Demetrio Pittarello

Expanding the eligibility for transcatheter aortic valve implantation the trans-subclavian retrograde approach using: the III generation CoreValve revalving system.

OBJECTIVES Our aim was to assess the safety and feasibility of the retrograde trans-subclavian approach to transcatheter aortic valve implantation (TAVI) in selected high-risk patients with aortic stenosis (AS) and severe peripheral vasculopathy. BACKGROUND TAVI is an emerging therapeutic option to treat inoperable/high-risk patients affected by symptomatic AS. However, these patients are also often affected by severe iliac-femoral arteriopathy, rendering the transfemoral approach unemployable for percutaneous revalving procedure. METHODS From among those patients in our department between May 2007 and December 2008, who were refused surgical aortic valve replacement because of high surgical risk and were ineligible for transfemoral percutaneous aortic valve replacement, we scheduled 3 for TAVI by the subclavian approach. Procedures were performed by a combined team of cardiologists, cardiac surgeons, and anesthetists in the catheterization laboratory. The III generation CoreValve Revalving System (CoreValve Inc., Irvine, California) with an 18-F delivery system was introduced in all cases by the left subclavian artery. RESULTS Prosthetic valves were successfully implanted in all 3 cases, leading to a fall in transvalvular gradient without significant paravalvular regurgitation. No intraprocedural or periprocedural complications occurred. Two patients developed an atrioventricular block requiring the implantation of a permanent pacemaker. All patients were discharged in asymptomatic status, with good prosthesis performance. No adverse events occurred within the 3-month follow-up. CONCLUSIONS TAVI by subclavian retrograde approach seems safe and feasible in inoperable/high-risk patients with AS and peripheral vasculopathy, who are neither eligible for surgical valve replacement nor transfemoral percutaneous aortic valve implantation. Further studies are needed to evaluate the long-term efficacy of this new therapy.

Randomized Evidence for Reduction of Perioperative Mortality

OBJECTIVE With more than 220 million major surgical procedures performed annually, perioperative interventions leading to even minor mortality reductions would save thousands of lives per year. This international consensus conference aimed to identify all nonsurgical interventions that increase or reduce perioperative mortality as suggested by randomized evidence. DESIGN AND SETTING A web-based international consensus conference. PARTICIPANTS More than 1,000 physicians from 77 countries participated in this web-based consensus conference. INTERVENTIONS Systematic literature searches (MEDLINE/PubMed, June 8, 2011) were used to identify the papers with a statistically significant effect on mortality together with contacts with experts. Interventions were considered eligible for evaluation if they (1) were published in peer-reviewed journals, (2) dealt with a nonsurgical intervention (drug/technique/strategy) in adult patients undergoing surgery, and (3) provided a statistically significant mortality increase or reduction as suggested by a randomized trial or meta-analysis of randomized trials. MEASUREMENTS AND MAIN RESULTS Fourteen interventions that might change perioperative mortality in adult surgery were identified. Interventions that might reduce mortality include chlorhexidine oral rinse, clonidine, insulin, intra-aortic balloon pump, leukodepletion, levosimendan, neuraxial anesthesia, noninvasive respiratory support, hemodynamic optimization, oxygen, selective decontamination of the digestive tract, and volatile anesthetics. In contrast, aprotinin and extended-release metoprolol might increase mortality. CONCLUSIONS Future research and health care funding should be directed toward studying and evaluating these interventions.

