Routine use of mesh during hiatal closure is safe with no increase in adverse sequelae.

BACKGROUND: Primary laparoscopic hiatal repair with fundoplication is associated with a high recurrence rate. We wanted to evaluate the potential risks posed by routine use of onlay-mesh during hiatal closure, when compared to primary repair. METHODS: Utilizing single-institutional database, we identified patients who underwent primary laparoscopic hiatal repair from January 2005 through December 2014. Retrospective chart review was performed to determine perioperative morbidity and mortality. Long-term results were assessed by sending out a questionnaire. Results were tabulated and patients were divided into 2 groups: fundoplication with hiatal closure + absorbable or non-absorbable mesh and fundoplication with hiatal closure alone. RESULTS: A total of 505 patients underwent primary laparoscopic fundoplication. Mesh reinforcement was used in 270 patients (53.5%). There was no significant difference in the 30-day perioperative outcomes between the 2 groups. No clinically apparent erosions were noted and no mesh required removal. Standard questionnaire was sent to 475 patients; 174 (36.6%) patients responded with a median follow-up of 4.29 years. Once again, no difference was noted between the 2 groups in terms of dysphagia, heartburn, long-term antacid use, or patient satisfaction. Of these, 15 patients (16.9%, 15/89) in the 'Mesh' cohort had symptomatic recurrence as compared to 19 patients (22.4%, 19/85) in the 'No Mesh' cohort (p = 0.362). A reoperation was necessary in 6 patients (6.7%) in the 'Mesh' cohort as compared to 3 patients (3.5%) in the 'No Mesh' cohort (p = 0.543). CONCLUSIONS: Onlay-mesh use in laparoscopic hiatal repair with fundoplication is safe and has similar short and long-term results as primary repair.

Vascular complication can be minimized with a balloon-expandable, re-collapsible sheath in TAVR with a self-expanding bioprosthesis.

OBJECTIVE: This study evaluates the feasibility and safety of a balloon-expandable, re-collapsible sheath for TAVR patients, including those with small iliofemoral access (≤5.0 mm). BACKGROUND: The recommended iliofemoral diameter for the CoreValve TAVR system is ≥6.0 mm, but the lowest limit has not been determined. METHODS: Of 322 consecutive patients who underwent TAVR from 1/2014 to 8/2015 at two institutions, 64 underwent transfemoral CoreValve implantation, using an 11/19-French balloon-expandable, re-collapsible sheath, which has a 4.45 mm outer diameter (OD) on arterial entry, expands to 7.67 mm, then re-collapses upon removal. Valve sizing and vascular access were determined by computed tomography, and outcomes were assessed using the Valve Academic Research Consortium 2 (VARC-2) definitions. RESULTS: Thirteen of 64 patients had a minimal iliofemoral artery luminal diameter (MLD) of ≤5.0 mm (mean 4.38+/-0.59 mm, range 3.1-5.0 mm), with vessel calcification ≤90° to 360° and tortuosity <45° to >90°. At the MLD point, the sheath-to-artery ratios, based on the fully expanded 7.67 mm OD, ranged 1.53-2.47, higher than previously reported ratios that risk vascular complications. Major comorbidities included chronic renal failure, severe chronic obstructive pulmonary disease, extreme thrombocytopenia, cirrhosis, prior cardiac surgery, poor ventricular function, and frailty. All 64 patients had TAVR with IV sedation and local anesthesia, with 0% sheath malfunction, 0% vascular complications, and 0% bleeding in-hospital and at 30 days per VARC-2 definitions. CONCLUSIONS: TAVR using a balloon-expandable, re-collapsible sheath is safe, including in small iliofemoral access ≤5.0 mm, thus considerably expanding the population suitable for transfemoral approach. © 2015 Wiley Periodicals, Inc.

Value of C-Arm Cone Beam Computed Tomography Image Fusion in Maximizing the Versatility of Endovascular Robotics.

