A. Häussler

Right-Sided Univentricular Cardiac Assistance in a Failing Fontan Circulation

Fontan patients are doomed to a circulatory failure and many of them will require a circulatory assistance as a bridge to transplantation. The univentricular heart with a total cavopulmonary connection presents a special challenge for the insertion of an assist device. We report a patient in multiple organ dysfunction and failure who was supported by right-sided univentricular assistance. Technically, a new chamber was created between both vena cava for implantation of the inflow cannula, and the extracardiac conduit was used to set the outflow cannula. The patient dramatically recovered and is currently in the best condition for heart transplantation.

Sixteen-channel multidetector row computed tomography versus coronary angiography in a surgical view.

BACKGROUND Invasive coronary angiography (ICA) is the gold standard for the diagnosis of coronary artery disease and also for imaging procedures for preoperative planning of coronary artery bypass grafting (CABG). Sixteen-multidetector row computed tomography (MDCT) represents an alternative depiction of coronary vessels. METHODS Preoperative exams included ICA and MDCT in 50 patients. Two blinded surgical readers independently investigated both diagnostic modalities regarding location, severity, and morphology of the stenoses. The right coronary artery, left anterior descending branch, and circumflex branch--each divided in 3 sections--and the left main artery with a diameter (3) 1.5 mm were rated in both procedures, and the percentage of complete evaluations by MDCT was assessed. RESULTS Heart rate was 72 +/- 8 bpm. Forty-six percent of patients received a complete MDCT evaluation, and 54% received an incomplete MDCT evaluation. In 62% of these incompletely examined patients, 1 branch was not completely analyzable, in 31% 2 branches; and in 7% all 3 branches. In total, 9% of all segments were incompletely assessed. Investigators detected coronary stenoses in complete evaluations with a sensitivity of 94% and a specificity of 95%. Positive predictive value was 87% and negative predictive value was 98%. Plaque classification in soft and hard plaques was possible. CONCLUSION Sixteen-MDCT is not a viable alternative diagnostic tool at present. However, although the percentage of incomplete evaluated patients is more then 50%, only 9% of all segments were incompletely assessable. If this technology can be further improved, especially its software, it will become a valid diagnostic tool for coronary artery disease.

Tricuspid Valve Repair for the Poor Right Ventricle: Tricuspid Valve Repair in Patients with Mild-to-Moderate Tricuspid Regurgitation Undergoing Mitral Valve Repair Improves In-Hospital Outcome.

Background Tricuspid regurgitation (TR) in patients undergoing surgery for mitral valve (MV) increases morbidity and mortality, especially in case of a poor right ventricle. Does repair of mild‐to‐moderate insufficiency of the tricuspid valve (TV) in patients undergoing MV surgery lead to a benefit in early postoperative outcome? Methods A total of 22 patients with mild‐to‐moderate TR underwent MV repair and concomitant TV repair with Tri‐Ad (Medtronic ATS Medical Inc., Minneapolis, Minnesota, United States) and Edwards Cosgrove (Edwards Lifesciences Irvine, California, United States) rings. The severity of TR was assessed echocardiographically by using color‐Doppler flow images. The tricuspid annular plane systolic excursion (TAPSE) was under 1.7 cm. Additional procedures included coronary artery bypass (n = 9) and maze procedure (n = 15). The following parameters were compared: postoperative and peak dose of noradrenaline (NA), pre/postoperative systolic pulmonary pressure (sPAP), extubation time, operation time, cross‐clamp time, cardiopulmonary bypass (CPB) time, pre/postoperative ejection fraction (EF), intensive care unit (ICU)‐stay, hospital stay, cell saver blood transfusion, intra/postoperative blood transfusion, and postoperative TR. Results The mean age was 67 ± 14.8 years, 45% were male. Mean EF was 47 ± 16.2%, postoperative 52 ± 12.4%. sPAP was 46 ± 20.1 mm Hg preoperatively, sPAP was 40.6 ± 9.4 mm Hg postoperatively, NA postoperatively was 12 ± 10 &mgr;g/min, NA peak was 18 ± 11 &mgr;g/min, operation time was 275 ± 92 minutes, CPB was 145 ± 49 minutes, ICU stay was 2.4 ± 2.4 days, hospital stay was 10.8 ± 3.5 days, cell saver blood transfusion was 736 ± 346 mL, intraoperative transfusions were 2.5 ± 1.6. Two patients needed postoperative transfusions. A total of 19 patients were extubated at the 1st postoperative day, 2 patients at the 2nd day, and 1 at the 4th postoperative day. Two patients required a pacemaker. No reintubation, no in‐hospital mortality, and one reoperation because of bleeding complications. Conclusion Correction of mild‐to‐moderate TR at the time of MV repair does maintain TV function and avoid right ventricular dysfunction in the early postoperative period improving the clinical outcome.

New clip remover device to prepare saphenous vein graft for coronary bypass grafting

Objective: The accurate prepare of the saphenous vein (SV) is elementary to have good patency rates in myocardial revascularisation. To avoid intimal hyperplasia we use the eSVS Mesh (Kipps Bay Medical™, Minneapolis, USA). Caused by endoscopic harvesting technique of SV all side branches are clipped in situ. All Clips have to be removed and replaced by fine sutures (Prolene 6-0) in order to enable the covering the SV with the eSVS. How to remove the Clips without tearing the SV and its intima? Methods: We use a new designed clip remover in 40 patients. After harvesting the SV the distal end is intubated by a cannula with outlet. Into the SV a solution of sodium chloride 0.9% is applicated with a maximum pressure of 150 cm H2O. So the clips are exposed in a good position and they can be reopened and removed without sheer stress to the tissue by the clip remover device. Intraoperative graft patency was verified by MediStim. Result: All clips could be removed from vein. No tear that had to be repaired. Graft patency was 95% for eSVS treated with the new device. Histologic findings showed no intima lesions. Conclusion: This new tool is very feasible and save. Wrong placed clips on mammarian artery or veins are now easy and safely removable and a new can be applicated in correct position considering the potential intima lesion of the graft by clipping.

Surgical correction of Ebstein anomaly: the Zurich approach

Ebsteins anomaly is a congenital defect primarily due to a failed-development of the tricuspid valve. The defect affects significantly surrounding structures (conducting tissue, right atrium and ventricle), which often need concomitant correction. We have extended our techniques for the repair of conventional atrio-ventricular valve insufficiency to this specific pathology. The video sequences show the repair of a severe form of Ebsteins anomaly with extensive mobilisation of the displaced leaflets and creation of a subvalvular apparatus with artificial chordae. Because of the absence of arrhythmia, the adjunction of ablation surgery to abnormal atrio-ventricular pathways was not necessary in this case and is not demonstrated in the videos.