Alberto Weber

Treatment of isolated ascending aortic aneurysm by off-pump epiaortic wrapping is safe and durable

OBJECTIVES Isolated ascending aortic aneurysm (iAA) is usually treated by open graft repair requiring sternotomy, cardiopulmonary bypass (CPB) and cardioplegia. This approach carries significant mortality in older patients or those presenting with comorbidities. We report an original series of patients presenting with iAA and treated with epiaortic wrapping by using a synthetic mesh. This less invasive aortic repair technique allows reducing the aortic diameter to a predefined value and is performed without CPB. METHODS Data from patients presenting with an iAA and treated with the wrapping technique (WT) by polypropylene/polyester mesh from November 2006 to July 2015 were collected. The end-points that were analysed included maximal aortic transverse diameter, perioperative mortality and morbidity, survival, freedom from reinterventions and aortic valve function during follow-up. The maximal aneurysm transverse diameter was analysed based on contrast-enhanced computed tomography (CTA) or magnetic resonance (MR) performed preoperatively, and during the follow-up. RESULTS The off-pump WT was used in 33 cases with no perioperative mortality. The median radiological follow-up was 33.47 (range: 1-106) months. Overall, the WT achieved a 30% diameter reduction. The mean preoperative and postoperative ascending aortic transverse diameter was 5.5 cm [standard deviation (SD): 0.6] and 3.7 cm (SD: 0.30), respectively (P = 0.001). In addition, CTA or MR follow-up showed stable diameters at the level of the aortic root and the distal ascending aorta. No death occurred during the follow-up. At 5 years, the estimated freedom rate from reinterventions of the aortic root and ascending aorta was 94%. CONCLUSIONS This series shows that the WT with a polypropylene/polyester mesh allows safe off-pump treatment of patients with iAA. Mid- and long-term results are promising. This technique could be an attractive alternative, especially for patients unfit for aortic surgery with CPB and cardioplegia.

Current challenges in interventional mitral valve treatment

Transcatheter mitral valve therapies have emerged as an alternative option in high surgical risk or inoperable patients with severe and symptomatic mitral regurgitation (MR). As multiple technologies and different approaches will become available in the field of mitral valve interventions, different challenges are emerging, both patient- (clinical challenges) and procedure-related (technical challenges). This review will briefly explore the current open challenges in the evolving fields of interventional mitral valve treatment.

Long-Term Outcomes after Minimally Invasive Aortic Valve Surgery through Right Anterior Minithoracotomy

Background Minimally invasive aortic valve surgery (MIAV) through a right anterior minithoracotomy evolved to an accepted procedure with favorable short‐ and mid‐term outcomes, whereas long‐term results lack. The aim of this study was to evaluate the long‐term outcomes. Materials and Methods All our MIAV patients were included (n = 225). Mean age was 68 ± 12 years, 29% were older than 75 years, and median EuroSCORE was 5 (0‐11). Baseline characteristics, inhospital outcomes, and follow‐up information about survival, major adverse cardiac and cerebrovascular events (MACCE), and need for reoperation were collected and analyzed. Results In this study, 30‐day mortality was 1.3%, and there was no permanent stroke. Mean follow‐up time was 69.65 ± 24 months, being the longest so far reported in the literature. At 1 and 7 years, survival was 95.8 and 79%, freedom from MACCE 98.1 and 95.7%, and from reoperation 99.5 and 98.7%, respectively. Conclusion MIAV is safe and feasible with favorable long‐term outcomes. In the future, it could serve as benchmark for interventional methods as soon as indications are expanded to young and low‐risk patients. Randomized studies are needed to compare the long‐term outcomes of these approaches.

Infective endocarditis after transcatheter aortic valve implantation with LOTUS valve

Prosthetic valve endocarditis (PVE) after transcatheter aortic valve implantation (TAVI) is a serious complication, but limited number of cases has been reported. An 84-year-old man who had performed TAVI with a 25 mm LOTUS valve (Boston Scientific, Natick, Massachusetts) for severe aortic stenosis was readmitted to our institution at 1 …

Superior Flow Pattern of Internal Thoracic Artery over Saphenous Vein Grafts during OPCAB Procedures

Abstract  Background: The advantages of the use of the internal thoracic artery (ITA) over that of the saphenous vein (SV) for revascularization of the circumflex (Cx) or right coronary artery (RCA) are still debated. Methods: Serial intraoperative flow measurements were carried out in 306 consecutive patients (mean age 64 years, mean Euroscore 5.1) undergoing off‐pump coronary artery bypass grafting (OPCAB). The LAD was grafted in 302 patients [293 ITA (97%), 9 SV], the Cx in 252 patients [117 ITA (46%), 135 SV], and the RCA in 260 patients [36 ITA (14%), 224 SV]. Results: Averages of 3.7 ± 1.0 distal anastomoses/patient were constructed. Mean pulsatile index (PI) was significantly better for the single ITA/Cx‐grafts (2.8 ± 1.9, n = 92) than for the single SV/Cx‐grafts (3.3 ± 1.7, n = 43, p < 0.05), whereas the mean flow did not differ (28 ± 22 and 31 ± 25 mL/min respectively, p = ns). Accordingly, the mean PI was significantly better for the single ITA/RCA‐grafts (2.2 ± 1.2, n = 36) than for the single SV/RCA‐grafts (3.4 ± 2.6, n = 178, p < 0.01), whereas the mean flow did not differ (30 ± 16 and 32 ± 22 mL/min respectively, p = ns). The incidence of perioperative myocardial infarction tended to be lower in patients receiving an ITA to either the Cx or the RCA than in those receiving a SV, but the difference did not reach statistical significance [2/92 of ITA/Cx (2.2%) vs. 2/43 of SV/Cx (4.6%), 1/36 of ITA/RCA (2.8%) vs. 8/178 of SV/RCA (4.5%)]. Conclusion: The internal thoracic artery provides superior flow properties than the SV to the Cx and RCA regions with reduced perioperative ischemia. Whether this advantage persists after adjusting for the grade of the proximal coronary stenosis needs further studies.

