Elisabetta Lapenna

Mitral Valve Repair for Functional Mitral Regurgitation in End-Stage Dilated Cardiomyopathy Role of the “Edge-to-Edge” Technique

Background—The aim of this study was to assess the results of mitral valve (MV) repair in functional mitral regurgitation because of end-stage dilated cardiomyopathy (DCM). Methods and Results—Seventy-seven patients with end-stage idiopathic (26 patients) or ischemic (51 patients) DCM underwent MV repair for functional mitral regurgitation (3 to 4+/4+). Fifty-eight patients (75.3%) were in New York Heart Association class III, and 19 (24.6%) were in IV. In 23 patients (29.8%) with a coaptation depth <1 cm, an isolated undersized annuloplasty was used. In the remaining 54 (70.1%), with a coaptation depth ≥1 cm, the “edge-to-edge” technique was associated with the annuloplasty. In most of the cases (88.3%), a complete rigid/semirigid ring was used. Concomitant coronary artery bypass graft was performed in 39 patients (50.6%). Hospital mortality was 3.8% (3 of 77). Actuarial survival was 90.7±3.64%, and freedom from cardiac events was 81.8±7.96% at 2.7 years. At a mean follow-up of 18.4±9.8 months (range, 1 month to 5 years) New York Heart Association class improved from 3.4±0.4 to 1.4±0.6 (P<0.0001). Mitral repair failure (recurrence of MR ≥3+/4+) was documented in 7 patients (9%): 2 in the edge-to-edge (2 of 54, 3.7%) and 5 in the isolated annuloplasty group (5 of 23, 21.7%) (P=0.03). Freedom from repair failure at 1.5 years was 95.0±3.4% and 77±12.1%, respectively (P=0.04). The absence of the edge-to-edge was the only predictor of repair failure (P=0.03). When residual MR was absent or mild, a reverse left ventricular remodeling was clearly documented. Conclusions—In patients with end-stage DCM, MV repair is feasible with low hospital mortality and important symptomatic improvement. The association of the edge-to-edge technique to the undersized annuloplasty can significantly improve the durability of the repair.

Topical use of tranexamic acid in coronary artery bypass operations: A double-blind, prospective, randomized, placebo-controlled study

OBJECTIVES We sought to investigate the effect of topical application of tranexamic acid into the pericardial cavity in reducing postoperative blood loss in coronary artery surgery. METHODS A prospective, randomized, double-blind investigation with parallel groups was performed. Forty consecutive patients undergoing primary coronary surgery were randomly assigned to group 1 (tranexamic acid group) or group 2 (placebo group). Tranexamic acid (1 g in 100 mL of saline solution) or placebo was poured into the pericardial cavity and over the mediastinal tissues before sternal closure. The drainage of mediastinal blood was measured hourly. RESULTS Chest tube drainage in the first 24 hours was 485 +/- 166 mL in the tranexamic acid group and 641 +/- 184 mL in the placebo group (P =.01). Total postoperative blood loss was 573 +/- 164 mL and 739 +/- 228 mL, respectively (P =.01). The use of banked donor blood products was not significantly different between the two groups. Tranexamic acid could not be detected in any of the blood samples blindly collected from 24 patients to verify whether any systemic absorption of the drug occurred. There were no deaths in either group. None of the patients required reoperation for bleeding. CONCLUSIONS Topical application of tranexamic acid into the pericardial cavity after cardiopulmonary bypass in patients undergoing primary coronary bypass operations significantly reduces postoperative bleeding. Further studies must be carried out to clarify whether a more pronounced effect on both bleeding and blood products requirement might be seen in procedures with a higher risk of bleeding.

Evolution of tricuspid regurgitation after mitral valve repair for functional mitral regurgitation in dilated cardiomyopathy.

