Outcomes of Video-assisted Minimally Invasive Cardiac Myxoma Resection.

BACKGROUND: Myxomas are the most frequent cardiac tumours. Their diagnosis requires prompt removal. In our centre, for valve surgery we use a minimally invasive approach. Here, we report our experience of cardiac myxoma removal through right lateral mini-thoracotomy (RLMT) with particular focus on its feasibility, efficacy and patient safety. METHODS: Between February 2006 and January 2017, 30 consecutive patients (aged 66±12.6years, range 35-83 years) underwent atrial myxoma resection through video-assisted RLMT. Percutaneous venous drainage was performed in all patients and direct cannulation of the ascending aorta was performed in 28 out of 30 (93.3%). The diagnosis of atrial myxoma was confirmed by histology. RESULTS: Complete surgical resection was achieved in all patients. The mean cardiopulmonary bypass (CPB) time was 76.5±40.8minutes and average aortic cross-clamping time was 41.5±29.8minutes. No patient suffered postoperative complications. Five patients (16.7%) received a blood transfusion. Mechanical ventilation ranged from 3 to 51hours (median 6hours), intensive care unit (ICU) stay ranged from 1 to 5days (median 1day). Total hospital length of stay (HLOS) was 5.6±2 days. Home discharge rate was 56.7%. No in-hospital mortality was reported. During follow-up (55.6±32.3 months; range 4-132 months), one tumour recurrence was observed. There were three late non-cardiac deaths. Overall survival was 100%, 85.7% and 85.7% at 1, 5 and 10 years, respectively. CONCLUSIONS: The use of video-assisted RLMT is an effective and reproducible strategy in all patients requiring expedited surgery for left atrial myxoma, independently of coexisting morbidity such as systemic embolisation or previous surgery. This technique leads to complete tumour resection, prompt recovery, early home discharge and high freedom from both symptoms and tumour recurrence.

Successful percutaneous implantation of symetis ACURATE neo transcatheter aortic bioprosthesis for the treatment of pure aortic regurgitation.

Transcatheter aortic valve implantation (TAVI) was initially developed for the treatment of calcific aortic stenosis. In the recent years, however, TAVI has been used to treat selected patients with pure, severe AR. We report successful transfemoral implantation of a Symetis ACURATE neo bioprosthesis in a severely symptomatic, 87-year-old woman with pure AR and major comorbidities. We decided to use the ACURATE neo bioprosthesis for some of its features appeared to us as potentially useful in the setting of pure AR: the stabilization arches ensure perfect coaxial alignment and extreme stability of the device during deployment, and the "waist" and the skirt were considered useful to obtain a good seal in the absence of significant valvular and annular calcifications. Finally, we decided to use a self-expanding valve to minimize the trauma to the aortic annulus. The procedure was successful and the patient was discharged home on postoperative day 3. At the 3-month control echocardiography, there was no residual AR, and the mean transprosthetic gradient was 3 mm Hg. The current case demonstrates that percutaneous TAVI with the ACURATE neo bioprosthesis may be used to treat pure, isolated AR in selected patients. The device has several interesting features that could make it advantageous in this setting. © 2016 Wiley Periodicals, Inc.

Surgical resection of colorectal carcinomas metastatic to the heart.

Colorectal carcinomas metastatic to the heart are rare. We present a case of colonic carcinoma metastatic to the right atrium and discuss the management and prognosis of these rare lesions.

Large Abdominal Aortic Aneurysm in a High-Risk Surgical Patient: Combined Percutaneous Transfemoral TAVI and EVAR Procedure.

A 78-year-old man was referred for surgical treatment of a 55 x 59 mm abdominal aortic aneurysm (AAA). However, clinical and instrumental data revealed a more complex case than was initially thought, the patient having a large AAA in the setting of severe symptomatic aortic stenosis with multiple comorbidities. Following multidisciplinary discussion, a combined transcatheter aortic valve implantation and endovascular aneurysm repair was performed. The present case represents a good example of the importance of the heart team in the project of tailored operative strategies, and in the optimization of the interventional therapy for the individual patient.