Ascending aortic dissection after proximal bypass anastomotic device

Aortic dissection is a rare complication of cardiac operations that is associated with surgical maneuvers such as the placement of the proximal anastomosis and carries a high mortality rate. To maintain the quality of care for patients undergoing off-pump coronary artery bypass grafting (OPCAB), a no-touch technique of the ascending aorta is important. If that is not possible, it is important to perform the proximal anastomoses on the aorta with a no-clamp technique.

Prosthetic valve endocarditis involving the MitraClip device

The MitraClip system has been associated with injuries to the mitral valve leaflets, the development of mitral stenosis, and endocarditis. We now present a case of endocarditis involving both a Mitraclip and an aortic valve prosthesis. A 75-year-old male underwent a Bentall (#27mmSt. JudeMedical, Minneapolis, MN) procedure and coronary artery bypass grafting in 1988 followed by the implantation of two MitraClips (Abbott Vascular Inc., Santa Clara, CA) in the A2-P2 segment for functional mitral regurgitation in 2014. He was now admitted with Stahphylococcous aureus and Streptococcus beta-haemolyticus group B sepsis with complete heart block and hemodynamic instability. A transesophageal echocardiogramrevealeda thinmobile vegetationadherent to theaortic

THIS ARTICLE HAS BEEN RETRACTED: Ascending Aortic Dissection After Proximal Bypass Anastomotic Device

Abstract  Ascending aortic dissection is a known complication of cardiac surgery. Different type of devices allowing performance of proximal bypass anastomoses without aortic side‐clamping are supposed to reduce the risk for aortic dissection. We report a case in which ascending aortic dissection occurred six months after off‐pump coronary artery bypass surgery, with the entry tear arising directly from a proximal anastomosis performed with the Heartstring hemostatic seal system.

Early Clinical Experience with Double Ring Implantation for Aortic and Mitral Valve Repair

Reconstruction of cardiac valves is associated with reduced mortality, including in multiple valve surgery. However, multiple valve repair is still considered a challenge, even with established techniques. Recently, internal aortic ring annuloplasty has been introduced and could simplify multiple valve reconstruction. This study reports early results with double ring aortic and mitral valve repair. Three patients with bivalvular degenerative regurgitation were managed with combined aortic and mitral valve repair using double rings. Mean (±SD) age was 41 ± 21 years, preoperative left ventricular end-diastolic volume was 119 ± 53 mL/m2, and ejection fraction was 0.50 ± 0.07. Mean aortic ring diameter was 21 mm, and mitral rings averaged 32 mm. No operative mortalities or major complications were observed. No valve-related events occurred. Postoperative echo showed complete resolution of mitral and aortic regurgitation. Postoperative left ventricular end-diastolic volume decreased to 98 ± 10 mL/m2; no left ventricular outflow tract obstruction or significant transvalvular gradients were observed. Postoperative cardiac CTs showed an optimal three-dimensional configuration of aortic and mitral annuloplasty devices. This initial series demonstrated the feasibility and safety of combined aortic and mitral repair with double rings. Clinical and hemodynamic results were promising. Increasing application and more clinical experience with combined aortic and mitral double ring repair seems indicated.

“Double-ring” combined aortic and mitral valve repair

Multiple valve repair still represent a challenge and several techniques have been proposed. Recently, an internal aortic ring has been introduced as and adjunctive tool in aortic valve reconstruction and it could simplify multiple valve reconstruction. This paper reports the first case of double-ring aortic and mitral valve repair. The Bart of repair^ cardiac valves is associated with lower early and late mortality, restoration of normal life expectancy and quality of life, low rate of thromboembolic events, endocarditis, no need for anticoagulation, and better preservation of left ventricle function [1]. In this setting, multiple valve reconstruction represents still a challenge and long-term durability is matter of debate despite encouraging results have been reported [2, 3]. Recently, the hemispherical annuloplasty aortic repair technology (HAART) 300TM device (BioStable Science and Engineering, Austin, TX) has been introduced as an adjunctive tool for aortic valve repair: the rigid device is implanted in sub-valvular position, about 2–3 mm below the aortic annulus and its design has been developed to resize the annulus to reduce dilation, reshape the aortic valve to guarantee normal leaflet coaptation and prevent re-dilation. Current indications consist in the treatment of isolated aortic regurgitation due to annular dilation or combined root and ascending aorta replacement procedures, with the aim to stabilize aortic annulus. Although acceptable results have been reported [4], its role in multiple valve surgery has not been reported yet. The anatomical position could theoretically create impingement with mitral prosthetic ring with a risk of subaortic dynamic obstruction. Here we present the first case of bivalvular mitral and aortic ring implantation performed in a 30-year-old man affected by degenerative regurgitation. Post-operative 3D CT reconstruction of double ring implantation with optimal spatial relationship between the devices (Fig. 1a). (Fig. 1b, c) shows preoperative mitral and aortic regurgitation. No postoperative regurgitations were recorded (Fig. 1d, e). The CTscan analysis showed aortic (green square) and the mitral ring with an optimal interaction at the level of mitro-aortic continuity (Fig. 1f). One-year follow-up was event free and no recurrence of aortic or mitral regurgitation was recorded.