OBJECTIVE To assess the evolution of tricuspid regurgitation (TR) in dilated cardiomyopathy (DCM) patients submitted to mitral repair for functional mitral regurgitation (MR). METHODS Ninety-one DCM patients (mean age 61+/-11.3) submitted to MV repair (+/-tricuspid repair) for functional MR were included. Preoperative EF was 30.9+/-6.5%, left ventricular (LV) end-diastolic volume 113+/-31.5 ml/m(2), LV end-systolic volume 81.8+/-26.7 ml/m(2), functional MR > or =3+/4+. TR was classified as < or =1+/4+ in 57 patients (62.6%), 2+/4+ in 21 (23%) and > or =3+/4+ in 13 (14.2%). Most of the patients were in NYHA class III or IV. A tricuspid annuloplasty was associated to mitral repair whenever preoperative TR was > or =3+. Therefore 13 patients (14.2%) underwent concomitant tricuspid annuloplasty whereas the remaining 78 (with preoperative TR < or =2+) did not. RESULTS At follow-up (mean 1.8+/-1.2 years), 12% of the patients (11/91) had still 3-4+ TR due to failure of the tricuspid repair or progression of untreated < or =2+ TR. Freedom from TR > or =3+ was 78+/-8.8% at 3.5 years. Among the 78 patients not submitted to tricuspid repair, 14 (18%) showed a progression of TR severity equal or greater than two grades. The multivariate analysis identified grade of TR at discharge (OR 5.4, p=0.01) and preoperative RV dysfunction (OR 19.6, p=0.02) as the only independent predictors of TR > or =3+/4+ at follow-up. CONCLUSIONS A significant number of patients submitted to mitral repair for functional MR present > or =3+ TR at follow-up as consequence of progression of untreated TR or failure of tricuspid repair. A more aggressive and effective treatment of functional TR in this setting should be pursued.

Long-Term Results (≤18 Years) of the Edge-to-Edge Mitral Valve Repair Without Annuloplasty in Degenerative Mitral Regurgitation Implications for the Percutaneous Approach

Background— To assess the long-term results of the edge-to-edge mitral repair performed without annuloplasty in degenerative mitral regurgitation (MR). Methods and Results— From 1993 to 2002, 61 patients with degenerative MR were treated with an isolated edge-to-edge suture without any annuloplasty. Annuloplasty was omitted in 36 patients because of heavy annular calcification and in 25 for limited annular dilatation. A double-orifice repair was performed in 53 patients and a commissural edge-to-edge in 8. Hospital mortality was 1.6%. Follow-up was 100% complete (mean length, 9.2±4.21 years; median, 9.7; longest, 18.1). Survival at 12 years was 51.3±7.75%. At the last echocardiographic examination, MR ≥3+ was demonstrated in 33 patients (55%). At 12 years, freedom from reoperation was 57.8±7.21% and freedom from recurrence of MR ≥3+ was 43±7.6%. Residual MR >1+ at hospital discharge was identified as a risk factor for recurrence of MR ≥3+ (hazard ratio, 3.8; 95% confidence interval, 1.7–8.2; P=0.001). In patients with residual MR ⩽1+ immediately after surgery, freedom from MR ≥3+ at 5 and 10 years was 80±6% and 64±7.58%, respectively. Conclusions— In degenerative MR, the overall long-term results of the surgical edge-to-edge technique without annuloplasty are not satisfactory. Early optimal competence (residual MR ⩽1+) was associated with higher freedom from recurrent severe regurgitation.

Vacuum-assisted venous drainage in extrathoracic cardiopulmonary bypass management during minimally invasive cardiac surgery.

The diffusion of minimally invasive cardiac surgery (MICS) during open-heart surgery has increased the use of assisted venous drainage support for cardiopulmonary bypass (CPB). Peripheral cannulation with small cannulae and vacuum-assisted venous drainage (VAVD) during MICS has been adopted in our institution since 1998. After the Heartport technique (HP) experience, the trans-thoracic clamp technique is now currently used. The aim of this study is to report our experience with extrathoracic CPB with VAVD application (on CPB) during open-heart MICS. From October 1999 to June 2006, 193 patients underwent MICS. Thirty-seven (19.2%) patients were treated with the HP - 13 (35%) with robotic technology and 156 (80.8%) with trans-thoracic aortic clamping (TTAC). Mean age was 39 years (range: 12-77), and 114 patients (59.1%) were female. A total of 128 patients (66.3%) underwent mitral valve surgery, 57 (29.6%) atrial septal defect closure, five (2.6%) cardiac mass removal, and three (1.5%) tricuspid valve repair. Four patients (2.0%) had a previous cardiac procedure. Peripheral CPB was established with a standard coated circuit. A 14 Fr arterial cannula was inserted into the right jugular vein and positioned at the atrial/superior vena cava junction. A 21 or 28 percutaneous femoral cannula, depending on body surface area, was inserted in the femoral vein and an arterial cannula in the right femoral artery. Gravitational drainage was combined with VAVD. To improve the safety and effectiveness of this technique, we monitored the pressure on each venous cannula and in the reservoir. The mean CPB time was 74.8∓30 min (TTAC) and 119∓48 min (HP); mean aortic clamping time was 51∓19 min (TTAC) and 73∓29 min (HP). We did not record any neurological complication. Two patients (1.0%), one from each group, were converted to sternotomy. Three patients (1.5%) underwent re-exploration for bleeding. In-hospital mortality was 0.5% (N = 1) (HP). Mechanical ventilation time and intensive care unit stay were comparable to those recorded with conventional sternotomy. In conclusion, we found that extrathoracic CPB and VAVD during trans-thoracic clamping is a safe, simple, and effective technique for MICS. However, there is a potential risk of haemolysis and air embolism, which can be prevented with vacuum monitoring, and with the addition of gravitational drainage to reduce vacuum pressure.

