Alvise Guariento

Evolving strategies for preserving the pulmonary valve during early repair of tetralogy of Fallot: mid-term results.

BACKGROUND The aim of the study was to evaluate our results with pulmonary valve (PV) preservation in selected patients with tetralogy of Fallot (TOF). METHODS From January 2007, 69 patients who underwent early transatrial TOF repair were enrolled in the study. The patients were divided into 2 groups: PV preservation by PV annulus balloon dilation (group 1) and PV cusp reconstruction after annular incision (group 2). RESULTS Thirty-four patients underwent a successful PV annular preservation (49%). Median age at surgery was 113 days (range, 36-521 days) (group-1 vs group-2, P = not significant). Median preoperative PV Z score was -3.15 (range, -0.95 to -5.62) (group-1 vs group-2, P = .03). Median intensive care unit and hospital stays were 3 and 10 days, respectively (group 1 vs group 2, P = not significant). Median follow-up time was 580 days (range, 189-1940 days) (group 1 vs group 2, P = .08). Two patients were reoperated for residual right ventricular outflow tract (RVOT) obstruction (1 in group 1 and 1 in group 2). The remaining patients are alive and well. Median peak RVOT gradient was 25 mm Hg (range, 8-60 mm Hg) (group 1 vs group 2, P = not significant). The degree of PV regurgitation in group 1 was none/mild in 24 patients (80%) and moderate in 6 (20%) and was none/mild in 8 patients (25%), moderate in 11 (34.4%), and severe in 13 (28.6%) in group 2 (P = .001). Median right ventricular fractional area change was 55% (range, 42%-70%) in group 1 and 50% (range, 40%-63%) in group 2 (P = .003). CONCLUSIONS The integrity and function of the PV can be preserved in selected patients during early repair of TOF by concomitant balloon dilation, leading to a better mid-term right ventricular function.

Preserving the pulmonary valve during early repair of tetralogy of Fallot: Anatomic substrates and surgical strategies

OBJECTIVE To describe the anatomy of the PV in tetralogy of Fallot (TOF) and to define the influence of PV anatomy on the development of surgical techniques for PV preservation during early repair. METHODS The PV was evaluated in 79 anatomic specimens of patients with TOF who had not undergone surgery for repair, and in 82 patients who underwent early TOF repair at our institution. New surgical techniques for PV preservation during early repair are described. RESULTS The PV in TOF was predominantly bicuspid (n = 118 of 160; 73.7%), less frequently tricuspid (n = 28 of 160; 17.5%), and seldom unicuspid (n = 14 of 160; 8.8%). In 82 cases (51.3%), the PV cusps were normal; in 78 cases (48.7%), they were thickened and dysplastic. Preservation of the PV was possible in 46 of 82 (56%) consecutive patients during TOF repair in our more recent experience, either using balloon dilation alone (18 of 46; 39%) or in association with other PV plasty procedures (28 of 46; 61%). Most bicuspid and tricuspid valves were salvageable, but unicuspid valves were not suitable. After a median follow-up time of 2.8 years (range, 0.5-6.8 years), the degree of PV regurgitation continued to be zero or mild in 40 patients (86%), and moderate in 6 (14%). CONCLUSIONS The majority of patients with TOF (>90%) have a bicuspid or tricuspid PV, which is the most favorable surgical anatomy for preserving the PV, independent of the degree of leaflet dysplasia. The recent introduction of more-complex PV plasty techniques, such as delamination plasty, allowed us to further extend the applicability of PV-preservation techniques.

Bilateral mini-thoracotomy off-pump Jarvik 2000 implantation in regional asymmetric paravertebral analgesia

We describe the surgical technique and treatment of a 59-year-old male with cardiogenic shock, who underwent a minimally invasive off-pump ventricular assist device (VAD) implantation with the aid of paravertebral regional analgesia in bilateral mini-thoracotomies as first procedure described in the literature. He was extubated soon after the procedure, in the operating room, with the aim to reduce the right ventricle impairment. These issues are particularly true for patients suffering from pulmonary hypertension and disease, in whom the shortest time of postoperative intubation is fundamental to allow self-inotropic support and recovery of the right ventricle. We illustrate how a minimally invasive implant may improve the clinical outcomes of VAD patients shortening their return time to active life.

Novel valve replacement with an extracellular matrix scaffold in an infant with single ventricle physiology

Valve replacement in children with functionally univentricular hearts remains challenging. The absence of small prostheses, the lack of growth, and the need for anticoagulation limit these procedures. We describe a 1-year follow-up of an extracellular matrix scaffold tube used as systemic atrio-ventricular valve in an infant.

Minimally invasive surgical Jarvik 2000 off-pump implantation

Therapy with mechanical ventricular assist devices (VADs) in severe heart failure, open to discussion decades ago, is now well established for temporary or long-term support. The typical VAD candidate is very compromised and may not have sufficient resources to tolerate major surgical insults and trauma. Therefore, device implantation through smaller, less traumatic incisions is a desirable goal. The median sternotomy decreases lung volumes and reduces thoracic motion with a significant decrease in functional residual capacity and total lung capacity months later. Minimally invasive cardiac surgery was devised to reduce morbidity because of its potentially less inflammatory response, reduced transfusion requirements and minimal scarring with consequent rapid rehabilitation to normal life activity. Additionally, avoiding cardiopulmonary circulatory support (CPB) even for a short period might reduce the release of inflammatory cytokines and their consequences, as most CPB-related damage happens within the first few minutes. We describe the tricks and traps of minimally invasive approach during VAD implantation, by associating mini-anterior left thoracotomy in the fifth intercostal space with a mini-anterior right thoracotomy in the second intercostal space, without the aid of CPB in paravertebral block regional analgesia combined with mild general anasthesia.

