Clinical Outcomes Following Transcatheter Mitral Valve-in-Valve Replacement Using a Meril Myval Transcatheter Heart Valve.

AIM: Transcatheter mitral valve-in-valve (TMViV) replacement for degenerated surgically implanted bioprosthetic valves has been described by both transseptal and transapical approaches. The balloon-expandable Myval transcatheter valve (Meril Life Sciences, Vapi, India) is commonly used for transcatheter valve-in-valve procedures in India. This study aimed to report in-hospital, 30-day, and 1-year outcomes of Myval patients who underwent TMViV in a single tertiary care centre in India. METHODS: Symptomatic patients with surgical bioprosthetic mitral valve failure with New York Heart Association (NYHA) class III-IV symptoms, despite optimal medical therapy and high or very high risk for redo surgery, were assigned to TMViV following heart team discussions. Data were retrospectively collected and outcomes assessed. RESULTS: Twenty patients were treated, with mean age 64.4 years, 60% were female, and mean Society of Thoracic Surgeons (STS) predicted risk of operative mortality score was 8.1. The failure mechanism was combined stenosis and regurgitation in 60% of patients. Technical success was achieved in 100% of patients. The mean postprocedure and 30-day gradients were 4.6±2.7 and 6.3±2.1, respectively. None of them had significant valvular or paravalvular leaks or left ventricular outflow tract obstruction. All-cause mortality at 1 year was 10%, and all survivors were in New York Heart Association (NYHA) class I or II. CONCLUSION: TMViV replacement with a Meril Myval can be safely performed with high technical success, and low 30-day and 1-year mortality.

Planning and execution of catheter closure of a giant left atrial appendage aneurysm causing recurrent cardioembolism.

Giant left atrial appendage aneurysms (LAAAs) are rare causes of recurrent cardioembolism and managed routinely by surgery. A first catheter closure of a giant LAAA is reported, when a recent cerebral infarct precluded immediate surgery. Planning included ostial measurement on multimodal imaging, echo navigation for septal puncture, rotational angiogram for profiling, overlay imaging for device placement, and cerebral embolic protection from thrombus debris.

Cavopulmonary Anastomosis in a Patient With Arrhythmogenic Right Ventricular Cardiomyopathy With Severe Right Ventricular Dysfunction.

A 26-year-old lady presented with exertional dyspnea, palpitations, central cyanosis, and oxygen saturations of 80% in room air. Her electrocardiogram, echocardiogram, and cardiac magnetic resonance were diagnostic of arrhythmogenic right ventricular dysplasia. There was no documented ventricular arrhythmia or syncopal episodes and Holter recordings were repeatedly normal. Cardiac hemodynamics showed right to left shunt through atrial septal defect, low pulmonary blood flow, normal atrial pressures, and minimally elevated right ventricular end-diastolic pressures. Since her presenting symptoms and cyanosis were attributed to reduced pulmonary blood flow, she underwent off-pump cavopulmonary anastomosis between right superior vena cava and right pulmonary artery. As we intended to avoid the adverse effect of extracorporeal circulation on the myocardial function and pulmonary vasculature, we did not attempt to reduce the size of the atrial septal defect. Her postoperative period was uneventful; oxygen saturation improved to 89% with significant improvement in effort tolerance. At 18-month follow-up, there were no ventricular arrhythmias on surveillance. The clinical presentation of this disease may vary from serious arrhythmias warranting defibrillators and electrical ablations at one end to right ventricular pump failure warranting cardiomyoplasty or right ventricular exclusion procedures at the other end. However, when the presentation was unusual with severe cyanosis through a stretched foramen ovale leading to reduced pulmonary blood flows, Glenn shunt served as a good palliation and should be considered as one of the options in such patients.

Descending aortic translocation procedure for relief of bronchial compression in left aortic arch and right descending aorta.

Compression of the left bronchus by a right-sided descending aorta arising from a left aortic arch constitutes an exceedingly rare form of vascular ring. This manuscript describes the surgical technique that involves translocation of the descending aorta directly to the proximal ascending aorta, thereby relieving the bronchial compression.

Translocation of Intramural Coronary Artery During Switch Procedure: A New Technique.

Intramural course of a coronary artery is a rare association in patients with transposition of great arteries. Various techniques have been described for translocation of these during the arterial switch procedure, with mixed results. This report focuses on a novel technique that is reproducible and provides an alternative in this difficult subset of patients.

Anomalous origin of right pulmonary artery from innominate artery: Repair using pulmonary artery pedicled flap plasty.

Origin of the right pulmonary artery from innominate artery is an exceedingly rare anomaly. We report two cases with this anomaly that underwent surgical repair. The surgical technique described achieves tissue-to-tissue anastomosis using a pedicled flap from the main pulmonary artery.

Unusual presentation of total anomalous systemic venous connection.