Simultaneous transapical paraprosthetic leak occlusion and valve-in-valve implantation into a degenerated mitral bioprosthesis.

Transcatheter valve-in-valve implantation is an emerging treatment option for high-risk patients with failing mitral bioprostheses. The presence of a paravalvular leak is considered a contraindication to this procedure that would leave the patient with significant residual regurgitation. The case is described of a patient with a severely degenerated 29 mm Carpentier-Edwards mitral bioprosthesis successfully treated by simultaneous transapical transcatheter valve-in-valve implantation and paraprosthetic leak occlusion. The potential advantages of this approach are discussed.

Balloon valuloplasty prior to transcatheter valve-in-valve implantation in a degenerated Mitroflow aortic bioprosthesis.

Transcatheter valve-in-valve implantation is an emerging treatment option for high-risk patients with failing aortic bioprostheses. The presence of the prosthesis stents is thought to prevent coronary artery obstruction, a known complication of transcatheter aortic valve implantation in the native aortic valve. The Sorin Mitroflow aortic bioprosthesis (Sorin Group, Saluggia, Italy) has a particular design in that the pericardial leaflets are mounted outside the valve stent. As a consequence, the pericardial leaflets of this prosthesis may be displaced well away from the stents during the deployment of transcatheter valves. This might explain why both the cases of coronary occlusion following valve-in-valve implantation reported to date occurred in patients with a malfunctioning Mitroflow bioprosthesis. We describe a patient with a malfunctioning 25 mm Mitroflow bioprosthesis successfully treated by percutaneous transcatheter valve-in-valve implantation, and discuss the role that balloon aortic valvuloplasty plays in the performance of this delicate procedure.

Sutureless aortic valve replacement through a right minithoracotomy.

During the past decade, interest in the development of less-invasive cardiac valve surgery has undergone a steady increase, with many surgeons having supplanted full sternotomy with minimal-access incisions. While the minimally invasive approaches for the treatment of mitral disease have been standardized, the preferred route for aortic valve replacement (AVR) remains a matter of debate. Although AVR through a right minithoracotomy avoids opening the sternum, it does require a greater surgical ability and may be a challenging procedure, even for expert surgeons. By simplifying the valve implantation, the availability of sutureless prostheses might provide an important incentive for the diffusion of this approach. Herein are reported the details of three patients who received a 3f-Enable sutureless aortic bioprosthesis via a right minithoracotomy. The advantages and possible improvements of this procedure are also discussed.

Case Report: Three-Dimensional Printing Model for Surgical Planning of Left Ventricular Aneurysm: Evolution Toward Tailoring Surgery.

A 59-year-old woman was admitted to the emergency department for heart failure (HF), New York Heart Association (NYHA) IV, showing an anterior, evolved myocardial infarction (MI) with a wide apical left ventricular aneurysm (LVA), ejection fraction (EF) 24%, and global longitudinal strain (GLS) -5. 5% by echo. Cardiac magnetic resonance imaging (MRI) confirmed an apical LVA without thrombus, EF 20%, and a transmural delayed enhancement in the myocardium wall. Coronarography showed a three-vessel disease with occluded proximal left anterior descending (LAD) and proximal right coronary artery (RCA). Based on the cardiac CT scan, we decided to generate a three-dimensional (3D) print model of the heart, for better prediction of residual LV volumes. After LVA surgery plus complete functional revascularization, an optimal agreement was found between predicted and surgical residual LV end-diastolic (24.7 vs. 31.8 ml/m2) and end-systolic (54.1 vs. 69.4 ml/m2) volumes, with an improvement of NYHA class, from IV to I. The patient was discharged uneventfully and at 6- and 12-month follow-up, the NYHA class, and LV volumes were found unchanged. This is a second report describing the use of the 3D print model for the preoperative planning of surgical management of LVA; the first report was described by Jacobs et al. among three patients, one with a malignant tumor and the remaining two patients with LVA. This article focused on the use of the 3D print model to optimize surgical planning and individualize treatment of LVA associated with complete functional revascularization, leading to complete recovery of LV function with a favorable outcome.