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.

Mediastinitis following graft replacement of the ascending aorta: conservative approach by omental transposition.

A 57-year-old patient underwent prosthetic replacement of a previously implanted ascending aorta graft and developed a periprosthetic purulent collection 1 month later. He was successfully treated by debridement of infected tissues, antiseptic irrigation and transposition of an omental flap. The postoperative course was uneventful. A chest computed tomography scan performed 15 months later showed no signs of perigraft infection. Prompt conservative surgical treatment including omental transposition can be effective in the treatment of mediastinitis following graft replacement of the ascending aorta.

Long-term outcomes of tricuspid valve replacement after previous left-side heart surgery †

OBJECTIVES To assess long-term outcomes of tricuspid valve replacement (TVR) after previous left-side heart surgery. METHODS We reviewed reoperative TVR after left-side heart surgery performed at our institution between March 1997 and June 2012. In-hospital data were retrieved from our institutional database or medical records; follow-up was performed through telephone call, surviving patients being asked to provide a recent (≤6 months) echocardiogram. RESULTS Reoperative TVR was performed in 117 patients. Preoperative characteristics included: mean age 63.7 years, median logistic EuroSCORE (LES) 11.8, New York Heart Association (NYHA) class >2 in 79.5% of patients, right ventricle (RV) dysfunction >mild in 23.9% of patients and mean systolic pulmonary artery pressure (sPAP) 48.4 mmHg. A mechanical prosthesis was implanted in 5.1% of patients. A right thoracotomy was preferred to median sternotomy in 8.6% of cases. Isolated-TVR (I-TVR) was performed in 52.1% of patients, a beating-heart approach being used in 85.2% of I-TVR cases. Postoperative RV failure occurred in 46.1% of patients. Median length-of-stay was 11.5 days. Thirty-day mortality was 6.0% overall and 8.2% in the I-TVR group. Higher preoperative LES (P = 0.002), ascites (P = 0.004), RV dysfunction (P = 0.033) and sPAP (P = 0.046) were associated with acute mortality. No significant difference in acute outcomes was observed between beating and arrested-heart I-TVR, except for postoperative median length-of-stay (9 vs 28 days, respectively, P = 0.007). Among survivors median follow-up time was 5.1 years. Five-year and 10-year freedom from cardiac death were 79.4 and 61.0%, freedom from tricuspid reoperation were 97.3 and 87.5%, freedom from bioprosthesis degeneration were 92.8 and 74.3%, respectively. Five-year and 10-year survival in the I-TVR subgroup were respectively 74.4 and 61.6%. Higher preoperative sPAP was associated with increased follow-up mortality (P = 0.048). At the last follow-up, NYHA class I-II was found in 86.1% of surviving patients. CONCLUSIONS In selected cases, TVR is currently feasible with low acute mortality, especially if performed in the absence of ascites, significant RV dysfunction and pulmonary hypertension. Long-term mortality remains more difficult to predict, although it appeared to be also associated with higher preoperative pulmonary pressure. The global high-complexity profile of these patients is likely to impair long-term outcomes.

MitraClip therapy and surgical edge-to-edge repair in patients with severe left ventricular dysfunction and secondary mitral regurgitation: mid-term results of a single-centre experience†.