BACKGROUND: To report our initial experience and highlight the value of using intraoperative C-arm cone beam computed tomography (CT; DynaCT(®)) image fusion guidance along with steerable robotic endovascular catheter navigation to optimize vessel cannulation. METHODS: Between May 2013 and January 2015, all patients who underwent endovascular procedures using DynaCT image fusion technique along with Hansen Magellan vascular robotic catheter were included in this study. As a part of preoperative planning, relevant vessel landmarks were electronically marked in contrast-enhanced multi-slice computed tomography images and stored. At the beginning of procedure, an intraoperative noncontrast C-arm cone beam CT (syngo DynaCT(®), Siemens Medical Solutions USA Inc.) was acquired in the hybrid suite. Preoperative images were then coregistered to intraoperative DynaCT images using aortic wall calcifications and bone landmarks. Stored landmarks were then overlaid on 2-dimensional (2D) live fluoroscopic images as virtual markers that are updated in real-time with C-arm, table movements and image zoom. Vascular access and robotic catheter (Magellan(®), Hansen Medical) was setup per standard. Vessel cannulation was performed based on electronic virtual markers on live fluoroscopy using robotic catheter. The impact of 3-dimensional (3D) image fusion guidance on robotic vessel cannulation was evaluated retrospectively, by assessing quantitative parameters like number of angiograms acquired before vessel cannulation and qualitative parameters like accuracy of vessel ostium and centerline markers. RESULTS: All 17 vessels were cannulated successfully in 14 patients' attempted using robotic catheter and image fusion guidance. Median vessel diameter at origin was 5.4 mm (range, 2.3-13 mm), whereas 12 of 17 (70.6%) vessels had either calcified and/or stenosed origin from parent vessel. Nine of 17 vessels (52.9 %) were cannulated without any contrast injection. Median number of angiograms required before cannulation was 0 (range, 0-2). On qualitative assessment, 14 of 15 vessels (93.3%) had grade = 1 accuracy (guidewire inside virtual ostial marker). Fourteen of 14 vessels had grade = 1 accuracy (virtual centerlines that matched with the actual vessel trajectory during cannulation). CONCLUSIONS: In this small series, the experience of using DynaCT image fusion guidance together with a steerable endovascular robotic catheter indicates that such image fusion strategies can enhance intraoperative 2D fluoroscopy by bringing preoperative 3D information about vascular stenosis and/or calcification, angulation, and take off from main vessel thereby facilitating ultimate vessel cannulation.

Open Removal of Penetrating Inferior Vena Cava Filter with Repair of Secondary Aortic Dissection: Case Report.

Inferior vena cava (IVC) filters are indicated for the management of venous thromboembolism in patients who are not candidates for anticoagulation, have a contraindication to anticoagulation or who have recurrent thromboembolism despite anticoagulation. As IVC filter usage has increased, there has been a corresponding increase in presentation of filter-related complications. Filter leg penetration is commonly seen although is infrequently associated with complications. But in a small percentage of patients, penetration can result in damage to adjacent structures: duodenum, lumbar spine, and rarely the aorta. We report the case of a 77-year-old man with a chronic aortoiliac dissection secondary to aortic IVC filter penetration who underwent open filter retrieval and aortic repair.

Hybrid Approach to Pulmonary Valve Replacement with Melody Prosthesis Following Pulmonary Banding.

We report the case of a 27-year-old Jehovah's Witness patient with severe pulmonary insufficiency and right ventricular dilatation 16 years after primary repair, who sought transcatheter therapy as a means to avoid surgery and the risk of blood product administration. A hybrid procedure involving pulmonary artery banding to a diameter amenable to fixation of a Melody valve (Medtronic Inc.) via trans-ventricular puncture was performed.

Use of three-dimensional models to assist in the resection of malignant cardiac tumors.

The application of three-dimensional (3D) printing enables the creation of material objects from digital images by depositing layers of plastic material into 3D structures and can be used for training, education, and surgical planning. We report two patients with large complex cardiac tumors where 3D technology was utilized to analyze the tumor size, location, and extension more precisely, allowing better preoperative planning and decision making.

Development of a Severe Mitral Valve Stenosis Secondary to the Treatment of Mitral Regurgitation with a Single MitraClip.

We report a patient with class III heart failure symptoms due to mitral regurgitation (MR) subsequent to nonischemic cardiomyopathy. The patient underwent percutaneous transcatheter mitral valve repair using a single MitraClip, which reduced the MR; however it created mild-to-moderate mitral stenosis, which progressed to severe mitral stenosis. Subsequently the patient underwent mitral valve replacement surgery.

Short-Term Outcomes with Direct Aortic Access for Transcatheter Aortic Valve Replacement.