Transcatheter valve in valve implantation for failed mitral and tricuspid bioprosthesis.

OBJECTIVE: We report our experience with the transapical transcatheter "Valve in valve" implantation (T-VIV) in patients with a failed mitral or tricuspid bioprosthesis; we briefly review the pertinent literature, and discuss some technical aspects of this procedure. BACKGROUND: Redo valve surgery for failure of a mitral or tricuspid bioprosthesis might become extremely challenging, both because of the patients' condition, which is frequently poor, and for the technical aspects of the operation itself, that can be very demanding. T-VIV has been widely employed with good results for the treatment of aortic bioprosthesis failure, and could represent an attractive option in this setting. METHODS: Four patients with multiple comorbidities (age: 63-83 years; logistic Euroscore: 37.2-81.5) underwent T-VIV at our institution for failure of a mitral [3] or tricuspid [1] bioprosthesis. A 26 mm Sapien valve was used in all cases. All the mitral procedures were performed via a transapical approach. The tricuspid procedure was performed via a transjugular approach. RESULTS: The first mitral procedure was complicated by the splaying of the xenograft stents and embolization of the valve. The procedure was converted to conventional surgery, and the patient died on postoperative day 1. In the subsequent procedures, the valve was positioned more atrially, and was fixed to the malfunctioning xenograft sewing ring. All subsequent procedures were successful, all patients were discharged home and were alive and well at follow-up. CONCLUSIONS: The results of T-VIV procedure in the mitral position have been suboptimal, and four of the sixteen patients reported to date died. However, all patients were extremely diseased, and some of the reported failures were related to amendable technical factors relative to the surgical access or to the valve deployment technique. With increasing experience, this procedure might become indicated as an alternative to conventional surgery in selected patients, encouraging increased use of bioprosthesis, and marking a pivotal change in the management of valvular disease.

Case Report: Lithoplasty-Assisted Trans-Axillary Transcatheter Aortic Valve-in-Valve Implantation.

We present the case of a severely symptomatic patient with a malfunctioning aortic bioprosthesis and severe multidistrict atherosclerosis that was addressed to our unit for transcatheter valve-in-valve implantation. The imaging and clinical assessment that led to the selection of the access route is discussed.

Cardiac Metastasis of Sacral Chordoma.

Chordoma is a rare tumor, usually diagnosed when the disease is advanced. Despite its slow growth, it is locally aggressive and has a poor long-term prognosis. Surgery is the mainstay treatment. Although cardiac metastases are very rare, the heart is frequently involved in systemic neoplastic diseases. This report describes a typical case of metastatic chordoma: the age at first diagnosis, the site of the primary tumor, and the slow growth of the cardiac metastasis were all typical features. Surgical excision of the mass from the right ventricular outflow tract is described together with echocardiographic, radiologic, and histopathologic characteristics of the metastatic chordoma.

A simple method to visualize the bicuspid aortic valve pathology by cardiac computed tomography.

Bicuspid aortic valve (BAV) disease is a spectrum of anomalies ranging from mild underdevelopment of a commissure to severe underdevelopment of two interleaflets triangles. Many different classifications of BAV, based on the echocardiographic, surgical or pathological appearance of the valve, and more recently on cardiac CT, have been proposed. We describe a simple technique, based on three-dimensional curved multiplanar reconstruction images, to obtain a pathology-like visualization of the full line of insertion (Hinge) of the aortic valve leaflets and of the interleaflet triangles with cardiac CT. This method could help to obtain a detailed categorization of any specific BAV anatomy based on the degree of underdevelopment (or on the absence) of one interleaflet triangle. Adherence to this concept could help to improve the imaging based analysis of BAV patients undergoing TAVR, and could lead to the adoption of a BAV classification based on the effective pathologic appearance of the valve also for patients undergoing TAVR.

