Maurizio Salati

Posterior pericardial annuloplasty: a physicological correction?

Since the introduction of the annuloplasty ring, many attempts have been made to obtain a flexible ring that preserves the physiological motion of the mitral annulus. We experimented with a new technique using autologous pericardium to construct a more flexible ring. Twenty patients underwent mitral valve repair for degenerative disease and were treated by a posterior pericardial annuloplasty and the usual valvuloplasty procedures. A long strip of pericardium was prepared, marked with metal clips and rolled up in a tubular fashion with the serosal surface on the outside. The pericardial tube was apposed on the posterior annulus just beyond the commissures. No patient required early or late reoperation. Doppler analysis showed good valve function: 18 patients had no or mild, and 2 had moderate regurgitation. Transmitral flow indexes were nearly normal (MVA = 3.7 +/- 0.4 cm2; flow velocity peak = 1.06 +/- 0.2 m/s). Fluoroscopic examination was employed for assessing annular motion using the metal clips as radiopaque markers. Planimetry of the hemiarea showed a mild narrowing (mean 8.5% +/- 6.4%) of annular size during ventricular systole. There was a trend toward a systolic reduction of the anteroposterior diameter of the annulus. These findings demonstrate that the mitral orifice preserves its flexible properties after this type of annuloplasty. Posterior pericardial annuloplasty seems to be a physiological correction of annular dilatation in patients with degenerative disease.

Mitral Valve Remodeling: Long-Term Results With Posterior Pericardial Annuloplasty

BACKGROUND We studied the long-term results of a technique of mitral annuloplasty using autologous pericardium. METHODS Between June 1989 and December 1994, 113 mitral valvuloplasties were performed for myxomatous degenerative disease. Repair of isolated anterior leaflet prolapse was performed in 26 patients (23%), posterior leaflet prolapse in 38 (33.6%), and prolapse of both leaflets in 49 (43.4%). Posterior pericardial annuloplasty was performed in all patients. In 20 patients, the pericardial graft was marked with metal clips for postoperative cinefluoroscopic assessment of annulus motion. RESULTS The operative mortality rate was 2.7% (3/113). One patient died of myocardial infarction and 2 of low cardiac output syndrome. One patient required replacement of the mitral valve 2 days after operation because of dehiscence of the annular plication. Follow-up (average length, 32.41 +/- 20.09 months; range 1 to 71 months) was 97% complete and revealed good clinical and functional results: 95 patients (84.1%) were in New York Heart Association class I and had no regurgitation or only mild residual regurgitation. Postoperative transmitral flow indices were almost normal (mitral valve area = 3.7 +/- 0.4 cm2; peak flow velocity = 1.06 +/- 0.2 m/s). Only 3 patients had reoperation within 3 years (actuarial 5-year reoperation-free rate, 89.7%) and event-free survival at 5 years was 91%. In patients with metal clips marking autologous pericardium, planimetry of the area derived by fluoroscopic examination showed systolic narrowing of annulus size (8.5% +/- 6.4%; p < 0.01) and a slight systolic fall in the anteroposterior diameter of the annulus contour (5.9% +/- 3.8%; p < 0.01). CONCLUSIONS Posterior pericardial annuloplasty seems to be a safe, effective and easily performed technique and a more physiologic correction that preserves mitral annulus motion.

Surgical treatment of left ventricular post-infarction aneurysm with endoventriculoplasty: late clinical and functional results