Mortality reduction in cardiac anesthesia and intensive care: results of the first International Consensus Conference

There is no consensus on which drugs/techniques/strategies can affect mortality in the perioperative period of cardiac surgery. With the aim of identifying these measures, and suggesting measures for prioritized future investigation we performed the first International Consensus Conference on this topic. The consensus was a continuous international internet‐based process with a final meeting on 28 June 2010 in Milan at the Vita‐Salute University. Participants included 340 cardiac anesthesiologists, cardiac surgeons, and cardiologists from 65 countries all over the world. A comprehensive literature review was performed to identify topics that subsequently generated position statements for discussion, voting, and ranking. Of the 17 major topics with a documented mortality effect, seven were subsequently excluded after further evaluation due to concerns about clinical applicability and/or study methodology. The following topics are documented as reducing mortality: administration of insulin, levosimendan, volatile anesthetics, statins, chronic β‐blockade, early aspirin therapy, the use of pre‐operative intra‐aortic balloon counterpulsation, and referral to high‐volume centers. The following are documented as increasing mortality: administration of aprotinin and aged red blood cell transfusion. These interventions were classified according to the level of evidence and effect on mortality and a position statement was generated. This International Consensus Conference has identified the non‐surgical interventions that merit urgent study to achieve further reductions in mortality after cardiac surgery: insulin, intra‐aortic balloon counterpulsation, levosimendan, volatile anesthetics, statins, chronic β‐blockade, early aspirin therapy, and referral to high‐volume centers. The use of aprotinin and aged red blood cells may result in increased mortality.

Safety and effectiveness of a selective strategy for coronary artery revascularization before transcatheter aortic valve implantation

We assessed the safety and effectiveness of a selective percutaneous revascularization strategy before TAVI in a single‐center prospective registry.

Transapical off-pump mitral valve repair with Neochord implantation: Early clinical results

BACKGROUND This prospective study aims to assess early clinical outcomes in patients undergoing Transapical Off-Pump Mitral Valve Intervention with Neochord Implantation (TOP-MINI). METHODS AND RESULTS Forty-nine patients with severe symptomatic degenerative mitral regurgitation (MR) were treated. Median age was 72 years (IQR 58-78) and median Euroscore-I was 3.26% (IQR 0.88-8.15). Forty-four patients (89.8%) presented with posterior leaflet prolapse (LP), 4 (8.2%) with anterior LP and 1 (2%) with combined disease. Acute procedure success (defined as successful placement of at least 3 neochords with reduction of residual MR to less than 2+) was achieved in all patients. In-hospital mortality was 2%. At 30 days major adverse events included one AMI (2%) successfully treated percutaneously and one sepsis (2%), no stroke or bleeding events occurred. At 3 months overall survival was 98%. MR was absent in 16 patients (33.4%), was grade 1+ in 15 (31.2%), and was grade 2+ in 12 (25%). Five patients (10.4%) developed recurrent severe MR due to anterior native chordae rupture. Four of them were successfully re-operated. At 3 months follow-up freedom from reoperation was 91.7 ± 4%. CONCLUSIONS Early results with Neochord procedure indicate that TOP-MINI is feasible and safe. Efficacy is maintained up to 3 months follow-up with significant clinical benefit for the patients.

The Role of Intraoperative Regional Oxygen Saturation Using Near Infrared Spectroscopy in the Prediction of Low Output Syndrome After Pediatric Heart Surgery

We report on the applicability of intraoperative regional oxygen saturation (rSO2) desaturation score by near‐infrared spectroscopy in the early detection of postoperative low output state (LOS) in infants with congenital heart disease who underwent cardiac surgery.

TEE-Guided Transapical Beating-Heart Neochord Implantation in Mitral Regurgitation

Transapical beating-heart neochord (Neochord DS1000, Minnetonka, Minnesota) implantation to repair mitral valve regurgitation has been demonstrated to be a safe and effective minimally invasive alternative to open surgical repair in selected patients with mitral leaflet prolapse (flail/chordae