BACKGROUND AND AIM OF THE STUDY: Transcatheter aortic valve replacement (TAVR) requires a safe route of access to the aortic valve. A direct aortic route has been used as alternate access approach in patients where ileo-femoral access is unsafe due to size, calcification and/or tortuosity. The study aim was to review the authors' results obtained with a direct aortic (DA) TAVR, examining in particular the safety and effectiveness of this approach. METHODS: A retrospective analysis was performed of all prospectively collected TAVR data from January 2011 to March 2015 at the authors' institution. DA-TAVRs were performed using either an upper mini- sternotomy (MST) into the second right intercostal space, or via a right anterior mini-thoracotomy (RAT) at the second intercostal space. The choice between MST and RAT approaches was made by the surgeon, based on aortic imaging, patent bypass grafts and pulmonary function. Both, Medtronic CoreValve and Edwards SAPIEN devices were used. All relevant perioperative and clinical outcomes were collected based on Valve Academic Research Consortium 2 (VARC-2) definitions. Median numerical values were used. RESULTS: Seventy-eight consecutive patients underwent DA-TAVR with 100% intraoperative survival and 92% 30-day survival. The procedural success was 97%. The majority of patients (79%) underwent DA-TAVR with the Medtronic CoreValve, via MST (92%). All patients were classified either as extreme (74%) or high risk (26%) for surgical aortic valve replacement. CONCLUSION: DA-TAVR provides a safe and viable alternate access approach for patients with inadequate ileo-femoral access. The clinical outcomes were acceptable in this very high-risk group of patients.

Direct Aortic Access Transcatheter Aortic Valve Replacement: Three-Dimensional Computed Tomography Planning and Real-Time Fluoroscopic Image Guidance.

BACKGROUND AND AIM OF THE STUDY: Direct aortic access for transcatheter aortic valve replacement (DA-TAVR) is an important alternative approach in patients with hostile ileo-femoral vessels. Planning the transaortic puncture site and an 'ideal' trajectory towards the annulus plane is important for safe and successful valve implantation. The feasibility of three-dimensional (3D) planning and real-time fluoroscopic image guidance for DA-TAVR was evaluated using pre-procedural multi-detector computed tomography (MDCT) and intra-procedural Dyna CT co-registration approaches. METHODS: Between May 2012 and August 2014, a total of 44 patients (40 mini-sternotomies, four mini-thoracotomies) was selected for DA-TAVR using the authors' MDCT-Dyna CT co-registration approach (32 CoreValve, 12 SAPIEN). Pre-procedural contrast-enhanced multi-slice CT (MSCT) and intra- procedural non-contrast Dyna CT images were co-registered based on cardiac outline and aortic root calcifications. Using a prototype software, the aortic root was segmented and relevant landmarks identified automatically. The intersection of a virtual perpendicular trajectory from the annulus with the greater curvature of the aorta was marked as the planned DA puncture site. The planned DA puncture site, trajectory and relevant landmarks were overlaid onto real-time fluoroscopic images for image guidance during DA-TAVR. RESULTS: Real-time fluoroscopic overlay of planned trajectory was feasible in all 44 cases of DA-TAVR. The mean 2D projection distance error between the actual and planned aortic puncture sites was 1.60 +/- 1.1 cm. The mean angular difference error (measure of co-axiality) between actual and planned DA trajectory was 11.86 +/- 9.3. Errors in distance and co-axiality were lower with the mini-thoracotomy than with the mini-sternotomy approach. The Multi-Slice CT (MSCT)-Dyna CT co-registration technique resulted in significantly less contrast usage, and trended towards shorter fluoroscopy and operative times. There was also a trend towards a reduction in acute kidney injury, but no difference was identified in the degree of paravalvular regurgitation or mortality. CONCLUSION: 3D access planning and real-time image guidance for DA-TAVR is feasible using an MDCT/non-contrast Dyna CT image co-registration-based approach. Such image co-registration strategies improve the accuracy of case planning and safety of valve deployment with a direct aortic approach. Further studies are necessary to determine if these enhancements translate into an improvement in clinical outcomes.

Extracellular matrix scaffold as a tubular graft for ascending aorta aneurysm repair.

BACKGROUND: Although extracellular xenograft repair has produced encouraging results when applied to cardiac, valvular, and specific aortic defects, its employment as a tube graft to replace the ascending aorta has not been reported. We describe a patient who underwent resection and replacement of an infected ascending aortic graft with an extracellular matrix conduit. The patient did well, but 14 months later developed a pseudoaneurysm from the staple line used to construct the extracellular matrix conduit. METHODS: The patient underwent a repeat sternotomy and removal of the graft. Because of the increased risk of graft failure, a homograft was felt to be more appropriate in this setting. Ultimately, we were unable to implant the homograft because it was too small for the aortic root; therefore we decided to construct a tubular graft from Cormatrix extracellular matrix (CorMatrix, Roswell, GA, USA). Fourteen months later, he presented with shortness of breath. Computed tomography scan revealed a 3.5 cm pseudoaneurysm of the ascending aorta. It appeared as if there was a disruption of the staple line in the extra cellular matrix graft. The plan was to replace it with a Dacron graft. RESULTS: The Cormatrix graft material was removed and sent for culture and histological analysis. A 28-mm Gel weave graft (Terumo Cardiovascular Systems, Ann Arbor, MI, USA) was implanted. The patient tolerated the procedure well with good hemodynamics. CONCLUSIONS: Our experience suggests that the superior strength, handling characteristics, and resistance to infection make extra cellular matrix scaffold a possible alternative conduit to cryopreserved homografts. Applicability as an aortic conduit merits further investigation to better understand behavior of extra cellular matrix in this situation.

