Periareolar approach in female patients undergoing mitral and tricuspid valve surgery: An almost invisible surgical access.

BACKGROUND AND AIM OF THE STUDY: Periareolar minithoracotomy represents an interesting option in minimally invasive cardiac surgery and it is our preferred approach for women. Our aim is to assess the results in female patients, in terms of nipple postoperative pain, local sensitivity, and eventual alterations in mammography after surgery. METHODS: Fifty-seven female patients underwent periareolar incision, as minithoracotomy approach, from December 2018 to December 2021. Their mean age was 56 ± 12 years, their body mass index was 22.5 ± 4.8; their surgery was elective in 93%, with mean Euroscore II about 2 ± 1.3. RESULTS: Of 57 patients, 87.7% (50 patients) underwent mitral valve repair, whose six with associated procedures; 8.8% (five patients) underwent mitral valve replacement whose two with tricuspid annuloplasty associated and 3.5% (two patients) had isolated tricuspid surgery. The cardiopulmonary bypass and aortic cross-clamp time were 123.2 ± 30.2 and 101.3 ± min respectively. There were no conversions to either full sternotomy or larger thoracotomy approach. There were no in-hospital and follow-up deaths. No strokes or wound infections were observed. Mean follow-up was 16± 9 months. Within the investigated follow-up, 100% of the patients were satisfied with the esthetic result, no remarkable postoperative pain was reported, two patients had slight hyposensitivity in the nipple area. About 50% IThad mammography as prevention screening after surgery and no abnormalities were found. CONCLUSIONS: Periareolar minithoracotomy is a feasible surgical option in female patients, with excellent healing and cosmetic results and preserving the tissues of the mammary gland.

Asymptomatic giant circumflex aneurysm in patient with a cisplatin treatment history.

We report a case of 62-years-old man with a previous history of squamocellular tumour at the jaw treated with cisplatin chemotherapy. Six years after the chemotherapy, a transthoracic echocardiography showed a large left atrial lateral wall mass causing mitral stenosis. The thoracic computed tomography angiography (CTA) scan confirmed the mass (66x88mm) with contrast enhancement and the coronary angiography defined it as a giant left circumflex aneurysm. The aneurysm was resected and bypass graft performed. The aetiology and the technique used to treat this aneurysm are worthy to be described.

Radial artery supply to the left mammary artery in a redo coronary bypass.

BACKGROUND: Single-inflow coronary bypass through left internal thoracic artery and Y graft is effective in myocardial revascularization, but left sublavian diseases may affect its safety. AIM OF THE STUDY: To assess that, in presence of a composite Y graft, issues involving the origin of the left internal thoracic artery are relatively easy to manage, even in reoperations. METHODS: A critical stenosis of the subclavian artery involving the origin of a bilateral internal thoracic artery Y graft was bypassed using a free radial artery graft. RESULTS: Bypass was performed between the left thoracic artery and the ascending aorta, off-pump and with excellent results. CONCLUSIONS: In consideration of the excellent long term results of total arterial revascularization, radial artery is a feasible graft option, even in case of a composite Y graft in place.

Minimally invasive aortic valve surgery in obese patients: Can the bigger afford the smaller?

