Totally Endoscopic Constrictive Pericarditis Treatment: A Case Series.

Minimally invasive cardiac surgery has increased in popularity to reduce the morbidity associated with open heart surgery. In this article, a totally endoscopic case series is presented in which anterior pericardiectomy is performed by peripheral femoral arterial and venous cannulation. Right periareoal incision and right submammary incision were used for male and female patients, respectively, to access the heart by the fourth intercostal space.

Minimally Invasive Endoscopic Aortic Valve Replacement: Operative Results.

To describe our endoscopic aortic valve replacement (E-AVR) technique and to evaluate its early results regardless of the type of prosthetic valve implanted and the patients' characteristics. From July 2013 to September 2018, 125 patients (76 males, mean age 68.8 ± 10.9 years, mean EuroScore II 1.51 ± 1.39) underwent isolated E-AVR due to a severe stenosis in 99 cases and insufficiency in 26 cases. The surgical access was a 3-4 cm working port in the second right intercostal space with no rib-spreading and 3 additional 5 mm miniports for the introduction of a 30-degree thoracoscope, the Chitwood clamp, and the vent line. Cardiopulmonary bypass (CPB) was achieved through a femoro-femoral cannulation. All patients successfully underwent E-AVR. Stended bioprostheses were implanted in 56 cases, Rapid Deployment and Sutureless valves in 23 and 46 cases, respectively. Mean cross-clamping and CPB times were 87.5 ± 22.1 and 126.1 ± 28.4 minutes, respectively, and a significant difference between the types of prostheses was observed: 69.1 ± 15.1 and 106.2 ± 21.8 minutes (Sutureless) vs 93.2 ± 15.1 and 135.5 ± 21.8 minutes (Rapid Deployment) vs 100.6 ± 17.2 and 138.9 ± 21.9 minutes (Stented). Mean ventilation and ICU times and hospital stay were 10.9 ± 39.3 hours, 45.9 ± 58.4 hours, and 8.3 ± 9.3 days, respectively. Thirty-day mortality was 0.8%. One patient (0.8%) needed a re-exploration for bleeding and 3 patients (2.4%) required a new permanent pacemaker implantation. No major neurologic events were observed. No paravalvular leakage was detected at discharge. E-AVR is associated with low mortality and few complications. Sutureless bioprostheses significantly reduce cross-clamping and CPB times. In dedicated centers, this approach may become a valid alternative to other minimally invasive techniques.

Redo After Failure of Aortic Homografts With a Rapid Deployment Valve.

Homograft implantation in the aortic position was a common approach for full root aortic surgical procedures in the early 2000s. Reintervention after degeneration of such homografts remains a challenge. We report two cases of successful implantation of the Edwards Intuity Elite rapid deployment valve into patients with degeneration of existing aortic homograft implants leading to severe aortic regurgitation.

Fate of the aortic root late after Ross operation.

BACKGROUND: The Ross operation is an alternative to mechanical aortic valve replacement in the young. Early dilatation of the pulmonary autograft root exposed to the systemic circulation has been reported. To define the prevalence of, risk factors for, and consequences of late autograft dilatation, outcome in all consecutive patients operated since May 1994 was reviewed. METHODS AND RESULTS: Ninety one patients, 77 males and 14 females, with at least 1 year of follow-up underwent cross-sectional clinical and echocardiographic examination. Age at operation was 27+/-10 years (range 6 to 49), and the indication was aortic regurgitation in 54 (59%) patients and bicuspid valve was present in 62 (68%). End-points of the study were freedom from autograft dilatation (root diameter >4 cm or 0.21 cm/m2), from (moderate) autograft regurgitation and from reoperation. Follow-up (4.0+/-1.9, range 1 to 8 years) autograft root diameters were anulus, 29+/-4 mm (18-39); sinus of Valsalva, 38+/-7 mm (24-53); sinotubular junction, 37+/-6 mm (23-54); and ascending aorta, 37+/-5 mm (27-54). Late autograft dilatation was identified in 31 (34%) patients and regurgitation in 13 (14%), 7 of whom had autograft dilatation. At 7 years, freedom from dilatation was 42+/-8%, freedom from regurgitation was 75+/-8%, and freedom from reoperation was 85+/-10%. Cox proportional hazard analysis identified younger age (P=0.05), preoperative sinus of Valsalva (P=0.02), root replacement technique (P=0.03), and absence of pericardial buttressing (P=0.04) as predictive of autograft dilatation, whereas female sex (P=0.002), follow-up sinus of Valsalva (P=0.003), and sinotubular junction diameter (P=0.02) as predictive of autograft regurgitation. CONCLUSIONS: Autograft dilatation is common late after the Ross procedure, particularly in younger patients, in those with preoperative aortic aneurysm, and those having root replacement without support of anulus and sinotubular junction. Bicuspid aortic valve is not a risk factor. Significant autograft valve dysfunction affects a minority of patients, but it is more prevalent in those with autograft dilatation.