OBJECTIVE The temporal response to endoventriculoplasty (EVP) has not been well defined. We have evaluated the long-term clinical and functional results of this technique. METHODS From 1988 to 1997, 121 patients underwent aneurysmectomy by EVP associated with myocardial revascularization for anteroapical left ventricular postinfarction aneurysm. Among these, 39 patients (43%) underwent early post-operative cardiac catheterization (within 3 months maximum), and were available to be revaluated after a mean follow-up time of 56+/-28 months, by means of a new hemodynamic study. Left ventricular silhouettes were analyzed by means of a special software. RESULTS The mean New York Heart Association functional class decreased from 2.5+/-0.9 to 1.6+/-0.8 (P<0.001) late postoperatively. The global ejection fraction improved early postoperatively from 43+/-13 to 61+/-13% (P<0.001), and late postoperatively slightly decreased to 42+/-13% (ns) versus preoperative values. Left ventricular end diastolic pressure early postoperatively fell from 16.8+/-7 to 15.7+/-6.7 (ns), and late postoperatively increased to 21.6+/-8.8 (ns) versus preoperative values. Pulmonary artery pressure rose early postoperatively from 31.5+/-6.4 to 32.1+/-6.7 (ns), and late postoperatively to 34.9+/-8.9 (ns). The global contractility score decreased early postoperatively from 42.3+/-9.6 to 28.4+/-13.6 (P<0.001); the global late postoperative contractily was 35+/-14 (ns) versus preoperative values. Patients who benefit most from the operation were those with a normal postoperative contraction pattern, where ejection fraction improved respectively early postoperatively from 43+/-13 to 63+/-11% (P<0.001), and late postoperatively to 49+/-10% (P<0.001) versus preoperative values. Occlusion or critical stenosis of bypass grafts occurred in 10 patients (25.6%). There were no significant differences in hemodynamic data and hypokinesis score changes between patients with patent or occluded bypass graft, and between patients with mono or multivessel disease. The operative mortality was 6.3%, and 8.8% needed intraaortic balloon counterpulsation. The actuarial survival rates at 5 and 7 years were 73+/-6 and 61+/-6%. The mean follow-up period was 68 months (with 112 months maximum). CONCLUSIONS We conclude that, in our patients group, EVP of left ventricular aneurysm associated with coronary grafting improves clinical status after operation. We registered a trend for a mild hemodynamic worsening, irrespective of coronary artery disease except in those patients who had shown a normal postoperative contraction pattern.

Chordal transposition for anterior mitral prolapse: early and long-term results.

OBJECTIVE Chordal transposition was advocated for correction of anterior mitral prolapse. We have evaluated the early and late results of this technique in different anatomical presentations. METHODS From 1986 to 1995, 185 mitral valve repairs were carried out for pure mitral regurgitation due to a degenerative disease. Eighty-nine patients had either an anterior prolapse (39) or prolapse of both leaflets (50) at initial presentation and underwent chordal transposition from the mural leaflet to the anterior leaflet. The corrective procedure was completed by polytetrafluoroethylene or pericardial posterior annuloplasty. Twenty patients presented a complex pathology and 26 had chordal elongation of mural leaflet. Annular calcifications were found in 9 patients. Seven patients required shortening of transposed chordae and two patients the additional shortening of an anterior chorda. RESULTS Operative mortality was 3.3% and follow-up was 95% complete (average 41 months). There were five postreconstruction valve replacements (two earlier and three later) for a probability of freedom from late reoperation or 3+ mitral regurgitation of 88.6 +/- 4.8% at 5 years. Of the patients 79% presented no or trivial residual MR, 17% moderate MR and 4% severe MR. The presence of a complex pathology or posterior chordal elongation did not influence the entity of postoperative residual regurgitation. On the contrary, the patients with annular calcifications had a residual regurgitation/left atrium area ratio greater than patients without annular calcification (15.8 +/- 11.5% vs. 6.1 + 9.9%; P = 0.009). CONCLUSIONS Chordal transposition is an effective and easily carried out technique for the correction of anterior mitral prolapse. The presence of a complex pathology or posterior chordal elongation do not rule out the procedure. The absence of annular calcification is important in order to obtain a satisfactory correction.

Severe diastolic dysfunction after endoventriculoplasty

Endoventriculoplasty with pericardial patch has been advocated to repair anteroseptal ventricular aneurysm, but not studies have reported the influence of this technique on diastolic left ventricular function. We have evaluated the changes on ventricular filling by means of pulsed Doppler recording of diastolic transmitral flow. Doppler analysis reveals three distinct spectral patterns: (1) normal, (2) inverted, and (3) restrictive. We have found an abrupt change from a preoperative normal to postoperative restrictive pattern in a significant minority of patients (8%) who underwent endoventriculoplasty. These patients had clinical and hemodynamic signs (New York Heart Association class, time from anterior myocardial infarction, left ventricular end-diastolic pressure, pulmonary hypertension, and mitral regurgitation) of severe impairment but no differences were found in ejection fraction, aneurysmal extension, or remote myocardial function. Moreover, after operation they had a satisfactory ejection fraction, a low end-diastolic volume, and an apex-base length shorter than the predicted value for a normal population. The presence of a postoperative restrictive pattern of diastolic filling is a strong predictor of 3-month mortality and makes the medical treatment difficult. Caution must be taken to perform endoventriculoplasty in patients who are severely ill, especially those recently affected by myocardial infarction. When the clinical conditions dictate the operation, a nonenthusiastic volume reduction seems to be a prudent option.