BACKGROUND: Ministernotomy and right minithoracotomy are well-known minimally invasive approaches for aortic valve replacement (AVR); however, controversial opinions exist for their utilization in obese patients. The aim of this study is to check a potential positive role of minimally invasive surgery in this population. METHODS: From January 2010 to November 2019, 613 obese patients (defined by a body mass index ≥30) underwent isolated AVR at our institution. Surgical approach included standard median sternotomy (176 patients), partial upper sternotomy (271 patients), or right anterior minithoracotomy (166 patients). Intra- and postoperative data were retrospectively collected. RESULTS: Patients treated with minimally invasive approaches had shorter cardiopulmonary bypass time (p = .012) and aortic cross-clamp time (p = .022), mainly due to the higher utilization of sutureless valve implantation. They also presented advantages in terms of reduced postoperative ventilation time (p = .010), incidence of wound infection (p = .009), need of inotropic support (p = .004), and blood transfusion (p = .001). The univariable logistic regression showed the traditional full sternotomy approach as compared with ministernotomy (p = .026), active smoking (p = .009), peripheral vascular disease (p = .003), ejection fraction (p = .026), as well Logistic European system for cardiac operative risk evaluation (EuroSCORE; p = .015) as factors associated with hospital mortality. The multivariable logistic regression adjusted for the logistic EuroSCORE revealed that surgical approaches do not influence hospital mortality. CONCLUSIONS: Obese patients with severe aortic valve pathology can be treated with minimally invasive approaches offering a less biological insult and reduced postoperative complications, but without impact on hospital mortality.

Preservation of the Pulmonary Valve During Early Repair of Tetralogy of Fallot: Surgical Techniques.

During the last decade interest in preserving pulmonary valve (PV) function has stimulated a few surgeons to apply valve-sparing techniques in repairing tetralogy of Fallot (TOF), with the aim of preserving long-term right ventricular function. Since June 2007, we embarked upon a program for preserving PV function in selected patients during TOF repair. More recently, the introduction of more complex PV plasty techniques allowed us to further extend the applicability of PV preservation techniques. We believe that preservation of PV function during early repair of TOF, by combining different intraoperative surgical maneuvers, can be extended to almost all patients with classic TOF.

Combined Surgical and Interventional Approaches for Treating Patients with Congenital Heart Disease.

AIMS: During the last decade the cooperation between surgeons and cardiologists has further expanded by combining surgical and interventional techniques (CCBSI) performed in the operating room, without the use of fluoroscopy. We sought to evaluate the results of our experience with CCBSI. METHODS: All children with congenital heart disease (CHD) who underwent a CCBSI in the operating room between June 2007 and January 2014 were enrolled. RESULTS: Sixty-eight patients were included. Median age at CCBSI was five months (range 1-48 months). The three main diagnoses leading to surgery included: (1) tetralogy of Fallot (TOF) (n = 40), (2) muscular ventricular septal defects (VSD) (n = 12), (3) single ventricle with pulmonary artery branch stenosis (n = 4). There were 72 catheter-based procedures associated with surgical maneuvres, including: (1) transatrial balloon dilation (BD) of the pulmonary valve (n = 45), (2) transinfundibular BD of the main pulmonary artery trunk (n = 12), (3) perventricular VSD closure with septal occluder (n = 8), (4) BD of pulmonary artery branches (n = 5), and other less common procedures (n = 2). There were no procedure-related complications and no hospital deaths. Median follow-up time was four years (range 0.95-7.9 years). There was one late death for respiratory distress after transapical balloon dilation of the aortic valve. One patient required BD and stenting of the left pulmonary artery branch 3.6 years after intraoperative BD for residual stenosis. CONCLUSIONS: The CCBSI represents a safe and effective treatment for selected patients with complex CHD. It will be helpful in minimizing patients' surgical trauma and in shortening or avoiding the use of cardiopulmonary bypass.

Simultaneous transapical aortic and mitral valve-in-valve implantation for double prostheses dysfunction: case report and technical insights.

