M. Pellerin

Nitric oxide inhalation in the treatment of primary graft failure following heart transplantation

BACKGROUNDnPrimary graft failure from right or left ventricular insufficiency remains a serious cause of early death following heart transplantation. Inhaled nitric oxide (NO) is a potent pulmonary vasodilator that could decrease pulmonary pressure and improve right ventricular function.nnnMETHODSnTwo cases of early graft failure following orthotopic heart transplantation were treated with NO inhalation. The treatment consisted of inhalation of 20 ppm of NO, introduced 4 to 6 hours following transplantation, in 2 patients supported with high doses of inotropic agents and vasopressors in addition to the intra-aortic balloon pump.nnnRESULTSnIn the first and second cases, NO inhalation resulted in a decrease in pulmonary artery pressure, in a decrease in pulmonary vascular resistance and in an increase in cardiac index. In the second patient, systemic oxygenation improved markedly 30 minutes after initiation of NO. In the 2 patients, NO inhalation, mechanical ventilation and the intra-aortic balloon pump were weaned 4 days following transplantation.nnnCONCLUSIONnPrimary graft failure from donor ischemic damage, reperfusion injury or pulmonary hypertension remains a serious complication. The use of an intra-aortic balloon pump, inotropic agents and of inhaled NO appears to offer the best support for recovery of donor heart function. Primary graft failure from right or left ventricular insufficiency remains a serious cause of early mortality following heart transplantation. Ischemic damage of donor heart, reperfusion injury or pulmonary hypertension are the main causes of early graft failure. Although the cause is multifactorial, treatment of primary organ failure remains difficult with dismal results. The objective of the present study was to review the result of 2 patients with donor right heart failure following heart transplantation treated with inhaled nitric oxide (NO).

Hemodynamic and Clinical Benefits Associated With Chronic Sildenafil Therapy in Advanced Heart Failure: Experience of the Montréal Heart Institute

BACKGROUNDnPulmonary hypertension is highly prevalent in advanced heart failure (HF) despite optimal medical and device therapies. The objective of this investigation was to report on a single centres experience of open-label chronic sildenafil therapy in patients with advanced HF.nnnMETHODSnWe conducted a retrospective systematic medical record review of all patients evaluated at our institution for heart transplantation who had also been treated with chronic sildenafil therapy. Baseline demographics, comorbidities, and concomitant medications, as well as the results of laboratory investigations and physiological testing, were abstracted from patient medical records. Change in systolic and mean pulmonary artery pressure (PAP), transpulmonary gradient, cardiac output and cardiac index, and selected laboratory parameters was analyzed by means of the Wilcoxon rank sum test. Outcomes of interest included New York Heart Association (NYHA) functional class after 6 months of therapy and adverse effects attributable to sildenafil.nnnRESULTSnThe 16 patients undergoing evaluation for cardiac transplantation combined for 4166 patient-days on sildenafil, with a mean dose of 102.5 ± 54.0 mg/d. None discontinued because of side effects. At 6 months, there was an improvement in the cardiac index (P = 0.014) and systolic PAP (P = 0.049) without any significant change in other hemodynamic parameters. Ten patients (62.5%) experienced an improvement in their NYHA functional class, 8 (50%) received a heart transplantation, and 2 (12.5%) improved sufficiently to be removed from the transplant list.nnnCONCLUSIONnChronic sildenafil therapy was well tolerated and associated with improved functional capacity and decreased systolic PAP. Properly controlled randomized studies of the long-term usefulness of sildenafil therapy in advanced HF populations are warranted.

Long-Term Results Following Concomitant Radiofrequency Modified Maze Ablation for Atrial Fibrillation

Abstractu2002 Background and aim of study: This study evaluated the long‐term outcome of linear, endocardial, radiofrequency (RF) atrial ablation for the treatment of atrial fibrillation (AF) concomitantly to open‐heart procedures for acquired cardiac organic disease. Methods: A saline‐irrigated “pen‐like” RF ablation catheter (Cardioblate®, Medtronic, Minneapolis, MN, USA) was used to perform endocardial lines of conduction block in 293 patients with AF who underwent open‐heart procedures between September 2000 and February 2008. Results: Patients (age of 65 ± 11 years) underwent left atrial ablation for permanent (44%), paroxysmal (51%), or undetermined (4.4%) AF. Maintenance in sinus rhythm (SR) at discharge and at the end of follow‐up (average 3.3 ± 1.2 years) was observed in 52% and 71% of patients, respectively. Preoperative type or duration of AF did not influence the results (p = NS). Multivariate analysis with a logistic regression model showed left atrial diameter and increasing age were independent predictors of recurrent AF. In this study, return to SR did not influence survival. Conclusions: This study confirmed that concomitant intraoperative RF ablation is an effective technique to restore long‐term SR after cardiac surgery in patients with preoperative AF but does not influence long‐term survival.u2002(J Card Surg 2010;25:608‐613)

