Fabrizio Gazzoli

Left ventricular aneurysm resection with port-access surgery: a new mini-invasive surgical approach

BACKGROUND In recent years port-access and endovascular extra-corporeal circulation techniques have allowed valvular and coronary operations to be performed by mini-thoracotomy. Experience with the technique suggested application to resection of ventricular aneurysms, which are usually approached through a median sternotomy with the use of traditional cardiopulmonary bypass. METHODS We performed a left port-access mini-thoracotomy, with 6 to 8 cm skin incisions, in 7 patients undergoing endoventricular pericardial patch repair for anterior left ventricular aneurysm. Cardiopulmonary bypass was effected using the Heartport system. The mean interval between myocardial infarction and operation was 60.4 +/- 57.7 months. Three patients developed sustained ventricular tachicardia. Mean preoperative ejection fraction was 34% +/- 11%. Associated procedures were coronary bypass grafting in 2 patients and cryosurgery in 3 patients. RESULTS All patients survived to discharge and are alive and well after an average 14.5 months. They are all in NYHA class I-II. Postoperative echocardiograms revealed an average ejection fraction of 48.0% +/- 7.5% (p = 0.006 compared with preoperative value). The 3 patients who had cryosurgery did not demonstrate any recurrence of arrhythmias. CONCLUSIONS Left ventricular aneurysm can be successfully treated through port-access mini-thoracotomy with endovascular cardiopulmonary bypass, avoiding median sternotomy. This mini-invasive approach allows effective ventricular remodeling. Revascularization and antiarrhythmia surgery can also be done at the same time. In case of severely reduced ventricular function this approach permits fibrillatory arrest without aortic cross-clamping. The results are also good in terms of hospitalization time and long-term survival.

Results of the European Clinical Trial of Arrow CorAide Left Ventricular Assist System

The aim of this study was to evaluate the safety and performance of the Arrow CorAide left ventricular assist system (LVAS) (Arrow International, Reading, PA, USA), a continuous-flow left ventricular assist device, as bridge to transplantation or recovery as well as destination therapy in patients with New York Heart Association (NYHA) class IV heart failure. Twenty-one patients were implanted with the CorAide LVAS between February 2005 and February 2006 in a prospective, multicenter, nonrandomized trial. Seventeen patients (81%) survived to >180 days or to transplantation. The cumulative time on device was 16.58 patient years (range 23-796 days, median 192 days). No intraoperative technical issues were observed at the time of implantation. Of the 21 implants, nine patients died on device, two were converted to other devices, and 10 were transplanted. Three patient deaths were attributed to pump polymer coating delamination. Postmortem device inspection determined delamination of the polymer coating on the pumps internal surface to be the cause of the late hemolysis and sudden fatal pump stops. No embolic or driveline infection event was recorded. The automatic flow control algorithm functioned reliably throughout the trial. Primary performance trial endpoint was achieved with 81% survival to 180 days or transplantation. Delamination of the polymer coating on the internal surface of the pump with resultant hemolysis and pump stops was the sole major device event in this trial. Elimination of the polymer coating and replacement with an amorphous carbon coating has resolved this in preclinical testing, prior to initiation of further clinical testing of this device.

Initial results of clinical trial with a new left ventricular assist device (LVAD) providing synchronous pulsatile flow.

Objectives A multicentric European Clinical Study is ongoing to evaluate safety and efficacy of a new pulsatile implantable LVAD (BestBeat), smaller and lighter than similar devices, capable of providing synchronous and counterpulsating flow with respect to the LV of end-stage heart failure patients. Preliminary clinical results are reported. Methods The new BestBeat LVAD was used, consisting of an implantable pulsatile blood pump, electromechanically driven by a ball screw mechanism, and a wearable electronic controller and power sources. The clinical trial was conducted at 5 European centers. Adult patients affected by CHF in NYHA Class IV despite optimized medical treatment were enrolled. The primary study endpoint was survival at 90 days. Further study endpoints were maintenance of adequate LVAD pump flow and a minimum rate of adverse events during support. Results As of June 2008, 6 patients received the implant. Cumulative support time was 3.7 years, median support time 176 days. All patients who completed the study survived except for one, who died after 48 days, due to combined infection and cerebrovascular accident. Another two patients died: one from intracranial bleeding 113 days after implant, and one from septic shock after 123 days. Hemodynamic improvement with Cl>2.0 l/min/m2 and recovery of end-organ function expressed by consistent improvement of BUN, creatinine and bilirubin were reached in all patients. No device failure was observed. There was no bleeding requiring re-exploration, no hemolysis and only two device-related infections (both in one patient). Neurologic events were reported, the most serious ones occurring in patients with pre-implant respiratory and kidney failure. Three patients were discharged home. Two patients were successfully transplanted, one after 6 months and one after 13 months on device. Conclusions Good performance and efficacy of the device were observed; the endpoints of the study were achieved, and its safety was consistent with expectations. The ongoing study will allow further conclusions to be drawn.