Transcatheter "Valve-in-Valve" implantation (ViV) has shown promising results in high-risk patients suffering from structural valve deterioration (SVD) of a previously implanted heart valve bioprosthesis. We present a case of a 68-year-old woman with a history of three previous cardiac operations on the aortic and mitral valve. At the time of admission she was severely symptomatic due to a simultaneous SVD of a 23 mm aortic and of a 29 mm mitral St. Jude Biocor bioprosthesis. Because of the history of several cardiac operations and to her comorbidities, the patient was considered with an extremely high surgical risk profile and was therefore scheduled for double concomitant mitral and aortic ViV. Through a trans-apical approach, the patient underwent 23 and 29 mm Edwards Sapien XT implantation in the aortic and mitral bioprosthesis, respectively. The procedure was uneventful as well as the following hospital stay. At 6-months follow-up the patient is in NYHA class I. Echocardiography shows that the aortic bioprosthesis has no leak and the mean gradient is 20 mm Hg while the mitral valve has mild leak and maximum and mean gradients are 21 and 10 mm Hg, respectively. The three main technical aspects that should be carefully considered in double concomitant ViV are: sequence of valve deployment (whether to implant the mitral or the aortic valve first), choice of access and valve sizing. In conclusion, double simultaneous trans-apical mitral and aortic ViV is technically feasible. © 2014 Wiley Periodicals, Inc.

Intraoperative indocyanine green imaging as an adjunctive technique to reduce any circumflex artery damage during mitral valve surgery: a feasibility study.

Iatrogenic injuries to the circumflex coronary artery during mitral valve surgery are probably underestimated (reported rates of 0.3-1.8%). This complication arises from the artery's close proximity to the mitral annulus, particularly at the anterolateral commissure. The study aimed to assess this risk in a patient group prone to such injury. The surgical procedure utilized a minimally invasive approach and indocyanine green-based fluorescence imaging. This technique allows a real-time visualization of the circumflex artery, aiding precise placement of annular sutures and minimizing the risk of injury. The method, applied in 6 patients, integrates preoperative assessments with intraoperative fluorescence imaging, ensuring accurate arterial depiction and preventing iatrogenic damage. The study highlights the safety and efficacy of fluorescence imaging, especially in identifying vessel anomalies, indicating potential applications in various cardiac procedures.

Surgical Treatment of Active Endocarditis Pre- and Post-COVID-19 Pandemic Onset.

BACKGROUND: Despite advanced diagnosis and treatment, infective endocarditis (IE) is a potentially life-threatening condition. The impact of COVID-19 on the diagnosis and outcome of the surgical treatment of IE is uncertain. The aim of this study was to analyze the incidence, characteristics, and outcomes of surgically treated IE before and after the COVID-19 pandemic. METHODS: This study retrospectively analyzed the data of 535 patients who underwent valve surgical procedures for IE between January 2010 and December 2022 in a single cardiac surgery center. Patients were divided into two groups depending on the date of their operation: before (n = 393) and after (n = 142) COVID-19 onset. In order to balance the groups, inverse probability of treatment weighting (IPTW) calculated from the propensity score (PS) was applied. Weighted univariate logistic regressions were reported for outcomes; weights were derived from IPTW. Interrupted time series analysis (ITSA) according to Linden's method was used to evaluate the changes in the manifestation of IE after 11 March 2020. RESULTS: Patients from the post-COVID-19 cohort (after 11 March 2020) had a greater number of comorbidities such as diabetes (29.6% vs. 16.3% p = 0.001), hypertension (71.1% vs. 59.5% p = 0.015), and preoperative kidney injury requiring dialysis (9.2% vs. 2.5% p = 0.002), but the median additive and logistic EuroSCORE were not statistically different. In the post-COVID-19 group, we observed a greater prevalence of Staphylococcus aureus-related endocarditis (24.5% vs. 15.4% p = 0.026), a consequent reduction in Staphylococcus non aureus-related endocarditis (12.2% vs. 20.1% p = 0.048), and a decrease in aortic valve replacements (43.0% vs. 53.9%), while the number of mitral valve replacements and repair was greater (21.1% vs. 15.0% and 6.3% vs. 4.3%, respectively). No differences were found in the two groups concerning early death, death, or relapse at 1 year after surgery. Data obtained by multivariable analysis identified preoperative renal dysfunction requiring dialysis as the only common risk factor for early mortality via stratifying by time periods in analysis. CONCLUSIONS: The incidence of surgically treated IE significantly increases after the COVID-19 pandemic with a higher incidence of mitral valve involvement with respect to the aortic valve. Although a delay in surgical timing occurred during the COVID-19 pandemic, data in terms of mortality and outcomes were largely unaffected.

