Federico Milla

Management of systolic anterior motion after mitral valve repair: An algorithm

OBJECTIVE To evaluate the effectiveness and outcomes of an intraoperative and postoperative algorithm for managing systolic anterior motion (SAM) after mitral valve repair (MVRr). METHODS All consecutive patients who underwent MVRr for degenerative disease from January 2002 to June 2011 were included, with the data collected retrospectively. Patients who underwent MVRr for primary SAM were excluded from the study. Patients who developed SAM after the repair were systematically treated according to the algorithm. The intraoperative algorithm first involved medical management techniques, followed by surgical correction for significant SAM (mild or greater mitral regurgitation, left ventricular outflow tract gradient > 50 mm Hg). The postoperative algorithm focused on medical management and symptoms to guide the treatment decisions. RESULTS The overall in-hospital incidence of SAM was 6.6% (52/785). In 41 patients, SAM was identified in the operating room, and in 11 patients, it was found postoperatively on the predischarge echocardiogram. Of the 41 patients with intraoperative SAM, 35 (85.4%) had resolution with medical management and 6 (14.6%) required surgical repeat repair while in the operating room. No patient required mitral valve replacement for persistent SAM. Postoperatively, 11 new cases were identified, and 7 cases of resolved intraoperative SAM recurred. These postoperative cases of SAM were managed according to the postoperative SAM algorithm. At last follow-up, 17 (94.4%) of 18 patients had resolution of SAM and 1 (5.6%) patient had mild SAM (less than mild mitral regurgitation, peak left ventricular outflow tract gradient < 50 mm Hg) and were asymptomatic. No patients with postoperative SAM required reoperation after their initial surgery. The median echocardiographic follow-up was 1.3 years. During follow-up, 1 early death (noncardiac) and 2 late deaths (1 noncardiac, 1 of unknown etiology) occurred. CONCLUSIONS SAM is a relatively frequent complication after MVRr and can occur intraoperatively or postoperatively. A systematic approach addressing perioperative SAM after MVRr yields excellent mid-term results.

Implantable left ventricular assist devices as initial therapy for refractory postmyocardial infarction cardiogenic shock

OBJECTIVES Recently, the initial therapy for refractory cardiogenic shock has largely been based on use of short-term mechanical devices with later conversion to durable options. The premise is that such patients cannot tolerate cardiopulmonary bypass and the extended surgery needed for implantable left ventricular assist device (LVAD) placement. We have adopted an alternative strategy to implant long-term LVADs as the initial device therapy in such patients. METHODS Over a 3 year period, we used implantable LVADs (Jarvik 2000, one; Ventrassist, one; Heartmate XVE, two; and Heartmate II, nine) in 13 patients (11 men and two women; mean age 54 years) with postmyocardial infarction shock without prior use of a short-term LVAD. The median time interval from myocardial infarction to LVAD implantation was 3.5 days. Eight patients were on a ventilator, two had unknown neurological status and four had suffered cardiac arrest in the preceding 24 h. Two had prior coronary artery bypass graft. Nine had received dual antiplatelet therapy postmyocardial infarction. The mean laboratory value of creatinine was 1.5 mg/dl, alanine aminotransferase 748 U/l, international normalized ratio 1.5 and lactate 3.2 mmol/l. One procedure was carried out off pump; for the others, the mean cardiopulmonary bypass time was 72 min. Right ventricular assist devices were used in two cases and were later explanted. RESULTS One patient died of progressive multiorgan failure. All others survived to hospital discharge. There were no re-explorations for bleeding or major infectious complications; two patients had perioperative stroke. The median duration of mechanical ventilation, intensive care unit stay and hospital stay was 3, 9 and 18 days, respectively. At 1 year, of the 12 survivors, eight have since had heart transplant, one patient underwent device explant, two remained alive on support and one died 7 months post-LVAD. CONCLUSIONS Our data challenge the notion that patients in refractory cardiogenic shock are too ill to tolerate immediate placement of implantable LVADs. Despite the surgical challenges, a one-stop implantable LVAD approach for cardiogenic shock is feasible and may offer unique advantages over the bridge-to-bridge approach because it avoids the incremental costs, hospitalization and morbidity associated with repeated interventions.