The Pathologic Basis of Recovery

More patients with end-stage heart failure are now being supported by left ventricular assist devices (LVAD) as a bridge to heart transplant. The LVAD unloads the failing heart and modifies the myocardial structure, with regression of left ventricular hypertrophy. The regression of hypertrophy has been reported histomorphologically in paired samples of myocardial tissues obtained from the same patient at the time of LVAD implantation and the heart excised at transplant. The understanding of the mechanisms of recovery may contribute to strategic development for LVAD weaning and the use of LVAD as a destination therapy.

Excellent long-term result 10 years after minimally invasive quadruple coronary artery bypass

1558-2027 2011 Italian Federation of Cardiology proximal left anterior descending (LAD), resulting almost as a dual LAD], venous graft to second diagonal–sequential–LAD, venous graft to right coronary artery (RCA) associated with a double endarterectomy on the first diagonal branch and the RCA. Surgery was performed through a small 10-cm left submammary incision and cardiopulmonary bypass (CPB) was instituted between both femoral vein and artery. Aortic clamping was obtained by using a peripheral endoaortic balloon. The postoperative course was uneventful and the patient was discharged on postoperative day 4. Thereafter, she was asymptomatic and, due to a drug intolerance, suspended the antiaggregant therapy. An angiographic control was recently performed in the absence of clinical symptoms, showing a satisfactory result on all implanted grafts (Fig. 1a–d). The cosmetic result of surgery was excellent

Novacor left ventricular assist device inflow valve endocarditis

A 42-year-old male underwent Novacor left ventricular assist device. Readmitted after 11 months for fever and dyspnea, corynebacterium was isolated and treated with ampicillin and gentamicin for 6 weeks. Transplanted after 388 days on support, device inspection showed one leaflet of the porcine inflow valve perforated by endocarditis process (Fig. 1). www.elsevier.com/locate/ejcts European Journal of Cardio-thoracic Surgery 35 (2009) 910

EXPRESS: MitraClip procedure as “bridge to list”, the ultimate therapeutic option for end-stage heart failure patients not eligible for heart transplantation due to severe pulmonary hypertension

Patients with end-stage heart failure (HF), pulmonary hypertension and elevated pulmonary vascular resistance (PVR) despite medical therapy are not eligible for heart transplantation (HTx). In this ‘proof of concept’ case series, we demonstrate the feasibility and efficacy of the MitraClip procedure as ‘bridge to list’ in end-stage HF patients not eligible for HTx. In fact, in the three patients reported, who were initially excluded from the HTx list because of elevated PVR, the MitraClip procedure was followed by a sustained improvement of PVR, allowing the patients’ risk to be reclassified, and they were then considered eligible for HTx.

Right coronary thrombosis in patient supported by Jarvik 2000 left ventricular assist device.

A 62-year-oldmale, affected by ischemic cardiomyopathy, received a Jarvik 2000. Seventeen months later he complained of angina. An electrocardiogram (ECG) presented inferior leads ST-elevation, and blood chemistry showed increased Troponin-I. Angiography (Video 1) showed right coronary thrombosis, venous graft to obtuse marginal, and device in left ventricle apex (Figs. 1(a) and 2). After thromboaspiration/stenting, thrombolysis in myocardial ischemia-III (TIMI-III) flow was restored (Fig. 1(b) and Video 2). www.elsevier.com/locate/ejcts European Journal of Cardio-thoracic Surgery 39 (2011) 1076