Alessandro Verzini

The GeoForm annuloplasty ring for the surgical treatment of functional mitral regurgitation in advanced dilated cardiomyopathy

OBJECTIVE To assess the results of the three-dimensional (3D)-shaped GeoForm ring for the treatment of functional mitral regurgitation (FMR). METHODS Seventy-four patients with severe FMR and systolic dysfunction underwent GeoForm ring implantation. Forty-six patients (62%) were in the New York Heart Association (NYHA) class III-IV. Concomitant procedures were coronary artery bypass grafting (CABG) (33 patients (pts)), tricuspid repair (23 pts), atrial fibrillation ablation (20 pts), aortic valve replacement (eight pts) and left-ventricular (LV) reconstruction (five pts). RESULTS Hospital mortality was 9%. Three more patients died after hospital discharge. Overall survival was 81.1 ± 6.6% at 3.5 years. The 67 hospital survivors underwent clinical and echocardiographic follow-up at a mean follow-up period of 1.9 ± 1.25 years (median 1.7 years). MR was absent or mild in 83% of the patients (56/67), moderate in 7% (5/67), and moderate to severe in the remaining 9% (6/67). At 3.5 years, overall freedom from MR ≥ 3+ was 85.1 ± 8% and freedom from MR ≥ 2+ was 75.1 ± 8.6%. Statistical analysis identified preoperative asymmetric tethering with prevalent restricted motion of the posterior leaflet as the only predictor of recurrence of MR ≥ 2+ (hazard ratio (HR) 6.1, p=0.005). Reverse LV remodeling was demonstrated in 31 of the 54 patients eligible for this specific analysis (31/54, 57%): Both LV end-diastolic and end-systolic volumes indexed significantly decreased (both p=0.0001) as well as systolic pulmonary artery pressure (SPAP) (p=0.006). Ejection fraction increased from 33 ± 8% to 43 ± 8% (p<0.0001). Stress echocardiography was performed in a subgroup of eight patients. Mean mitral area at rest was 2.2 ± 0.3 cm² and did not change during stress. Cardiac output significantly increased in all patients during exercise. Although mean and peak transmitral gradients were 3.3 ± 1.3 and 8.1 ± 2.2 mmHg at rest and 6.6 ± 2.5 and 14.8 ± 3.9 mmHg under stress, respectively (both p<0.003), the increase in SPAP was not statistically significant (28 ± 3.0 vs 31 ± 7.5 mm Hg, p=0.17), revealing a preserved cardiac adaptation to exercise. CONCLUSIONS The GeoForm ring is effective in relieving FMR in most of the patients with dilated cardiomyopathy. In presence of prevalent restricted motion of the posterior leaflet, recurrence of significant MR is more likely to occur. Clinically relevant mitral stenosis was not detected during exercise.

Mitral Replacement or Repair for Functional Mitral Regurgitation in Dilated and Ischemic Cardiomyopathy: Is it Really the Same?

BACKGROUND This was a study to compare the results of mitral valve (MV) repair and MV replacement for the treatment of functional mitral regurgitation (MR) in advanced dilated and ischemic cardiomyopathy (DCM). METHODS One-hundred and thirty-two patients with severe functional MR and systolic dysfunction (mean ejection fraction 0.32 ± 0.078) underwent mitral surgery in the same time frame. The decision to replace rather than repair the MV was taken when 1 or more echocardiographic predictors of repair failure were identified at the preoperative echocardiogram. Eighty-five patients (64.4%) received MV repair and 47 patients (35.6%) received MV replacement. Preoperative characteristics were comparable between the 2 groups. Only ejection fraction was significantly lower in the MV repair group (0.308 ± 0.077 vs 0.336 ± 0.076, p = 0.04). RESULTS Hospital mortality was 2.3% for MV repair and 12.5% for MV replacement (p = 0.03). Actuarial survival at 2.5 years was 92 ± 3.2% for MV repair and 73 ± 7.9% for MV replacement (p = 0.02). At a mean follow-up of 2.3 years (median, 1.6 years), in the MV repair group LVEF significantly increased (from 0.308 ± 0.077 to 0.382 ± 0.095, p < 0.0001) and LV dimensions significantly decreased (p = 0.0001). On the other hand, in the MV replacement group LVEF did not significantly change (from 0.336 ± 0.076 to 0.31 ± 0.11, p = 0.56) and the reduction of LV dimensions was not significant. Mitral valve replacement was identified as the only predictor of hospital (odds ratio, 6; 95% confidence interval, 1.1 to 31; p = 0.03) and overall mortality (hazard ratio, 3.1; 95% confidence interval, 1.1 to 8.9; p = 0.02). CONCLUSIONS In patients with advanced dilated and ischemic cardiomyopathy and severe functional MR, MV replacement is associated with higher in-hospital and late mortality compared with MV repair. Therefore, mitral repair should be preferred whenever possible in this clinical setting.