Aortic valve replacement using stented or sutureless/rapid deployment prosthesis via either full-sternotomy or a minimally invasive approach: a network meta-analysis.

BACKGROUND: New technologies such as sutureless or rapid deployment prosthetic valves and access via minimally invasive incisions offer alternatives to traditional full-sternotomy aortic valve replacement (SAVR). However, a comprehensive comparison of these surgical techniques along with alternative valve prosthesis has not been completed. METHODS: Electronic databases were searched for studies comparing outcomes for SAVR, minimally invasive AVR (MiAVR), sutureless/rapid-deployment AVR (SuAVR) via full-sternotomy, or minimally invasive SuAVR (MiSuAVR) from their inception until September 2018. Early postoperative outcomes and follow-up data were included in a Bayesian network meta-analysis. RESULTS: Twenty-three studies with 8,718 patients were identified. Compared with standard SAVR, SuAVR had significantly lower incidence of postoperative AF [odds ratio (OR) 0.33, 95% confidence interval (CI): 0.14-0.79, P=0.013] and MiSuAVR greater requirement for postoperative permanent pacemaker (OR 2.27, 95% CI: 1.25-4.14, P=0.008). All sutureless/rapid-deployment procedures had reduced cardiopulmonary bypass and cross-clamp times, by a mean of 25.9 and 25.0 min, respectively. Hospital length of stay (LOS), but not intensive care LOS, was reduced for all groups (MiAVR -1.53 days, MiSuAVR -2.79 days, and SuAVR 3.37 days). A signal towards reduced early mortality, wound infections, and acute kidney injury was noted in both sutureless/rapid-deployment and minimally invasive techniques but did not achieve significance. Sutureless/rapid-deployment procedures had favourable survival and freedom from valve related reoperation, however follow-up times were short and demonstrated significant heterogeneity between intervention groups. CONCLUSIONS: Minimally invasive and sutureless techniques demonstrate equivalent early postoperative outcomes to SAVR and may reduce ventilation time, hospital LOS and postoperative atrial fibrillation (POAF) burden.

A new left atrial retractor for minimally invasive mitral valve surgery.

INTRODUCTION: The recent boost of the minimally invasive techniques for mitral valve surgery has led to the development of a dedicated surgical outfit, including retractors, arterial and venous cannulas, and surgical instruments. An effective left atrial retractor is crucial, since an optimal exposure is a prerequisite for a successful mitral valve repair. Most of the available retractors require a supporting arm that is inserted in the chest via a parasternal hole. This maneuver may be associated with significant bleeding from the internal thoracic artery and vein or from their collaterals, especially in patients undergoing redo operations in whom the identification of these vessels may be difficult. The MitraXs is a self-expanding, pliable, left atrial retractor that may be inserted in the atrium from the minithoracotomy, and does not require any supporting arm. We describe its use in a patient with a previous history of esophageal resection and retrosternal colon interposition. METHODS AND RESULTS: The mitral valve was approached via right minithoracotomy with femoral bypass and direct aortic cross-clamping. In this particular case, the MitraXs was used to avoid the blunt insertion of the conventional retractor's supporting arm in order to prevent any possible injury to the neo-esophagus.The mitral valve exposure was excellent, and the operation was easily performed. The postoperative course was uneventful. COMMENT: In our opinion, the described approach allows a safe exposure of the aorta and left atrium, and should be considered the approach of choice in patients with retrosternal anomalies. The use of the MitraXs retractor may represent a helpful addition in selected patients, and should be recommended for redo operations.

Massive Hemoptysis from a Pulmonary Artery Pseudoaneurysm during Cardiac Surgery.

Massive hemoptysis is a life-threatening condition usually related to a pathology of the bronchial arteries. Pulmonary artery pseudoaneurysms represent a relatively rare cause of severe airway bleeding, but are associated with a mortality rate of over 50%. A case of massive intraoperative hemoptysis treated with temporary occlusion of the right pulmonary artery and delayed endovascular occlusion of the feeding segmental artery is described.