Transcatheter Treatment of Apicoaortic Conduit Dysfunction.

We report a 77-year-old male patient with a history of aortic valve bypass with an apicoaortic conduit 11 years ago for severe aortic stenosis, presenting with acute decompensated congestive heart failure. Severe conduit valve regurgitation and was successfully treated with transcatheter aortic valve replacement (TAVR) of the native aortic valve using a self-expanding bioprosthesis followed by transcatheter closure of the apicoaortic conduit.

Improved Outcomes With the Evolution of a Neoadjuvant Chemotherapy Approach to Right Heart Sarcoma.

BACKGROUND: Right-side heart sarcomas tend to be bulky, infiltrative, and difficult to treat. We have previously examined our outcomes with right heart sarcomas. Surgical resection with R0 margins showed better survival than positive margins but in only one third of cases could R0 status be achieved. The hypothesis for this study was that preoperative neoadjuvant chemotherapy would shrink the tumor margins and allow an increase in R0 resection, and hence, better survival. METHODS: Review of our cardiac tumor database from 1990 to 2015 yielded 133 primary cardiac sarcoma cases. Of these, we identified 44 patients with primary right-side heart sarcomas. Prospective database and retrospective data collection and clinical outcomes were evaluated for all 44 patients. Primary outcomes included 30-day mortality and morbidity and long-term survival. We used univariate and multivariate analyses to identify independent predictors of overall survival. RESULTS: There were 27 male and 17 female patients with a mean age of 41 ± 12.7 years (range, 15 to 67). Seventy-three percent of the patients (32 of 44) received neoadjuvant chemotherapy. The most common tumor histology was angiosarcoma in 30 of 44 (68%). Thirty-day mortality was 4.5%, and statistically similar between the two groups. The median survival of patients who had R0 resection was 53.5 months compared with 9.5 months for R1. Neoadjuvant chemotherapy led to a doubling of survival (20 versus 9.5 months). CONCLUSIONS: Neoadjuvant chemotherapy followed by radical surgery is a safe and effective strategy in patients with primary right-side heart sarcoma. This multimodality treatment enhances resectability (R0 resection) that translates into improved patient survival.

Right Ventricular Outflow Tract Obstruction Caused by Isolated Sinus of Valsalva Aneurysm.

Isolated sinus of Valsalva aneurysm is a rare occurrence, with an incidence of <1.5% among congenital heart disease repairs in the world. We recount the case of a 64-year-old man who presented with right-sided heart failure symptoms caused by a severely dilated right coronary sinus of Valsalva aneurysm that substantially obstructed the right ventricular outflow tract. Successful surgical repair involved right ventricular outflow tract resection and subcoronary patch repair.

Cardiac Papillary Fibroelastoma: Single-Institution Experience with 14 Surgical Patients.

In general, treatment for symptomatic and asymptomatic cardiac papillary fibroelastoma is surgical resection-particularly of left-sided lesions, because of the risk of systemic embolization. However, few institutions have enough experience with these tumors to validate this approach. We present our institutional experience with papillary fibroelastoma and discuss our current approach. We searched our institution's cardiac tumor database, identified all patients diagnosed with cardiac papillary fibroelastoma from 1992 through 2014, and recorded the clinical and pathologic characteristics of each case. We found 14 patients (mean age, 60.5 ± 12.3 yr) who had 18 lesions. Eleven patients (79%) were symptomatic; however, we could not always definitively associate their symptoms with a cardiac tumor. Most lesions were solitary and ≤1.5 cm in diameter; half involved the left side of the heart. All 18 lesions were surgically excised. There were no operative or 30-day deaths, and no patient needed valve replacement postoperatively. There was one late death; at one year, another 3 patients were lost to follow-up, and the others were alive without tumor recurrence. Because of the embolic risk inherent to intracardiac masses and our relatively good postoperative outcomes, we recommend the surgical resection of all left-sided papillary fibroelastomas in surgical candidates, and we discuss with patients the advisability of resecting right-sided lesions.

Cannulation Strategies and Pitfalls in Minimally Invasive Cardiac Surgery.