Surgical Management of Carcinoid Heart Valve Disease

Carcinoid tumors are neuroendocrine tumors with an unpredictable clinical behavior. In the setting of hepatic metastases, the release of bioactive amines from the tumor into the systemic circulation results in carcinoid syndrome: a constellation of clinical symptoms, among which cutaneous flushing, gastrointestinal hypermotility, and cardiac involvement are the most frequent. Cardiac manifestations, also known as carcinoid heart disease, are secondary to a severe endocardial fibrotic reaction that leads to progressive valve thickening and retraction. Imaging studies commonly reveal severe right-sided valve disease, with fixed leaflets or cusps in a semiopen position. The replacement of the right-sided valves, including the patch enlargement of the right ventricular outflow tract, is currently the only definitive treatment to potentially improve quality of life and provide survival benefit. Although cardiac surgery has been traditionally reserved for those patients with symptomatic right ventricular failure, a significant trend toward improved surgical outcomes has triggered a more liberal referral for valve replacement during the past decade.

Indications for Heart Transplantation in Current Era of Left Ventricular Assist Devices

Although both heart transplantation and left ventricular assist device therapy have enjoyed clinical success in the treatment of patients with end-stage heart disease, newer left ventricular assist devices currently undergoing testing are likely to have a tremendous impact on the management of these patients. Smaller, more durable devices with improved safety profiles will allow for longer duration of therapy and make biventricular support more feasible, obviating the need for the total artificial heart. In this article we review the historical aspects of both forms of therapy and highlight the current use of left ventricular assist device therapy on patients awaiting heart transplantation.

Bench Mitral Valve Repair of Donor Hearts Before Orthotopic Heart Transplantation

Cardiac transplantation remains the most effective therapy for end-stage heart failure in appropriate candidates, with a median posttransplant survival of 10 years. At any given point of time there are ≈3000 candidates on the heart transplant waiting list in the United States with annual mortality on the waiting list ≈15%. The number of heart transplants performed in the United States per year has been fairly constant at ≈2500. In spite of this, many donor hearts remain unused. Bench repair of mitral valves remains rarely practiced and significant mitral valve regurgitation (MR) remains a standard contraindication to use of a donor heart. A 53-year-old male donor who had a cerebral infarct became available for a 61-year-old man with blood group O who received left ventricular assist device, Heartmate II (Thoratec, Pleasanton, CA), for decompensated dilated cardiomyopathy. The donor coronary angiogram was normal. Donor transthoracic echocardiogram (TTE) showed inferior wall hypokinesis, interventricular septum 1.15 cm, …

Successful use of a donor heart with quadricuspid aortic valve for orthotopic heart transplantation.

Quadricuspid aortic valve (QAV) is a rare congenital anomaly of the aortic valve. We describe transplanting a donor heart with a QAV with successful mid‐term outcome. doi: 10.1111/jocs.12108 (J Card Surg 2013;28:467–468)

Ruptured papillary muscle causing acute severe mitral regurgitation.

A 78-year-old male presented with angina and shortness of breath requiring intubation. A coronary angiogram demonstrated coronary occlusion of right coronary artery (RCA) and the first obtuse marginal artery (OM1) and a 90% left anterior descending (LAD) artery lesion. A drug eluting stent was placed in the RCA. He was stable for two days but later suddenly developed pulmonary edema and cardiogenic shock. A transesophageal echocardiogram demonstrated anterior mitral leaflet flail resulting from a torn papillary muscle (Fig. 1A) causing severe posteriorly directed mitral regurgitation (Fig. 1B). At the time of surgery, the posteromedial papillary muscle was found to be ruptured with a flail anterior mitral leaflet (Fig. 2A and B). The mitral valve was replaced with bioprosthetic valve and coronary artery bypass grafting was performed to OM1 and LAD. The patient had an uneventful postoperative course.