Increased Gradients After Aortic Valve Replacement With the Perceval Valve: The Role of Oversizing.

BACKGROUND: Significant underexpansion or distortion of valved stents may be associated with altered leaflet function, leading to increased transprosthetic gradients and, possibly, early structural degeneration. We investigated the relationship between a computed tomography measure of the degree of oversizing and the early hemodynamic and clinical outcomes in patients undergoing aortic valve replacement with the Perceval sutureless aortic valve (LivaNova, Saluggia, Italy). METHODS: The degree of oversizing of the implanted prosthesis was calculated as the ratio between the patients' aortic annulus cross-sectional area and the ex vivo cross-sectional area of the implanted prosthesis in 151 Perceval patients who underwent preoperative cardiac computed tomography. This value was then entered in a multivariate analysis to ascertain its role as a predictor of increased postoperative gradient. RESULTS: The operative mortality was 1.3%. Procedural success, defined as having a normally functioning valve in the proper anatomical location, was achieved in 150 patients (99.3%). The mean transprosthetic gradient was 13.4 ± 5.0 mm Hg, and 23 patients (15.2%) showed a gradient of 20 mm Hg or more at discharge or at the 1-month follow-up. The degree of oversizing of the implanted prosthesis was the most important predictor of increased postoperative gradient (odds ratio, 1.264; 95% confidence interval, 1.147 to 1.394; p < 0.0001). Interestingly, other relevant factors (patients' body surface area, prosthesis size) were not associated with increased gradients. CONCLUSIONS: Our study demonstrates that excessive oversizing should be avoided in Perceval patients and suggests that a different sizing algorithm, possibly based on cardiac computed tomography, should be developed. Further studies are needed to optimize the sizing strategy for the Perceval sutureless valve.

EuroSCORE Performance in Minimally Invasive Cardiac Surgery: Discrimination Ability and External Calibration.

OBJECTIVE: Prediction of operative risk in adults undergoing cardiac surgery remains a challenge. The European System for Cardiac Operative Risk Evaluation (EuroSCORE) is one of the most commonly used in clinical settings. Recently, the new EuroSCORE II was published attempting to improve the accuracy of risk prediction. We sought to assess the predictive value of EuroSCORE or EuroSCORE II in selected field of minimally invasive cardiac surgery. METHODS: Patients who underwent cardiac surgery operation with minimally invasive approach from 2007 to 2013 identified from prospective cardiac surgical database. Additional variables included in EuroSCORE II, but not in original EuroSCORE, were retrospectively collected via electronic health records reviewing. The C-statistic was calculated for the EuroSCORE (additive and logistic) and EuroSCORE II. The Hosmer-Lemeshow test was used to assess model calibration by comparing observed and expected morality in number of risk strata. RESULTS: There were 39 hospitals deaths (1.6%). A total of 2472 patients were identified from the main database. The mean ± SD logistic EuroSCORE was 7.6 ± 8.3, mean ± SD additive EuroSCORE was 6.1 ± 2.7, and mean ± SD EuroSCORE II was 2.9 ± 4.2. EuroSCORE logistic model performed with substantial accuracy of 0.78, EuroSCORE additive performed with accuracy of 0.78, and EuroSCORE II performed as almost perfect 0.82. Model calibration was poor in EuroSCORE II (χ = 17.57, P = 0.02), calibration for logistic EuroSCORE was also poor (χ = 140.58, P < 0.01), and additive model also (χ = 94.95, P < 0.01). The area under the curve was high in all algorithms; logistic EuroSCORE was 0.78 (95% confidence interval = 0.71-0.85), additive EuroSCORE was 0.79 (95% confidence interval = 0.71-0.86), and EuroSCORE II was 0.82 (95% confidence interval = 0.75-0.89). CONCLUSIONS: In overall settings, original EuroSCORE and EuroSCORE II perform poorly in minimally invasive operation conditions. Data suggest that EuroSCORE could not be used for estimating operative risks correctly. New risk score should be explored, developed, and implemented for selective minimally invasive cohorts.