A 9-year-old girl who presented with dyspnea on exertion was diagnosed with total anomalous systemic venous connection to the left atrium (both venae cavae), no left superior vena cava, and a moderate-sized atrial septal defect with severe pulmonary arterial hypertension and ectopic atrial rhythm. She underwent septation of the common atrium using autologous pericardium, thereby rerouting the superior vena cava, inferior vena cava, and coronary sinus to the right atrium. Her postoperative course was uneventful. This case is reported for its rarity of presentation with severe pulmonary arterial hypertension and ectopic atrial rhythm.

Pediatric heart transplant for unresectable primary cardiac tumor.

Surgery for primary cardiac tumors in children includes complete resection, partial resection, and cardiac transplantation. A pediatric heart transplant in this setting is associated with significantly higher mortality and poorer long-term outcome, and it is reserved for unresectable tumors. We recently performed an emergency pediatric heart transplant in a 7-year-old boy with an unresectable cardiac fibroma in the left ventricle.

The "excluding" suture technique for surgical closure of ventricular septal defects: A retrospective study comparing the standard technique.

BACKGROUND: Conventional methods of closure of ventricular septal defects involve placement of sutures 4-5 mm from the posterior inferior margin. This study compares the conventional method with an alternative technique wherein sutures are placed along the edge of the defect thereby "excluding" the conduction system and the tensor apparatus of the tricuspid valve from the suture line. MATERIALS AND METHODS: Between January 2013 and January 2016, 409 consecutive patients were retrospectively reviewed and divided into two matched groups. Group A (n = 174) underwent closure using the alternative technique and Group B (n = 235) with the conventional technique. Patients with isolated ventricular septal defects (VSDs) (n = 136) were separately analyzed as were infants within this subset. RESULTS: Immediate postoperative results were similar with no statistically significant differences in either group in terms of incidence of residual defects or postoperative tricuspid regurgitation. There was however a significantly increased incidence of post operative complete heart block (CHB) among patients in the conventional group (P = 0.02). Incidence of temporary heart block that reverted to sinus rhythm was also more in the conventional method group (Group B) (P = 0.03) as was right bundle branch block (P ≤ 0.05) in all the subsets of patients analyzed. CONCLUSION: Surgical closure of VSDs can be accomplished by placing sutures along the margins or away with comparable results. The incidence of CHB, however, seems to be less when the "excluding" technique is employed.

Lessons learnt from a series of hemodynamic and interventional complications during pulmonary valvotomy and device closure of ventricular septal defect.

In an adolescent girl with coexistent valvar pulmonary stenosis (PS) and muscular ventricular septal defect (VSD) causing right to left shunt and severe cyanosis, a series of complications were encountered during transcatheter intervention. After balloon pulmonary valvotomy (BPV) and device closure of the VSD, dynamic infundibular hypercontractility elevated the right ventricular (RV) systolic pressures leading to embolization of the device into the left ventricle. During retrieval of the device from the left ventricular outflow tract (LVOT), there was injury to the atrioventricular nodal tissue resulting in transient complete heart block. Even though the device was successfully retrieved out from the right femoral arterial access, there was a retroperitoneal hematoma causing severe anemia. A combination of dynamic infundibular obstruction, intravascular volume depletion caused by hemorrhage, low oxygen carrying capacity due to anemia, and inotropes resulted in a life-threatening hypercyanotic spell. Once this combination of suicidal hypercontractile right ventricle, anemia, and dehydration was recognized; management of the pathophysiology resulted in recovery of the patient. On a subsequent day, device closure of the VSD was complicated by unstable device position, but was finally achieved by an innovative device stabilization technique. We propose to explain the basis of hemodynamic and procedural complications, their recognition, and management. During preparatory stage before interventions in patients with multiple defects, which are linked by strong hemodynamic interdependence, meticulous planning should be done and multiple untoward events should be foreseen. While a few complications were completely unanticipated, some others could have been predicted.

The pressures of surgicel(®) in cardiac surgery.

Surgicel® is bioabsorbable hemostatic mesh, frequently packed around oozing surgical bed. We report two morbidities due to it. Following transannular patch repair for Fallot's tetralogy, Surgicel® was packed around distal main pulmonary artery. Echocardiography in the intensive care unit (ICU) showed right ventricular dysfunction due to extrinsic obstruction and complete occlusion of left pulmonary artery (LPA) flows. Another patient with arterial switch operation had postoperative fibrillatory cardiac arrest, needing resuscitation with internal cardiac massage. The arrest was triggered by coronary ischemia due to periaortic compression. Both instances were caused by hygroscopic nature of Surgicel®, which absorbed blood, swelled, and compressed the luminal tissues.

Surgical Repair of Interrupted Aortic Arch and Interrupted Pulmonary Artery.

Interrupted aortic arch (IAA) is usually associated with ventricular septal defect and patent ductus arteriosus. We report surgical repair in a case of IAA, ventricular septal defect, and interruption of the pulmonary artery with the right pulmonary artery arising from the innominate artery through a separate ductus arteriosus.