Very High Repair Rate Using Minimally Invasive Surgery for the Treatment of Degenerative Mitral Insufficiency

BACKGROUNDnMinimally invasive mitral valve surgery (MIMVS) is an established alternative to median sternotomy for mitral valve repair. However, this technique has yet to gain widespread adoption, partly because of concerns that this approach might yield lower repair rates or repairs that are less durable than those performed through a sternotomy. The purpose of this study was to report our inaugural experience with MIMVS, with a focus on mitral valve repair rate and midterm outcomes.nnnMETHODSnBetween May 2006 and April 2012, minimally invasive mitral valve repair was attempted in 200 consecutive patients with degenerative mitral disease. The approach used was a 4- to 5-cm right anterolateral minithoracotomy with femorofemoral cannulation for cardiopulmonary bypass. Mean follow-up was 2.9 ± 1.8 years, and follow-up was 99% complete.nnnRESULTSnThe mitral valve was successfully repaired in all but 2 patients, yielding a repair rate of 99%. Hospital mortality occurred in 2 patients (1%). Intraoperative conversion to sternotomy was necessary in 12 patients (6%), including 1 of the 2 unsuccessful repairs. Mean cardiopulmonary bypass and aortic cross-clamp times were 130.8 ± 41.3 minutes and 104.8 ± 35.6 minutes, respectively. Median hospital stay was 5 days. The 5-year survival and freedom from reoperation were 97.9% ± 1.5% and 98.1% ± 1.3%, respectively.nnnCONCLUSIONSnA very high repair rate can be achieved using MIMVS for the treatment of degenerative mitral regurgitation, including during the learning phase. Midterm survival and freedom from valve-related reoperation are excellent. MIMVS is a safe and effective alternative to mitral valve repair through a sternotomy.

Surgery Versus Transcatheter Interventions for Significant Paravalvular Prosthetic Leaks

OBJECTIVESnThis study sought to assess the relative merit of surgical correction (SC) versus transcatheter reduction onxa0long-term outcomes in patients with significant paravalvular leak (PVL) refractory to medical therapy.nnnBACKGROUNDnPVL is the most frequent dysfunction following prosthetic valve replacement. Although repeat surgery is the gold standard, transcatheter reduction (TR) of PVL has been associated with reduced mortality.nnnMETHODSnFrom 1994 to 2014, 231 patients underwent SC (nxa0= 151) or TR (nxa0= 80) PVL correction. Propensity matchingxa0and Cox proportional hazards regression models were used to assess the effect of either intervention on long-term rates of all-cause death or hospitalization for heart failure. Survival after TR and SC were further compared with the survival inxa0a matched general population and to matched patients undergoing their first surgical valve replacement.nnnRESULTSnOver a median follow-up of 3.5 years, SC was associated with an important reduction in all-causexa0deathxa0orxa0hospitalization for heart failure compared with TR (hazard ratio: 0.28; 95% confidence interval: 0.18xa0toxa00.44; pxa0<xa00.001). There was a trend towards reduced all-cause death following SC versusxa0TRxa0(hazardxa0ratio:xa00.61; 95%xa0confidence interval: 0.37 to 1.02; pxa0= 0.06). Neither intervention normalizedxa0survivalxa0whenxa0compared with axa0general population or patients undergoing their first surgical valvexa0replacement.nnnCONCLUSIONSnIn patients with significant prosthetic PVL, surgery is associated with better long-term outcomesxa0compared with transcatheter intervention, but results in important perioperative mortality and morbidity. Future studies are needed in the face of increasing implementation of transcatheter PVL interventions across thexa0world.

Minimally Invasive Mitral Valve Repair in a Patient With Porcelain Aorta

A woman aged 79 years with a history of stroke was admitted to undergo surgical treatment of a severe mitral regurgitation caused by active endocarditis. A preoperative computed tomography scan showed the presence of a porcelain aorta. The mitral valve was successfully repaired with an endovascular cardiopulmonary bypass system. The patient was discharged on postoperative day 10 with no complication. Endoaortic clamping is thought to be a useful technique in patients with a severely calcified aorta.

Left Ventricular Outflow Tract Obstruction Following Mitral Valve Replacement: Challenges for Transcatheter Mitral Valve Therapy

ABSTRACT In the race to develop a transcatheter mitral valve, experience with new techniques and devices has resulted in revisiting a previously known complication of surgical mitral valve replacement and repair: left ventricular outflow tract obstruction. This entity, first described in 1977, is dynamic in nature in many cases and multifactorial. The ability to appropriately predict and treat this complication rests on a thorough understanding of the pathophysiology and anatomical considerations. This review will review the pathophysiology of left ventricular outflow obstruction, discuss important pre-procedure imaging, procedural evaluation of obstruction, and therapeutic options.