The natural history and surgical outcome of patients with scimitar syndrome: a multi-centre European study.

Aims Treatment decisions in patients with scimitar syndrome (SS) are often challenging, especially in patients with isolated SS who are often asymptomatic and who might be diagnosed accidentally. We queried a large multi-institutional registry of SS patients to evaluate the natural history of this condition and to determine the efficacy of surgical treatment in terms of survival and clinical status. Methods and results We collected data on 485 SS patients from 51 institutions; 279 (57%) patients were treated surgically (STPs) and 206 (43%) were clinically monitored (CMPs). Median age at last follow-up was 11.6 years (interquartile range 4-22 years). Overall survival probability at 30 years of age was 88% [85-92% confidence intervals (CI)] and was lower in patients with associated congenital heart disease (CHD) (P < 0.001) and pulmonary hypertension (P < 0.001). Most patients were asymptomatic at last follow-up (279/451, 62%); STPs were more frequently asymptomatic than CMPs (73% vs. 47%, P < 0.001), with fewer cardiac [odds ratio (OR) 0.42, 95% CI 0.22-0.82] and respiratory symptoms (OR 0.08, 95% CI 0.02-0.28). Many STPs (63/254, 25%) had stenosis/occlusion of the scimitar drainage, and this was associated with a younger age at surgery (OR 0.4, CI 0.21-0.78). Conclusion Patients with SS have a high overall survival. Survival probability was lower in patients with associated CHDs and in patients with pulmonary hypertension. Surgical treatment of SS is beneficial in reducing symptoms, however, given the significant risk of post-operative scimitar drainage stenosis/occlusion, it should be tailored to a comprehensive haemodynamic evaluation and to the patients age.

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.

Prosthetic valve thrombosis: When prevention is better than treatment

We have recently read with great interest the study reported by Özkan et al, included in the 2015 second issue of your Journal. In this work, they accurately demonstrate how an ultraslow (25 hours) infusion of low-dose (25 mg) plasminogen activator represents a safer thrombolytic treatment in patients with prosthetic valve thrombosis (PVT), showing moderately low nonfatal complications and mortality. Prosthetic valve thrombosis is a rare but life-threatening process originating from the formation of a fibrous cloth, which can evolve to a definitive obstructing thrombus. The literature usually identified an obstructive and nonobstructive PVT type according with Doppler echocardiographic measurements. The obstructive form is the less frequent, including approximately 0.3% to 1.3% of patient-year and often requiring prosthesis replacement. On the contrary, the nonobstructive PVT represents a more common type, with a reported incidence as high as 10% in some transesophageal echocardiography (TEE) studies. As previously showed from the same group, TEE provides a useful guide to assess imaging of the thrombus, including the size, mobility, and location. In this way, it can help clinicians in treatment decisions, allowing to differentiate thrombi from pannus formation or strands. We have already shown that multidetector computed tomography can be used for the accurate imaging of thrombi on prosthetic aortic valves. Nevertheless, these techniques usually simply confirm an advanced PVT form, typically when critical symptoms have already appeared. Mortality and fatal complications, although reduced in recent years, can occur as a consequence of the subsequent treatment, which include reoperation or recently developed thrombolytic protocols (as previously described). Therefore, an early detection of thrombotic formations appears decisive for patients prognosis. For this purpose, we focused in an in vitro and in vivo ultrasound phonocardiographic analysis of the closing sound produced by several mechanical heart valves (MHVs), to assess an early detection of thrombotic apposition and consequent MHV dysfunction. Examining different simulated MHV thrombotic formations in a Sheffield pulse duplicator, we acquired closing sound in a specific frequency range related to power spectra, analyzing them with an artificial neural network (ANN). This allowed to classify the presence of thrombotic formations of different weight and shape, with an improvement in the efficiency related to the extension of the analysis to the ultrasound region. Several studies have dealt with this topic in the recent years. An in vivo study based on a hand-held device (Thrombocheck) evaluated MHV closing sound on the time domain (furthermore deriving a frequency domain analysis), being able to recognize a large number of MHV failure, later confirmed on cinefluoroscopy. Some other in vitro studies tested commercially available MHV closure sounds at different hemodynamic conditions, demonstrating that each particular valve has a typical “fingerprint” in spectral signal of frequencies produced by the closure of the valve at different conditions. This concept brought to the application of ANNs to analyze power spectra of different types of valve. In addition, this method showed to be able to distinguish functional and dysfunctional prosthesis, differentiating obstructive from nonobstructive forms and identifying precocious apposition of minimal cloths.

Long-term outcomes following transatrial versus transventricular repair on right ventricular function in tetralogy of Fallot

Outcomes after repair of tetralogy of Fallot (TOF) are good with either a transventricular (TV) or transatrial (TA) approach. We sought to determine if there is a relationship between the TV or TA approach and right ventricular (RV) function, and the role of residual pulmonary regurgitation (PR) on the long‐term outcomes.

Surgical Instruments and Materials

Abstract Improved surgical outcomes in patients with simple congenital heart diseases, combined with significant advantages in surgical and perfusion technologies have stimulated surgeons to adopt minimally invasive technique in adult and pediatric cardiac surgery. We would like to present our instrumental armamentarium, which developed and enriched over the past decade.