Hemodynamic effects of inhaled nitric oxide and phosphodiesterase inhibitor (dipyridamole) on secondary pulmonary hypertension following heart valve surgery in adults.

BACKGROUND: Inhaled nitric oxide (iNO) is proposed in the management of pulmonary hypertension (PH) in patients undergoing cardiac surgery. Secondary PH related to a long-standing heart valve disease however may be refractory to iNO. Aim of this prospective study was to determine whether the combination of iNO plus dipyridamole (DP), a cyclic guanosine monophosphate-specific phosphodiesterase inhibitor (PDE5), may enhance and/or prolong the response to iNO in adult patients with secondary valve-related PH undergoing cardiac surgery, and attenuate rebound events related to its discontinuation. METHODS: Responses in 27 patients, 11 male, mean age 72+/-11 years, with PH due to mitral and/or aortic valve disease, were studied in the Intensive Care Unit after cardiac surgery, during sedation and stable hemodynamic conditions. The effect of isolated iNO administration (40 ppm), iNO combined with DP (0.2 mg/kg i.v.), and DP alone (1 mg/kg/24 h) on pulmonary vascular resistance, mean pulmonary artery pressure, cardiac index, mixed venous O2Sat%, and mean arterial pressure were determined. RESULTS: All patients showed at least a 10% decrease in pulmonary vascular resistance vs. baseline after administration of iNO [responders]. Inhaled NO and the combination of iNO/DP produced a reduction of pulmonary vascular resistance and mean pulmonary artery pressure (p<0.05). Cardiac index improved with a significant difference between iNO and the association iNO/DP versus baseline (p<0.05). This significant hemodynamic improvement versus baseline was maintained during isolated DP administration (p<0.05), but not during isolated iNO discontinuation. Mixed venous oxygen saturation showed an overall improvement of 17% (p<0.05). CONCLUSIONS: Inhaled NO and DP infusion might represent a valuable association in the management of PH secondary to a heart valve disease in patients undergoing cardiac surgery. Their beneficial hemodynamic effects might be particularly valuable in the management of patients with associated right ventricular dysfunction.

Reoperations for aortic aneurysm after the Ross procedure.

BACKGROUND AND AIM OF THE STUDY: Among late complications after the Ross operation, autograft dilatation is likely the most common. In order to define prevalence, consequences and management of autograft dilatation, a 10-year clinical experience was reviewed. METHODS: A total of 112 patients (mean age 29 +/- 10 years) underwent cross-sectional echocardiographic follow up. End-points of the study were freedom from autograft dilatation (diameter >4 cm, indexed as 0.21 cm/m2) and from reoperation for dilatation. Risk factors for autograft dilatation were also identified. RESULTS: There were 110 late survivors; average follow up was 5.1 +/- 1.9 years (range: 0.3 to 10.6 years). At 10 years, autograft dilatation was identified in 32 patients (29%), compatible with aortic aneurysm (>5.0 cm) in seven patients (6%). Seven of 32 patients (22%) presented moderate or greater autograft insufficiency. Ten-year freedom from dilatation was 43 +/- 8%, and from regurgitation was 75 +/- 8%. At multivariate analysis, preoperative aneurysm (p = 0.02), root replacement technique (p = 0.03) and absence of root buttressing (p = 0.04) were predictive of dilatation. Reoperation for autograft aneurysm was performed in five patients at a mean of 7.3 +/- 0.8 years after the Ross procedure, while two patients await reintervention. Two patients had root replacement and three remodeling with valve preservation (two root replacements, one sinotubular junction replacement): all survived reoperation. Ten-year freedom from root reoperation was 81 +/- 6%, and from full root replacement was 94 +/- 2%. CONCLUSION: With increasing follow up after the Ross operation, the incidences of root dilatation and reoperation are likely to rise. Graft replacement of coexisting aneurysm, avoidance of root replacement technique and the use of root-stabilization measures may reduce the prevalence of late root pathology. Early replacement of dilated autograft roots may allow preservation of the autologous pulmonary valve.

The CarboMedics prosthetic heart valve: experience with 1,084 implants.