OBJECTIVES To compare the surgical and percutaneous edge-to-edge (EE) repair in patients with severe left ventricular (LV) dysfunction and secondary mitral regurgitation (MR). METHODS We reviewed the prospectively collected data of the first 120 consecutive patients (age: 65 ± 9.8 years, EF: 28 ± 8.2%) treated with surgical (65 patients) or percutaneous (55 patients) EE repair for severe secondary MR in our institution. Age (P = 0.005) and logistic European System for Cardiac Operative Risk Evaluation (P < 0.0001) were significantly higher in the MitraClip group. LVEF (P = 0.37), end-diastolic (P = 0.83) and end-systolic (P = 0.68) volumes and systolic pulmonary artery pressure (SPAP) (P = 0.58) were similar. The follow-up was 100% complete [median: 4 years; interquartile range (IQR): 2.2-7.2]. RESULTS The length of hospital stay was 10 days (IQR: 8-13) for surgery and 5 days (IQR: 3.9-7.8) for MitraClip (P < 0.0001). Hospital mortality (3 vs 0%, P = 0.49) and freedom from cardiac death at 4 years (80.8 ± 4.9% vs 79.1 ± 5.9%, P = 0.9) were not significantly different in the surgical and MitraClip group, respectively. Residual MR ≥ 2+ at hospital discharge was 7.6% for surgery and 29% for MitraClip (P = 0.002). At 4 years, freedom from MR ≥ 2+ (74.9 ± 5.6% vs 51.4 ± 7.4%, P = 0.01) and freedom from MR ≥ 3+ (92.8 ± 3.4% vs 68.1 ± 7%, P = 0.002) were both significantly higher in the surgical group. Multivariate analysis identified the use of MitraClip as an independent predictor of recurrence of MR ≥ 2+ [Hazard ratio (HR): 2.1, 95% confidence interval (CI): 1.1-3.9, P = 0.02] as well as of MR ≥ 3 (HR: 6.1, 95% CI: 1.5-24.3, P = 0.01). In the surgical group, no predictors of cardiac mortality were identified. In the MitraClip group, left ventricular end-diastolic diameter (HR: 1.1, 95% CI: 1-1.2, P = 0.005) and SPAP (HR: 1, 95% CI: 1-1.1, P = 0.005) were independent predictors of cardiac death at the follow-up. CONCLUSIONS MitraClip therapy is a safe therapeutic option in selected high-risk patients with secondary MR and relevant comorbidities. The surgical EE provides higher efficacy both postoperatively and at the mid-term follow-up.

Very long-term durability of the edge-to-edge repair for isolated anterior mitral leaflet prolapse: Up to 21 years of clinical and echocardiographic results

OBJECTIVE To assess the very long-term clinical and echocardiographic results of the edge-to-edge repair for mitral regurgitation (MR) due to isolated prolapse or flail of the anterior leaflet. METHODS From 1991 to 2004, 139 patients (age, 54±14.4 years; left ventricular ejection fraction 56%±7.8%, New York Heart Association class I-II in 68.9%, atrial fibrillation in 20.1%) with severe degenerative MR due to isolated segmental prolapse or flail of the anterior leaflet were treated with the EE technique combined with annuloplasty. MR had resulted from prolapse or flail of the central scallop of the anterior leaflet (A2) in 105 patients (75.5%) and scallops A1 or A3 in 34 (24.4%). RESULTS No hospital deaths occurred. At hospital discharge, MR was absent or mild in 130 patients (93.5%) and moderate (2+/4+) in 9 (6.4%). The clinical and echocardiographic follow-up data were 97.1% complete (mean length, 11.5±3.73 years; median, 11; longest duration, 21.5). At 17 years, the actuarial survival was 72.4%±7.89%, freedom from cardiac death was 90.8%±4.77%, and freedom from reoperation was 89.6%±2.74%. At the last echocardiographic examination, recurrence of MR grade≥3+ was documented in 17 patients (17 of 135, 12.5%). Freedom from MR grade≥3+ at 17 years was 80.2%±5.86%. At multivariate analysis, the predictors of MR recurrence grade≥3+ were residual MR greater than mild at hospital discharge (hazard ratio, 7.4; 95% confidence interval, 2.5-21.2; P=.0001) and the use of posterior pericardial rather than prosthetic ring annuloplasty, which was very close to statistical significance (hazard ratio, 2.8; 95% confidence interval, 0.9-8.7; P=.06). CONCLUSIONS In patients with MR due to segmental anterior leaflet prolapse, the very long-term results of the edge-to-edge repair combined with annuloplasty were excellent.