Myocardial Revascularization in Patients With Ischemic Cardiomyopathy: Functional Observations

OBJECTIVE A prospective angiographic study was undertaken to investigate, with an objective analysis, the global and regional wall response to myocardial revascularization. METHODS Thirty-one patients (30 men and 1 woman, mean age, 61 years) with a left ventricular ejection fraction of less than 0.30 were admitted to our institution between 1992 and 1995 for two- or three-vessel coronary artery disease requiring myocardial revascularization. All patients underwent isolated coronary artery bypass grafting and were studied 3 months later with angiography. Preoperative and postoperative wall motion were analyzed using special software that computed a segmental left ventricular ejection fraction, generating a segmental score. Computerized analysis allowed us to distinguish patients with diffuse hypokinesis and a symmetric contraction pattern from patients with akinesis involving at least two segments and an asymmetric contraction pattern. RESULTS There were no operative deaths and no patient required intraaortic balloon counterpulsation. One patient had postoperative enzymatic evidence of myocardial infarction. Postoperative angiography showed a graft patency rate of 84%. Global analysis showed a small but significant rise in the left ventricular ejection fraction (0.25 +/- 0.51 to 0.31 +/- 0.70, p < 0.001) and a fall in the left ventricular end-diastolic pressure (23.7 +/- 10 to 16.5 +/- 9 mm Hg, p < 0.01). Mean scores always have been lower after the operation than before it, with the best results obtained for the apex and the worst for the anterobasal segment. The group with a symmetric contraction pattern showed a trend toward a better hemodynamic response than the group with an asymmetric contraction pattern. Regression analysis revealed two important predictors of segmental functional improvement: (1) the absence of an echocardiographic scar, and (2) the presence of a collateral circulation. CONCLUSIONS Coronary artery bypass grafting produced a small but substantial improvement in patients with ischemic cardiomyopathy. The greater benefit occurred in patients with a symmetric contraction pattern. The absence of an echocardiographic scar and the presence of a collateral circulation predicted segmental functional improvement.

Free Edge Suture Plication and Remodeling: A Technique for Anterior Mitral Leaflet Prolapse Repair

This is a selected series of 28 patients with myxomatous mitral regurgitation that underwent correction of the anterior leaflet prolapse caused by chordal elongation by means of a running suture involving the chordal-cusp junction. Postoperative echocardiograms showed correction of anterior leaflet prolapse and mitral regurgitation in all patients. This technique is effective and easy to perform, and increases the number of options for restoring mitral valvular function.

Coronary artery bypass graft and mitral valvuloplasty in a patient with isolated ventricular non-compaction

A case of isolated ventricular non-compaction associated to three-vessel disease and a mitral regurgitation is described. The patient underwent triple coronary artery bypass graft and restrictive mitral annuloplasty. The postoperative course was unsuccessful despite the very depressed left ventricular (LV) function. At two years follow-up, no major adverse cardiac event has occurred and the LV function was slightly improved.

Simultaneous Aortic Valve Replacement and Left Lower Lobectomy: Technical Considerations

Abstract  An 84‐year‐old patient underwent combined aortic valve replacement and left lower lobectomy (LLL) for bronchogenic cancer. At surgery, which was performed via median sternotomy, the fissure was found to be totally fused. The fissure, artery, and bronchus were treated off pump, while the left inferior pulmonary vein and the inferior ligament were sectioned on pump. Finally, the stenotic aortic valve was replaced with a bioprosthesis. The postoperative course was smooth and the patient discharged on the ninth day. The simultaneous treatment of lung cancer and cardiac disease has been widely described. LLL, on the other hand, represents a surgical challenge because the left ventricle obscures the pulmonary hilum. We have performed LLL combined to aortic valve replacement using a mixed approach, partly on pump and partly off pump to reduce bleeding and hemodynamic instability, which are well‐known complications.

Late thoracic pseudo-aneurysm causing collapse of vascular prostheses

The outcome of patients with thoracic vascular prostheses is usually uneventful. We report two cases of collapse of thoracic vascular prostheses which occurred ten and forty years, respectively, after the implantation. The diagnoses were obtained preoperatively by CT-scan or NMR and angiography. Both patients were successfully treated with prosthetic replacement by an open approach.