BACKGROUND AND AIM OF THE STUDY: The study aim was to evaluate our clinical experience with the CarboMedics heart valve prosthesis. METHODS: Between October 1991 and December 2000, 942 consecutive patients (514 males, 428 females; mean age 58+/-11 years; range: 6-78 years) underwent mechanical valve implantation with the CarboMedics prosthesis. Preoperatively, 47% of patients were in NYHA class III and 22% in class IV; in addition, 134 patients (14.2%) had undergone a previous cardiac operation. Aortic valve replacement (AVR) was performed in 469 patients (49.8%), mitral valve replacement (MVR) in 330 (35.0%), double valve replacement (DVR) in 142 (15.1%), and isolated tricuspid valve replacement (TVR) in one patient. Eighty-eight patients (9.3%) underwent associated myocardial revascularization. Mean cardiopulmonary bypass and aortic cross-clamp times for the entire group were 107+/-39 min and 74+/-24 min, respectively. RESULTS: Overall early mortality was 2.3% (6/469 AVR, 1.2%; 12/330 MVR, 3.6%; 4/142 DVR, 2.8%). Late mortality was 3.1% (n = 29; including 17 cardiac deaths (10 were valve-related). Mean follow up was 66+/-31 months (range: 1-109 months), and was 98% complete yielding a total follow up of 4959 years. Actuarial survival at five years for the entire group was 89.3+/-1.6% (AVR 91.1%, MVR 86.4%, DVR 90.5%). Thromboembolism occurred in 26 patients (2.8%, 0.52%/pt-year) and major hemorrhagic events in 20 (2.1%, 0.4%/pt-year). Nine patients (0.9%) required a reoperation, in three cases (0.3%) after Staphylococcus epidermidis-mediated endocarditis. No structural deterioration occurred. Among 891 survivors, 94% of the patients are currently in NYHA classes I or II (p <0.05). CONCLUSION: This study confirmed the safety and reliability of the CarboMedics mechanical valve prosthesis, even in old age groups. This bileaflet prosthesis showed no structural deterioration, and a low incidence of overall complications.

Amplatzer septal occluder migration into the pulmonary trunk: surgical removal through a totally thoracoscopic approach.

The Amplatzer Septal Occluder for transcatheter closure of interatrial communications is a standard procedure and a widely accepted alternative to surgery in most patients with atrial septal defect (ASD). Device dislocation or embolization has been reported as one of the commonest complications of ASD percutaneous closure. In this case, if a transcatheter removal is not possible, it requires a surgical therapy, usually through a median sternotomy. We report on a case of a 30-year-old woman, who underwent percutaneous closure of an ostium secundum ASD. After a late embolization of the Amplatzer Septal Occluder into the pulmonary trunk 10 months later, the implant was successfully obtained via a surgical removal through a video-guided minimally invasive port-access approach. This case shows that, in experienced hands, the port-access technique for surgical procedures on the pulmonary trunk is feasible, and therefore, it might be a good alternative option to the traditional surgery, mainly in young patients.

Left atrial wall hematoma as a consequence of percutaneous coronary angioplasty.

Intramural left atrial dissection and hematoma as a complication of a coronary stenting procedure is a very rare entity. We report the case of a 73-year-old man who underwent percutaneous coronary angioplasty for a severe stenosis of the left circumflex coronary artery, complicated by a left atrial intramural hematoma, and was successfully treated with via a minimally invasive port-access surgical approach.

Chemical characterization and enological potential of Raboso varieties by study of secondary grape metabolites.

DNA studies supported by matrix-assisted laser desorption ionization-time of flight mass spectrometry analysis of seed proteins showed that the Vitis vinifera red grape variety Raboso Veronese is the progeny of a spontaneous cross between Raboso Piave (red) and Marzemina Bianca (white) varieties. In the present work, the main secondary grape metabolites of Raboso varieties were studied, and their enological potential was evaluated and compared with that of other red varieties reported in the literature. In general, Raboso grapes had high flavonoid contents and high percentages of polyphenols extractable in winemaking and substantial contents of norisoprenoid aroma precursors. Raboso Veronese stood out for its high content of cyanidin and had higher (+)-catechin and (-)-epicatechin contents than Raboso Piave and abundant quercetin glucoside, indicating substantial plant biosynthesis toward compounds dihydroxylated in the B-ring. Study of secondary grape metabolites is confirmed as an effective tool in differentiating similar varieties, in particular on the basis of polyphenol profiles.

Post-traumatic rupture of the anterolateral papillary muscle.