Pulmonary valve-sparing technique in patient with tetralogy of Fallot and anomalous coronary artery crossing the infundibulum.

A 15-month-old girl who presented at birth with tetralogy of Fallot and was followed after an echocardiographic diagnosis of an anomalous origin of the right coronary artery from the left anterior descending coronary artery, crossing the right ventricular infundibulum very close to the pulmonary valve annulus, was scheduled for repair. At surgery, after routine trans-atrial/trans-pulmonary repair, the pulmonary valve (PV) was balloon-dilated through the right ventricular outflow tract (RVOT) up to a 'normal size' PV annulus, based on the patient's body surface area. Two-dimensional echocardiography at discharge revealed an adequate relief of the RVOT obstruction, with a normal-sized PV annulus and a competent PV. In this subset of patients, this technique can be considered an additional surgical strategy to avoid the use of conduits.

Pulmonary artery branch stenosis in patients with congenital heart disease.

OBJECTIVE: We sought to evaluate our recent experience with surgical treatment of branch pulmonary artery (PA) stenosis both for native and acquired lesions. MATERIALS AND METHODS: The postoperative course of patients who underwent surgical PA plasty augmentation between January 2004 and January 2012 were reviewed. Primary outcomes included the need for further surgical procedures or interventional maneuvers on the branch PAs for residual stenosis. RESULTS: Thirty-four patients were included. Median age at PA plasty was eight months (range 8 days to 3.4 years). There were 12 native and 22 acquired PA stenoses, which were mainly located at the PA branch origin (n = 25, 73%). The PA plasty was defined as simple (n = 16, 47%) and as complex (n = 18, 53%), which included multiple maneuvers on the PA branches. Median follow-up time after surgical treatment was 4.7 years (range 0.9 to 8.7 years). One patient died 3 days after complex PA plasty for low output syndrome and another died 22 months later for congestive heart failure. Twenty-one (63.6%) underwent 40 catheter intervention procedures on the PA branches for residual stenosis. The majority of them (n = 10, 57.1%) were operated before the age of six months and the majority had an acquired PA stenosis (14, 66.7%). Three patients underwent additional surgical maneuvers on the PA branches. CONCLUSIONS: PA branch stenosis represents a life-threatening condition often necessitating further surgical or interventional treatment. A combined collaborative surgical followed by transcatheter approach is important, particularly in cases with an acquired PA stenosis who require complex surgical repair.

Impact of comorbidities on older patients undergoing open heart surgery.

BACKGROUND: The number of elderly patients undergoing cardiac surgery is increasing. Age greater than 80 years has been identified as a strong independent risk factor for shortand long-term survival. The current study is aimed to identify the impact of preoperative comorbidities on early and late outcomes in older patients undergoing cardiac surgery. METHODS: Baseline characteristics, procedurals and postoperative complications of all patients undergoing cardiac surgery at our institution are collected. The current analysis is focused on patients aged at least 80 years at the time of intervention and treated from January 2010 to December 2019. RESULTS: In-hospital mortality resulted as 6.3%. Redo intervention [odds ratio (OR) 2.49, 95% confidence interval (CI) 1.13-5.48], chronic obstructive pulmonary disease (COPD) (OR 2.99, 95% CI 1.75-5.12) and peripheral arterial disease (PAD) (OR 2.23, 95% CI 1.30-3.81) were independent baseline predictors of outcome in the multivariate analysis. Prolonged extracorporeal circulation time, need for transfusion and prolonged intubation time strongly and independently predicted in-hospital mortality. During a mean follow-up of 3.6 years 34.3% of patients died and unplanned admission (HR 1.33, 95% CI 1.05-1.67), NYHA class III-IV (HR 1.35, 95% CI 1.12-1.64), diabetes (HR 1.27, 95% CI 1.01-1.59), COPD (HR 1.60, 95% CI 1.25-2.04) and PAD (HR 1.32, 95% CI 1.03-1.71) resulted as independent predictors of all-cause death. CONCLUSION: Cardiac surgery is feasible in octogenarians, with an acceptable risk of mortality. Chronological age itself should not be the main determinant of choice while referring patients for cardiac surgical intervention. Comorbidities such as COPD, PAD and diabetes need to be taken into account for risk stratification.