Long-term results of mitral repair for functional mitral regurgitation in idiopathic dilated cardiomyopathy

OBJECTIVES While the results of mitral repair in ischaemic mitral regurgitation have been repeatedly reported, less data are available about the outcome of surgical repair of functional mitral regurgitation (FMR) in idiopathic dilated cardiomyopathy (iDCM) which represents the topic of this study. METHODS Fifty-four iDCM patients (mean age 63 ± 10.5 years) underwent mitral valve repair for severe FMR. Coronary angiography confirmed the absence of coronary disease in all patients. Most of the patients (77.7%) were in New York Heart Association (NYHA) class III-IV. Pre-operative ejection fraction (EF) was 30.4 ± 8.5%, left ventricle end-diastolic diameter (LVEDD) 67.5 ± 7.8 mm, left ventricle end-systolic diameter (LVESD) diameter 53.9 ± 8.3 mm. Concomitant procedures were atrial fibrillation (AF) ablation (19 patients) and tricuspid repair (17 patients). Follow-up was 100% complete (mean 4.2 ± 2.5 years, median 4.2 years, range 3.3 months-11.1 years). RESULTS In-hospital mortality was 5.6%. Actuarial survival at 6.5 years was 69 ± 8.8%. Patients submitted to successful AF ablation and/or cardiac resynchronization therapy (CRT) had a significantly better survival (91 ± 7.9 vs 67 ± 9.5%, P = 0.01). Freedom from MR≥3+/4+ was 89.1 ± 5.7% at 6.5 years. Follow-up echocardiography showed a reduction in LVEDD (P < 0.0001) and LVESD (P = 0.0003). Mean EF increased to 38.7 ± 12.4% (P < 0.0001). Multivariate analysis identified successful ablation of AF and/or CRT (P = 0.01) and higher preoperative EF (0.03) as predictors of overall survival. Successful ablation of AF and/or CRT (P = 0.02) and lower preoperative systolic pulmonary artery pressure (0.04) were identified as independent predictors of reverse LV remodelling at follow-up. At last follow-up, 86.2% of the patients were in NYHA II or less. CONCLUSIONS Mitral repair for FMR in well-selected iDCM patients is associated with low hospital mortality and significant clinical benefit at late follow-up. Concomitant successful AF ablation and/or CRT provide a major symptomatic and prognostic advantage and should be associated to mitral surgery whenever indicated.

Sternal closure using semirigid fixation with thermoreactive clips

Sternomy represents the standard approach to the heart and great vessels in most cardiothoracic procedures. Closure of this incision is simple; however, healing complications such as dehiscence, osteomyelitis, mediastinitis, and superficial wound infection or fistula may occur. We describe an alternative technique for sternal closure using semirigid fixation with thermoreactive clips.

Simultaneous operation for cardiac disease and lung cancer

Concomitant lesions of the heart and lung have been increasing and the issue of performing simultaneous pulmonary resection and cardiac surgery remains controversial. We report a retrospective study of 11 patients (ten male, one female) who underwent simultaneous lung resection and cardiac operation. In all cases the lung resection was performed before heparinization and cardiopulmonary bypass. All patients were discharged in 10 days. We did not have postoperative complications. Follow up mean was 41.2 months/patients. A combined procedure, when possible, avoids other thoracic procedure, permits to improve outcomes and provides economic benefit.

Vascular complications associated with a large cardiac fibroma

A case is reported of a 30-year-old patient with an intrapericardial tumour with heart failure. After the diagnostic protocol, surgery was performed initially without extra-corporeal circulation (ECC). Due to the location, size and to the large connection with the most important vascular structures, the ascending aorta ruptured accidentally during resection and was replaced after using ECC in emergency. The post-surgical course was regular and the tumour was identified histologically as a fibroma.

Reverse Remodeling Effect of the CorCap Despite the Presence of Severe Mitral Regurgitation

We report the case of a woman affected by severe functional mitral regurgitation secondary to idiopathic dilated cardiomyopathy, who underwent reductive mitral annuloplasty and implantation of CorCap cardiac support device (Acorn Cardiovascular Inc, St. Paul, MN). Despite the recurrence of severe mitral regurgitation early after surgery, a progressive reverse remodeling of the left ventricle has been echocardiographically demonstrated at a long-term follow-up due to the passive containment effect of the CorCap.

Amplatzer device migration through the sternum: A rare complication of percutaneous treatment for an aortic pseudoaneurysm solved by 2 length-adjustable bovine pericardium conduits

From the Division of Cardiac Surgery, San Raffaele University Hospital, Milan, Italy. Disclosures: Authors have nothing to disclose with regard to commercial support. Received for publication Feb 3, 2012; revisions received April 16, 2012; accepted for publication May 15, 2012; available ahead of print June 14, 2012. Address for reprints: Ignacio Bibiloni Lage, MD, Division of Cardiac Surgery, San Raffaele University Hospital, Via Olgettina 60, 20132, Milan, Italy (E-mail: igbibiloni@gmail.com). J Thorac Cardiovasc Surg 2012;144:e27-8 0022-5223/

Custom-Made E-Vita Graft for Frozen Elephant Trunk With Arch-First Technique

36.00 Copyright 2012 by The American Association for Thoracic Surgery http://dx.doi.org/10.1016/j.jtcvs.2012.05.033

Recurrence of Mitral Regurgitation Parallels the Absence of Left Ventricular Reverse Remodeling After Mitral Repair in Advanced Dilated Cardiomyopathy

A novel custom-made E-Vita Open prosthesis (JOTEC GmbH, Hechingen, Germany) has been designed with 2 additional side branches. The first one, the reperfusion branch, allows distal aortic perfusion after the collar anastomosis of a frozen elephant trunk repair has been performed. The second one, the debranching branch, permits reimplantation of any configuration of supraaortic debranching to the dacron graft. This modified graft provides two main advantages: first, combined with prior carotid-subclavian bypass and bilateral axillary perfusion, it allows continuous bihemispheric antegrade perfusion and arch-first technique under mild hypothermia (32°C); second, it grants distal aortic reperfusion after distal anastomosis completion performed under moderate hypothermia (28°C).