Rupture of cardiac valves as a consequence of nonpenetrating cardiac trauma is an uncommon phenomenon. We report the case of a 24-year-old patient with a "two-stage" traumatic rupture of the anterolateral papillary muscle of the mitral valve, after a blunt chest trauma, who successfully underwent emergency mitral valve replacement.

Aortic valve replacement with the Sorin Pericarbon Freedom stentless prosthesis: 7 years' experience in 130 patients.

OBJECTIVES: Aortic stentless pericardial valves were introduced into clinical practice to combine properties of both stentless and pericardial prostheses. The aim of this single-center retrospective study was to assess midterm clinical and hemodynamic results of aortic valve replacement with the Sorin Pericarbon Freedom stentless bioprosthesis. METHODS: From July 1999 through November 2005, 130 consecutive patients (73 [56.1%] male patients) underwent aortic valve replacement with the Sorin Pericarbon Freedom bioprosthesis at our institution. Mean age was 76 +/- 5 years (range, 42-86 years), and associated procedures were performed in 50 (38.4%) patients; of these, 41 were coronary artery bypass grafts. Surgical intervention under urgent/emergency conditions and reoperations were performed in 18 (13.8%) and 7 (5.3%) patients, respectively. Mean crossclamp and cardiopulmonary bypass times were 82 +/- 24 and 125 +/- 40 minutes, respectively. All patients underwent clinical and echocardiographic follow-up (100% complete), and the total cumulative follow-up was 324 patient/years (mean, 2.5 +/- 1.8; range, 6 months-7 years). RESULTS: Overall hospital mortality was 8.4%. Overall patient survival was 63% +/- 6% and 50% +/- 10% at 5 and 7 years, respectively. Late deaths occurred in 23 patients, and 6 of them were valve related (1.8% patient/years). Freedom from valve-related death and reoperation was 91% +/- 4% and 94% +/- 4%, respectively, at 7 years. No structural valve deterioration was observed. Endocarditis, thromboembolism, and hemorrhagic complications occurred in 2 (0.6% patient/years), 1 (0.3% patient/years), and 1 (0.3% patient/years) patients, respectively. Mean transprosthetic gradients for valve sizes 23, 25, and 27 were 12.1 +/- 3.8, 10.8 +/- 3.8, and 9 +/- 3.1 mm Hg, respectively. CONCLUSIONS: The Sorin Pericarbon Freedom stentless bioprosthesis provides good early and midterm results in terms of hemodynamic performance, survival, and freedom from valve-related complications.

Ross operation in the young: a ten-year experience.

BACKGROUND: The Ross operation is an alternative to mechanical aortic valve replacement in the young. However, early and late complications after operation have been reported. In order to assess the role of the Ross operation in children and young adults, a 10-year clinical experience was reviewed. METHODS: Ninety male and 22 female patients, aged 29 +/- 10 years (range, 6-49) underwent cross-sectional clinic and echocardiographic examination. Indication for Ross operation was aortic regurgitation in 79 patients, stenosis in 11, and mixed lesion in 22; 82 (73%) had a bicuspid valve. Endpoints of the study were survival and freedom from autograft dilatation, from autograft and homograft dysfunction, and from reoperation. RESULTS: There was 1 (1%) hospital and 1 late (1%) death, during an average follow-up of 5.1 +/- 1.9 years (range, 0.1-10.6). At 10 years, survival was 98 +/- 2%. Late autograft dilatation was identified in 32 (29%) patients and regurgitation in 15 (14%), 7 of whom had autograft dilatation. Ten-year freedom from autograft dilatation was 43 +/- 8% and from regurgitation was 75 +/- 8%. Multivariate analysis showed younger age (p = 0.05), preoperative aortic root dilatation (p = 0.02), root replacement technique (p = 0.03), and absence of pericardial strip buttressing (p = 0.04) to be predictive of autograft dilatation. Eleven (10%) patients required reoperation on the autograft (8 prosthetic valve replacement, 3 autograft root repair). Ten-year freedom from reoperation was 72 +/- 10% and from replacement of the autograft was 88 +/- 5%. Pulmonary homograft obstruction was identified in 6 (5%) patients, requiring homograft replacement in 1. All but 2 (2%) patients were in New York Heart Association class I, with a return to regular school grade or active employment. CONCLUSIONS: Late outcome for the Ross procedure is excellent in terms of survival and quality of life. Late root dilatation, autograft regurgitation, and homograft stenosis, however, show increasing prevalence with time. Technical modifications of the procedure, yearly aortic root imaging, and early reintervention on the dilated neoaortic root may further enhance the durability of the autologous pulmonary valve.