Chiara Tessari

The Evolution of the Right Anterolateral Thoracotomy Technique for Correction of Atrial Septal Defects: Cosmetic and Functional Results in Prepubescent Patients

BACKGROUND The aim of this study was to evaluate the results of a cosmetic right anterolateral thoracotomy (RALT) in prepubescent girls who underwent repair of atrial septal defect (ASD). METHODS All prepubescent girls who underwent RALT for ASD closure since January 1998 were included. Patient satisfaction with the cosmetic approach and the impact of RALT on breast development were evaluated. One hundred healthy women were used as controls. RESULTS One-hundred forty-one patients were included. Median age at repair was 4.6 years (range, 8 months-12 years). The median length of the surgical incision was 9 cm (range 3-20 cm); it was shorter during the last 5 years of our experience (median, 5 cm; range, 3-10 cm; p = 0.001). Fourteen patients (9.9%) experienced a transitory mild sensitive skin deficit in the mammary area, which was associated with the length of the RALT (p = 0.05). At median follow-up of 10.1 years (range, 1.5-14.5 years), 3/60 patients (5%) who had complete breast development had relevant asymmetrical breast development (indexes of breast symmetry > 2 standard deviations of the median value for controls). Six additional patients who underwent RALT (10%) had mild asymmetrical breast development, which was comparable to the control population (p = 0.1). The satisfaction rate for the cosmetic result of RALT was 97.8% (138/141 patients). Reasons for dissatisfaction were the presence of asymmetrical breast development (n = 2) and the presence of a keloid at the incision level (n = 1). CONCLUSIONS RALT is a reliable surgical technique that combines excellent cosmetic and functional results in almost all patients. With the latest technical refinements, it is our gold standard treatment for ASD in prepubescent girls.

Cardiac Operations After Patent Ductus Arteriosus Stenting in Duct-Dependent Pulmonary Circulation

BACKGROUND Stenting of the patent ductus arteriosus (PDA) has been recently introduced to palliate patients with duct-dependent pulmonary circulations. We evaluated the surgical outcome of patients who had a previous PDA stent, focusing on their pulmonary arteries status. METHODS This study included 15 patients (11 boys, 4 girls) who underwent cardiac operations after PDA stenting between August 2004 and April 2009. Outcomes included hospital mortality, morbidity, and need for reintervention or operation on the PDA and on the pulmonary artery branches. RESULTS Thirteen patients underwent elective cardiac operations at a median of 11 months (range, 0.3 months to 3.7 years) from PDA stenting. Two patients underwent emergency operations due to stent migration during percutaneous positioning. Six patients (46%) required a preoperative interventional cardiology procedure, including PDA stent dilatation in 5 and multiple left pulmonary artery dilatations in 1. During elective surgical repair, PDA stents were completely retrieved in 3 patients (23%) and partially removed in 10 (77%) due to the fusion of the stent to the vascular wall. Seven patients (53.8%) required surgical pulmonary artery plasty. One in-hospital death (6%) occurred after an emergency operation. Median follow-up was 16.7 months (range, 1 month to 2.5 years). Two late deaths (14%) occurred at 4 and 9 months. Four patients required additional interventional procedures on the left pulmonary artery after surgical repair. CONCLUSIONS Operations after PDA stenting are safe and low-risk. The presence of PDA stents requires additional surgical maneuvers on pulmonary arteries in near half of the patients, and postoperative interventions can be required.

Intermediate Clinical and Hemodynamic Outcomes After Transcatheter Aortic Valve Implantation

BACKGROUND Concerns still exist regarding long-term results and freedom from valve-related adverse events in transcatheter aortic valve implantation (TAVI). The aim of this single-center retrospective study was to assess intermediate-term (up to 5-year) clinical and hemodynamic outcomes in patients undergoing TAVI. METHODS From 2007 through 2013, 338 consecutive patients underwent TAVI at our institution. Preoperative variables were defined according to the European System for Cardiac Operative Risk Evaluation (EuroSCORE) definitions, and outcomes were reported according to the Valve Academic Research Consortium (VARC)-2 definitions. Multivariate logistic regression analysis was performed to identify independent predictors of mortality at follow-up. RESULTS transfemoral (TF) and transapical (TA) TAVI were performed in 233 (69%) and 105 (31%) patients, respectively. All-cause 30-day mortality was 4.4%, with no differences between TA and TF procedures. Thirty-day cardiovascular death, stroke, and myocardial infarction were not different between groups. The acute kidney injury (AKI) rate was higher in the TA group (30.5% versus 11.2%; p < 0.001). Access-related complications were more frequent in the TF group (36.1% versus 11.4%; p < 0.001). Mean follow-up was 22.3 ± 17.8 months (range, 1-74 months). Overall survival rates at 1, 3, and 5 years were 85.5% ± 2.1%, 69.9% ± 3.2%, and 61% ± 4.3%, respectively. Independent predictors of all-cause mortality at follow-up were previous myocardial infarction (odds ratio [OR], 2.7), any grade of paravalvular leak (PVL) (OR, 2.5), and AKI (OR, 3.1). Mean gradient and effective orifice area at follow-up were 10.7 ± 12.0 mm Hg and 1.1 ± 0.9 cm(2)/m(2), respectively. CONCLUSIONS Our data show that TAVI has good early and intermediate-term clinical and hemodynamic outcomes in high-risk or inoperable patients with severe symptomatic aortic valve stenosis. PVL of any grade has a significant impact on survival.