Intraoperative plasmapheresis in cardiac surgery

OBJECTIVE To determine the effects of intraoperative plasmapheresis on total transfusion requirements, mediastinal drainage, and coagulation. DESIGN The trial was prospective, randomized, and controlled. SETTING Inpatient cardiac surgery at a university medical center. PARTICIPANTS Two hundred ninety-three consecutive patients undergoing cardiac surgery requiring cardiopulmonary bypass. INTERVENTIONS Intraoperative plasmapheresis (IP) was performed in 147 patients before heparinization; platelet-rich plasma was reinfused immediately after heparin reversal. MEASUREMENTS AND MAIN RESULTS Mediastinal chest tube drainage during the first 12 postoperative hours was significantly less in the IP group (p = 0.022), but no difference was noted in total postoperative blood loss between the two groups. The amount of packed red cells and fresh frozen plasma transfused to the IP group in the intensive care unit was significantly lower (p = 0.02, p = 0.002, respectively); 51.4% of patients required no transfusion compared with the control group (34.5%) (p = 0.006). No differences were noted for data collected in the intensive care unit in terms of the mean duration of chest tube drainage, ventilator time, or any hematologic variables at baseline or at any subsequent time in the study. CONCLUSIONS After cardiac surgery, intraoperative plasma-pheresis reduces early postoperative bleeding and decreases the need for homologous transfusions.

Transapical off-pump mitral valve repair with Neochord Implantation (TOP-MINI): step-by-step guide

A wide variety of surgical approaches for mitral valve repair (MVR) are available. Recent studies have demonstrated that the techniques which “respect rather than resect” the diseased portion of the mitral valve (MV) have comparable clinical outcomes and potentially superior results in terms of physiology (1). Artificial chordal implantation has received increased attention as an MVR strategy during the last few decades, especially when performed through a minimally invasive approach. The Transapical Off-Pump Mitral Valve Repair with Neochord Implantation (TOP-MINI) is a new MVR option that has been approved for patients presenting with severe mitral regurgitation (MR) due to leaflet(s) prolapse or flail (2-4). The procedure is performed using the NeoChord DS1000 system (NeoChord, Inc., Eden Praire, MN) under guidance of direct 2D and 3D transesophageal echocardiography (TEE) (5,6) for both implantation and tension adjustment of the neochordae. The aim of this article is to describe the TOP-MINI procedure in a step-by-step fashion.

Propofol-fentanyl versus isoflurane-fentanyl anesthesia for coronary artery bypass grafting: Effect on myocardial contractility and peripheral hemodynamics

To avoid intraoperative awareness and postoperative respiratory depression from high-dose opioid anesthesia, propofol (P), or isoflurane (I) has been combined with moderate-dose opioid with varying results. However, the effects of both P and I on myocardial contractility and left ventricular afterload have not been completely quantified. The end-systolic pressure-diameter relationship (ESPDR) of the left ventricle (LV) is a reliable method to quantitatively assess LV contractility because it is relatively independent of changes in preload and incorporates afterload changes. The purpose of this study was to quantify the cardiodynamic effects of propofol-fentanyl (PF) anesthesia in comparison with isoflurane-fentanyl (IF) anesthesia in patients undergoing coronary artery bypass grafting (CABG). Thirty patients with normal or moderately impaired LV function (ejection fraction > or = 40% with LV end-diastolic pressure < or = 18 mmHg, no preoperative akinesia or dyskinesia) undergoing elective CABG were studied. After premedication with flunitrazepam, 2 mg orally, all patients were induced with thiopental, 1 mg/kg, fentanyl, 20 micrograms/kg, and vecuronium, 0.1 mg/kg, and were ventilated with oxygen/air (F(1)O2 0.6). Anesthesia was maintained throughout the procedure with a zero-order intravenous (IV) continuous infusion of P, 3 mg/kg/h (PF group), or with isoflurane inhalation of 0.6% (IF group), supplemented by intermittent boluses (5 micrograms/kg) of fentanyl (up to a total maintenance dose of 30 micrograms/kg). After intubation, a cross-section of the LV was visualized by two-dimensional transesophageal echocardiography and an m-mode echocardiogram was obtained at the maximum anterior-posterior diameter. The radial artery pressure tracing and the ECG were simultaneously recorded with the M mode.(ABSTRACT TRUNCATED AT 250 WORDS)