Pacemaker need after sutureless aortic valve replacement: the role of the learning curve.

AIM: Aortic valve replacement (AVR) using sutureless prosthesis is a reasonable alternative in those patients with aortic stenosis who would benefit from reduced cross clamp time, such as elderly and high-risk patients. Actually, excellent performances have been demonstrated in hemodynamic outcomes and safety, but some questions remain open regarding long-term durability and the need for postoperative pacemaker implantation. METHODS: Between January 2014 and August 2019, all 436 patients [male 40.6%, median age 78 years interquartile range (73-82)] treated with sutureless AVR with a Perceval prosthesis were included in our analysis. RESULTS: The univariate logistic regression showed previous aortic valve surgery [P = 0.028; odds ratio (OR) 3.248], dialysis (P = 0.036; OR 6.435), renal insufficiency (P = 0.021; OR 2.75), EuroSCORE II (P = 0.016; OR 1.051) and year of operation (P < 0.01; OR 0.658) as factors associated with the development of atrioventricular type II or type III block or junctional block requiring pacemaker implantation. The overall incidence of pacemaker implantation after sutureless AVR was 7.1% in the current study, but it dropped to 3.8 and 4.7%, respectively, in 2018 and 2019. CONCLUSION: The Perceval aortic valve is associated with encouraging postoperative results. The incidence of pacemaker implantation is strictly linked to the surgeons' experience, decreasing year by year after an adequate sizing, reaching a percentage comparable with sutured valve.

Acute intraoperative echocardiographic changes after transapical off-pump mitral valve repair with NeoChord implantation.

OBJECTIVES: Our aim is to investigate the acute intraoperative effects of the NeoChord repair procedure on mitral valve (MV) annular geometry and LV function and the impact of these changes on MR at 1-year follow-up. BACKGROUND: Recently transapical off-pump mitral valve repair with NeoChord implantation has been demonstrated to be safe and effective in patients with degenerative mitral regurgitation (DMR). METHODS: We retrospectively analyzed baseline and early postoperative 3-dimensional transesophageal echocardiography of 66 patients who underwent NeoChord repair for isolated posterior leaflet MV disease using semiautomatic off-line analysis software. RESULTS: We observed a significant acute reduction of indexed LV end diastolic volume (Δ% = 14, p < .001), LV ejection fraction (Δ = 5.7%, p = .002), indexed left atrial volume (Δ = 14.7%, p = .045), and pulmonary artery pressure (Δ = 2.1%, p = .026). Among MV geometric parameters, we observed a significant reduction of MV antero-posterior diameter (Δ = 7%, p < .001), sphericity index (Δ = 8%, p < .001), annulus circumference (Δ = 0.9%, p = .021), and annulus area (Δ = 2.7%, p = .018). At 1-year, 53 patients (85.5%) presented MR ≤ mild, while 9 patients (14.5%) had MR ≥ moderate. Reduction of AP diameter (OR = 0.14, CI -3.83; 0.08, p < .001), annulus circumference (OR = 0.27, CI -2.98; 0.37, p = .005), MV area (OR = 0.39, CI -2.46; 0.61, p = .04), aorto-mitral angle (OR = 0.38, CI -2.49; 0.54, p = .002) and iEDV (OR = 0.44, CI -2.44; 0.81, p = .001) were independent protective factors against recurrence of MR greater than mild at 1-year follow-up. CONCLUSIONS: Transapical NeoChord repair produces important acute intraoperative changes in MV anatomy in DMR patients. The acute changes observed were associated with procedure durability at 1-year FU.