Open transcatheter tricuspid balloon expandable valve-in-valve implantation for failed bioprosthesis.

From the Division of Cardiac Surgery, Department of Cardiac, Thoracic, and Vascular Sciences, and Institute of Anesthesia, University of Padua, Padua, Italy. Disclosures: Authors have nothing to disclose with regard to commercial support. Received for publication March 14, 2013; accepted for publication March 19, 2013; available ahead of print April 15, 2013. Address for reprints: Andrea Colli, MD, PhD, Division of Cardiac Surgery, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Via Giustiniani, 2, 35127 Padova, Italy (E-mail: colli.andrea.bcn@gmail.com). J Thorac Cardiovasc Surg 2013;146:e3-5 0022-5223/

Sapien XT implantation under direct vision as a bail-out procedure in case of hostile aortic root: A reasonable alternative for stentless bioprosthesis reoperation

36.00 Copyright 2013 by The American Association for Thoracic Surgery http://dx.doi.org/10.1016/j.jtcvs.2013.03.034

Early and Mid-Term Results of Rapid-Deployment Valves: The Intuity Italian Registry (INTU-ITA)

Reoperations for stentless bioprostheses structural dysfunction are quite common. These procedures represent a surgical challenge because complete aortic root replacement might be required due to severe root calcification. Valve-in-valve transcatheter aortic valve replacement (ViV-TAVR) has been proposed as an alternative treatment in high-risk patients requiring aortic valve reoperations. However, ViV-TAVR in bioprostheses has raised some concern related to the risk of coronary ostia occlusion by prosthetic leaflets. We present a case of a patient with a stentless valve dysfunction who was scheduled for conventional reoperation but who finally underwent ViV-TAVR for the presence of massive calcification of the aortic root and particularly of the coronary ostia, which made isolated valve replacement as well as Bentall operation technically impossible.

The peripheral cannulation technique in minimally invasive congenital cardiac surgery

BACKGROUND Rapid deployment bioprostheses (RDBs) have been recently introduced into clinical practice for the treatment of severe aortic valve stenosis. The aim of this retrospective multicenter study was to assess early and mid-term clinical and hemodynamic outcomes of patients undergoing RDB implantation. METHODS Data from a national registry that included patients who underwent isolated or combined aortic valve replacement with RDB in Italy were analyzed. Definitions of the European System for Cardiac Operative Risk Evaluation were used for preoperative variables and updated definitions from the Valve Academic Research Consortium were used for postoperative outcomes assessment. Univariable and multivariable analyses were performed to identify independent predictors of mortality. Follow-up was performed with clinical and echocardiographic examinations at each study site and, if this was not possible, through telephonic interviews. The Kaplan-Meier method was used for survival analysis. RESULTS A total of 902 patients (December 2012 through November 2017) from 20 national centers were included in the registry. Device success was 95.9%, and 30-day all-cause mortality was 2.8%. Postoperative pacemaker implantation was needed in 63 patients (6.9%). At discharge, peak and mean transaortic gradients were 19 ± 7 mm Hg and 11 ± 4 mm Hg, respectively. Mild and moderate aortic regurgitation were found in 71 patients (8.2%) and in 10 patients (1.2%), respectively. Median follow-up time was 357 days (interquartile range: 103 to 638 days). Survival at 4 years was 86% ± 1%. Preoperative conduction disturbances and history of previous myocardial infarction were independently associated with mortality. CONCLUSIONS Aortic RDBs provide good early and mid-term clinical and hemodynamic outcomes. These devices may be considered as a reasonable alternative to conventional bioprostheses, especially in minimally invasive and combined operations.

Acute ascending aortic dissection during transaortic balloon-expandable aortic valve implantation

Congenital minimally invasive cardiac surgery has gained wide acceptance thanks to its favorable outcomes. The introduction of peripheral cannulation for cardiopulmonary bypass further reduces surgical trauma by decreasing surgical access and allowing the spectrum of surgical access for the correction of simple congenital heart defects to be widened. Right internal jugular vein percutaneous cannulation, together with the direct surgical cannulation of femoral vessels, proves to be a safe and effective tool in patients with body weight above 15 kg.

Early Correction of Common Atrioventricular Septal Defects: A Single-Center 20-Year Experience

The final pathologic description of the right lung nodule was pulmonary meningotheliallike tumor. The clinicopathologic characteristic of this benign tumor remain unclear, but it is usually very tiny (1-3 mm) and discovered incidentally after lung resection for other lesions. Presentation as a solitary nodule 5 mm in size, as in our patient, is not common. In conclusion, the successful treatment in this patient suggests that nonintubated thoracoscopic operation may be feasible and safe in the treatment of selected patients with bilateral small peripheral pulmonary lesions and good preoperative cardiopulmonary function.