Repair of Anterior Mitral Leaflet Prolapse: Comparison of Midterm Outcomes With Chordal Transposition and Chordal Replacement Techniques

BACKGROUNDnThe repair of anterior mitral leaflet prolapse is known to be challenging. Hence, the study aim was to compare the mid-term results of anterior leaflet prolapse (ALP) using chordal transposition with results obtained using chordal replacement with expanded polytetrafluoroethylene (ePTFE) sutures.nnnMETHODSnBetween 1999 and 2012, a total of 96 consecutive patients (mean age 62 years) with ALP underwent mitral valve repair at the authors institution. Surgery involved either chordal transposition from the posterior to the anterior leaflet (n = 67), or chordal replacement using ePTFE sutures (n = 29). Clinical, operative and follow up data were recorded prospectively for each patient. The follow up was 100% complete (mean 3.4 years; range 0 to 12.9 years).nnnRESULTSnMitral valve repair was accomplished in all patients, with no operative mortality. The durations of cardiopulmonary bypass and aortic cross-clamp were significantly longer in the chordal replacement group. Actuarial overall survival at one, five and 10 years was 95 ± 3%, 87 ± 5% and 82 ± 7% versus 89 ± 6%, 89 ± 6% and 89 ± 6% in the chordal transposition and chordal replacement groups, respectively (p = 0.84). Freedom from reoperation in the two groups at five years was 95 ± 3% and 91 ± 7%, respectively (p = 0.24). The recurrence of moderate or severe mitral regurgitation (MR) (grade ≤2+) and of severe (grade ≤3+) MR was significantly higher in patients who underwent chordal replacement compared to chordal transposition (p = 0.04 and p = 0.01, respectively).nnnCONCLUSIONSnProvided that chordal quality is preserved, chordal transposition is easier and quicker to achieve for ALP repair, and is also durable in the mid term. Chordal replacement offers a satisfying durability even if the recurrence of severe MR appears to be higher. Preferably, both surgical techniques should be mastered to allow valve repair when anatomic conditions prevent chordal transposition.

614 Coronary Artery Bypass Grafting in octogenarians: Results over the course of three 5-year periods

BACKGROUND: The incidence of CABG in the octogenarian population is rising, making it essential to explore ways to minimize morbidity and mortality in this population with inherent increased surgical risk. The aim of this study was to compare outcomes in octogenarians undergoing either conventional CABG (CCAB) with cardiopulmonary bypass (CPB) or offpump CABG (OPCAB) in three consecutive five-year cohorts METHODS: A retrospective chart review included all octogenarians who underwent isolated CABG between 2000-2004 (n 177), and 2005-2009 (n 231) in our institution. Comparison of these cohorts was performed and findings were then compared to the previously published 1995-1999 cohort (n 125). RESULTS: OPCAB was performed in 49.6% of patients in the 1995-1999 cohort, 49.2% in the 2000-2004, and only 20.8% in the 2005-2009 cohort. In the earlier cohorts no surgeon performed more than 30% of cases in either group, however, a single surgeon dedicated to the technique performed 70% of OPCAB surgeries in the recent cohort. Mortality was similar for OPCAB and CCAB in 2000-2004 (5.9% vs 5%, P 0.96) and 2005-2009 (6.3% vs 8.7%, P 0.77). This was markedly different from the 1995-1999 cohort’s results of 4.8% vs 15.9% (P 0.04). Stroke rates were also not significantly different between operative strategies in the 2 recent cohorts (2000-2004 1.2% vs 0%; 2005-2009 2.1% vs 3.2%), while CCAB was associated with a significantly increased stroke risk in the early cohort (6.3% vs 0%, P 0.04). Degree of aortic atherosclerosis was not identified in the early group because transesophageal echocardiography was not yet routine. Severe aortic atherosclerosis was significantly higher in the OPCAB group of the 2000-2004 cohort (53% vs 21%, P 0.01), while there was no difference between groups in the recent cohort. For the 2005-2009 cohort, when patients operated by the dedicated OPCAB surgeon were excluded, incidence of severe aortic atherosclerosis was higher with OPCAB (64% vs 31%, P 0.001). CONCLUSION: These results support the conclusion that CABG surgery in an octogenarian population can be performed safely and with similar mortality and stroke rates with or without CPB when patients are appropriately selected. OPCAB may be especially beneficial in the context of severe aortic atherosclerotic disease, and should be considered even by surgeons who do not routinely perform off-pump surgery. Improved outcome compared to the earliest cohort may be due to better screening for aortic atherosclerotic disease and improved perioperative care. 615 INHALED MILRINONE ADMINISTRATION IN CARDIAC SURGERY: SIMPLE JET OR ULTRASONIC NEBULISATION?