For any given cardiac surgery, there are two invasive components: the surgical approach and the cardiopulmonary bypass circuit. The standard approach for cardiac surgery is the median sternotomy, which offers unrestricted access to the thoracic organs-the heart, lung, and major vessels. However, it carries a long list of potential complications such as wound infection, brachial plexus palsies, respiratory dysfunction, and an unpleasant-looking scar. The cardiopulmonary bypass component also carries potential complications such as end-organ dysfunction, coagulopathy, hemodilution, bleeding, and blood transfusion requirement. Furthermore, the aortic manipulation during cannulation and cross clamping increases the risk of dissection, arterial embolization, and stroke. Minimally invasive cardiac surgery is an iconic event in the history of cardiothoracic medicine and has become a widely adapted approach as it minimizes many of the inconvenient side effects associated with the median sternotomy and bypass circuit placement. This type of surgery requires the use of novel perfusion strategies, especially in patients who hold the highest potential for postoperative morbidity. Cannulation techniques are a fundamental element in minimally invasive cardiac surgery, and there are numerous cannulation procedures for each type of minimally invasive operation. In this review, we will highlight the strategies and pitfalls associated with a minimally invasive cannulation.

Case Report: Chronic Recurrent Unilateral Pulmonary Infection: Result of Congenital Unilateral Agenesis of Pulmonary Artery.

Unilateral agenesis of the pulmonary artery (UAPA) is a rare congenital anomaly. This report describes a 52-year-old female who gave a long history of chronic, recurrent, left-sided pulmonary infections related to UAPA. For many years, she was managed medically but the infection continued to recur. She eventually underwent left pneumonectomy and made a good recovery.

Case Report: Cardiac Tumor Resection And Repair With Porcine Xenograft.

Primary cardiac sarcomas are rare and carry a grave prognosis. Improved survival requires a complete margin negative resection of the tumor. These surgical resections are often large and complex, requiring extensive reconstructive procedures. The appropriate material for cardiac reconstruction is not known. We have used glutaraldehyde-fixed bovine pericardium in our early series but have recently employed the MatriStem(®) Surgical Matrix PSMX membrane (ACell(®), Inc.; Columbia, MD), a unique proprietary urinary bladder matrix derived from porcine urinary bladder with the potential for viability and tissue ingrowth. In our study of six patients at this institution, all six underwent successful surgical resection and repair with the MatriStem acellular porcine urinary bladder membrane (ACell). The postoperative course was uncomplicated in all patients, and they are still alive at this time. An aggressive surgical approach to cardiac tumors can possibly lead to complete resection but often requires reconstruction of the cardiac tissue with a membrane. We were able to achieve acceptable results in our cardiac reconstruction by using the ACell extracellular matrix to reconstruct the defect following tumor resection. Longer-term follow-up in these patients, including imaging studies, will be necessary to demonstrate the durability and integrity of the reconstruction.

Right Atrial Tumor Resection and Reconstruction with Use of an Acellular Porcine Bladder Membrane.

Malignant cardiac tumors typically have a grave prognosis; their resection with negative margins is optimal. We present the case of a 21-year-old woman in whom we surgically resected a primary cardiac sarcoma and reconstructed the right atrium with use of a porcine urinary bladder membrane-the MatriStem(®) Surgical Matrix PSMX. The patient recovered uneventfully. Six months postoperatively, the right atrial wall had retained its integrity. In addition to our patient's case, we discuss the benefits of using the MatriStem membrane in cardiac reconstruction.

Case Report: A Rare Case of Left Atrial Hemangioma: Surgical Resection and Reconstruction.

Hemangioma of the heart presenting as a primary cardiac tumor is extremely rare, accounting for approximately 2% of all primary resected heart tumors. Only a few cases of cardiac hemangiomas have been reported to arise from the left atrial wall. In this case report we share our experience in the diagnosis and surgical resection of a large (9 × 7 cm) left atrial hemangioma and reconstruction of the heart using porcine urinary bladder membrane.

Case Report: Delayed Type A Aortic Dissection Following Complete Debranching of the Aortic Arch and Stent Graft Placement.

Treatment options for aortic arch disease in high-risk patients includes supra-aortic debranching and thoracic endovascular aortic repair (TEVAR). Acute ascending aortic dissection is a concerning complication of this approach and has been reported to occur in a retrograde fashion. We report a case of a 60-year-old gentleman who had undergone thoracic endovascular aortic repair with debranching and presented 31 months later with acute isolated ascending aortic dissection. The patient underwent successful total replacement of the ascending aorta with a 30-mm gelwave Valsalva(™) graft using cardiopulmonary bypass.