access video-assisted right mini-thoracotomy. Among these, 241 (35.6%) were performed on patients who had undergone one or more previous cardiac surgery procedures. RESULTS: Mean cardio-pulmonary bypass time and endo-clamp time were 117+/-46 min and 71+/-31 min, respectively. Arterial cannulation was performed either on the ascending aorta, with the endo-direct cannula (112 patients, 46.5%), or peripherally with a femoral artery approach (129 patients, 53.5%). Conversion to median sternotomy was necessary in only two patients (0.8%) due to aortic dissection (one case) and left ventricle free wall rupture (one case). Median intensive care unit stay was 24h, median mechanical ventilation time was 12h; median hospital stay was 8 days. Bleeding requiring surgical revision occurred in 12 patients (4.9%). Hospital mortality was 4.9% (12/241 patients). CONCLUSIONS: Port-access video-assisted right mini-thoracotomy allows good results in a difficult subset of patients; it allows minimal adhesion dissection, short ICU and hospital stay. In our practice, this technique has become the treatment of choice for mitral valve re-do surgery.

Arrow CorAide left ventricular assist system: initial experience of the cardio-thoracic surgery center in Pavia.

PURPOSE: The aim of the present study is to describe our preliminary experience with the Arrow CorAide left ventricular assist system (LVAS). DESCRIPTION: The Arrow CorAide LVAS is a small implantable, continuous flow centrifugal pump, with a fully suspended rotating assembly, intended as a bridge to transplant device, bridge to recovery, and for long-term use. EVALUATION: Since April 2005 we have implanted the CorAide LVAS in 2 male patients, with a patient follow-up of more than 6 months. Surgical procedures were uneventful, and both patients had an uneventful postoperative course, with fast weaning from mechanical ventilation and inotropic support. No thromboembolic events, infective complication, hemolysis, or mechanical failure occurred. To date, both patients are in New York Heart Association class I. CONCLUSIONS: In our initial experience the CorAide LVAS blood pump is nonthrombogenic, nonhemolytic, and easy to implant. Both patients have improved their functional status. Further follow-up is needed to assess long-term results.