Prognostic impact of leaflet-to-annulus index in patients treated with transapical off-pump echo-guided mitral valve repair with NeoChord implantation.

BACKGROUND: The transapical echo-guided NeoChord repair is a procedure to correct mitral regurgitation (MR) without the need for concomitant annuloplasty for degenerative mitral valve (MV) disease. Lacking strict criteria to define normal annular dimensions for patients undergoing MV repair, we consequently missed having precise selection criteria to identify patients who can benefit from a ringless procedure with respect to who would need a combined annular and leaflet repair. The aim of this study is to identify whether a new preoperative echocardiographic index may predict postoperative outcomes after NeoChord repair. METHODS: All consecutive patients with posterior leaflet disease who underwent NeoChord repair between November 2013 and January 2016 presenting complete postoperative echocardiographic assessment up to 1year were included. Leaflet-to-Annulus Index (LAI) was defined as the ratio between the sum of anterior leaflet length (AML) and posterior leaflet length (PML) over antero-posterior length (AP; AML+PML/AP). Measurements were performed with 2D transesophageal echocardiography. RESULTS: Sixty-six patients were enrolled. At 1year MR was absent in (24) 38% of patients, mild in (28) 44%, moderate in (10) 16% and severe in (1) 2%. Logistic regression analysis identified LAI as positive prognostic predictor of MR≤mild for values >1.35 at 3months, 1.30 at 6months and 1.25 at 1year. At 30days LAI was not associated with the grade of residual MR. CONCLUSIONS: LAI is a positive postoperative predictor of MR≤mild at 1-year follow-up and can be used to identify patients who could benefit from a ringless NeoChord repair procedure for the absence of a leaflet-to-annulus mismatch.

Learning curve analysis of transapical NeoChord mitral valve repair.

OBJECTIVES: Transapical off-pump mitral valve intervention with neochordae implantation is a novel, minimally invasive procedure for treatment of degenerative mitral valve regurgitation. The aim of this study was to apply control charts (CUSUM curves) to monitor the performance of NeoChord repair during the initial phase of its adoption. METHODS: The first 112 consecutive patients who underwent NeoChord repair at our institution between November 2013 and March 2016 were included in the analysis. Mitral Valve Academic Research Consortium criteria for 1-year patient success was utilized to determine failed procedures. Control charts had predetermined acceptable and unacceptable failure rates of 5% and 15%, respectively. RESULTS: The actual incidence of 1-year-patient failure was 11% (12 of 112 cases), with a cluster of failures within the first 20 cases. The CUSUM analysis demonstrated an initial learning curve; however, the upper boundary (alarm line) was never crossed. The reassurance line was first crossed after 40 procedures and performance remained stable after 49 procedures. CONCLUSIONS: NeoChord repair is a safe procedure, and the results are maintained through the 1-year follow-up. A relative high number of implants were required to overcome the learning curve at our institution due to the concurrent development of patient selection criteria and the technical refinement of the procedure. Future studies are needed to assess the evolution of the learning curve after the wide adoption of the procedure across European and North American centres.

Use of Computed Tomography to Guide Mitral Interventions.

With increasing utilization of cardiac computed tomographic angiography (CTA) and widespread adoption of fusion imaging technology allowing the merger of pre-procedural CTA with fluoroscopy, the ability of CTA to guide structural heart interventions has evolved significantly. It has opened new possibilities in mitral valve (MV) interventions with improved pre-procedural planning and intra-procedural guidance. Given the lack of fluoroscopic landmarks of the mitral apparatus and continued growth of native MV device technologies, the value of CTA will continue to develop. The goal of this chapter is to detail the role of CTA in MV imaging and support for transcatheter therapies.