P. Demers

Same day discharge after transcatheter aortic valve replacement: Are we there yet?

Early discharge after transcatheter aortic valve replacement (TAVR) has been increasingly reported, and is now becoming routinely performed in experienced TAVR centers. However, to the best of our knowledge, no case has been described where a patient was safely discharged on the same the day of the procedure. This report will present the case of a patient who underwent a successful transfemoral TAVR and was safely discharged home the same day. Specific requirements and criteria are proposed to ensure the safety of this approach.

Sutureless aortic valve replacement in patients who have bicuspid aortic valve

OBJECTIVEnBicuspid aortic valve (BAV) is generally considered to be a contraindication to sutureless aortic valve replacement (AVR). The aim of this study was to evaluate the feasibility and perioperative outcomes of this technique in patients with BAV.nnnMETHODSnFrom June 2011 to January 2014, a total of 25 patients who underwent sutureless AVR had documented BAV. Thirteen patients (52%) had median sternotomy, and 12 patients (48%) a minimally invasive approach.nnnRESULTSnThe study population included 17 (68%) men with a median age of 77.8 ± 5.4 years. The mean EuroSCORE II was 3.4% ± 2.6%. Concomitant procedures included coronary artery bypass grafting in 8 patients (32%), 2 AVRs (8%), 1 mitral valve repair (4%), 1 septal myomectomy (4%), and 1 atrial septal defect closure (4%). The mean transaortic valve gradient decreased from 49.4 ± 15.7, to 14.5 ± 5.4 mm Hg postoperatively. The mean aortic valve area increased from 0.78 ± 0.18, to 1.75 ± 0.43 cm(2) postoperatively. Five patients (20%) suffered from atrioventricular block that required permanent pacemaker implantation. Two patients (8%) suffered a stroke. No major paravalvular leakage occurred, and no postoperative valve migration. In-hospital mortality occurred in 1 patient (4%). The mean intensive care unit length of stay was 3 ± 2 days postoperatively.nnnCONCLUSIONSnThis study demonstrates that a sutureless aortic valve can be deployed in patients with BAV without increasing the risk of paravalvular leakage. BAV should not be considered a contraindication to sutureless AVR.

Sutureless aortic valve replacement in the presence of a mechanical mitral prosthesis

From the Faculty of Medicine, Universit e de Montr eal; and the Department of Surgery, Montreal Heart Institute and Universit e de Montr eal, Montreal, Quebec, Canada. Disclosures: Authors have nothing to disclose with regard to commercial support. Received for publication April 8, 2013; revisions receivedMay 24, 2013; accepted for publication June 5, 2013. Address for reprints: Philippe Demers, MD, FRCSC, 5000 Belanger St E, Montreal, Quebec, H1T 1C8, Canada (E-mail: demersph@gmail.com). J Thorac Cardiovasc Surg 2013;146:e27-8 0022-5223/

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

36.00 Copyright 2013 Published by Elsevier Inc. on behalf of The American Association for Thoracic Surgery http://dx.doi.org/10.1016/j.jtcvs.2013.06.008

Differences and similarities in risk factors for postoperative acute kidney injury between younger and older adults undergoing cardiac surgery

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.

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

Objectives Acute kidney injury is a frequent complication after cardiac surgery. The purpose of this study was to assess the risk factors for acute kidney injury in patients ≤60 years of age undergoing cardiac surgery and to compare these risk factors with those identified in patients ≥65 years of age. Methods From 2010 to 2012, 1253 patients ≤60 years (mean age 52 ± 9 years) and 2488 patients ≥65 years (mean age 74 ± 6 years) underwent cardiac surgery. Linear regression models using least absolute shrinkage and selection operator methods and mixed effects linear regression models were used to assess factors associated with maximum postoperative increase in serum creatinine in these two cohorts. Results In both age groups, the following variables were associated independently with greater degrees of postoperative increase in serum creatinine on multivariable analysis: greater body mass index, peripheral vascular disease, preoperative use of diuretics, lower preoperative hemoglobin, preoperative intra‐aortic balloon pump, urgent or emergent status, long cardiopulmonary bypass time, and hemofiltration. In younger patients, a greater increase in serum creatinine was associated with diabetes, and previous cardiac surgery, whereas female sex was associated with a lower degree of increase in serum creatinine. In older patients, a greater increase in serum creatinine was associated with age, hypertension, smoking, and lower left ventricular left ejection fraction. Operation type and coronary artery disease had a different impact on postoperative creatinine increase between younger and older patients. Conclusions This study identified both common and distinct risk factors associated with postoperative increase in serum creatinine between patients ≤60 years and those ≥65 years undergoing cardiac surgery. Importantly, all potentially modifiable risk factors were present in both groups.

A rare case of left coronary sinus Valsalva aneurysm in a woman

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

Sinus Valsalva aneurysms (SVAs) are rare cardiac malformations observed in 0.09% of autopsies. SVAs are often diagnosed during evaluation of associated cardiac abnormalities requiring surgery, and the incidence is up to 1.5% in surgical series. The pathognomonic histologic finding is lack of continuity between the annulus fibrosus and the muscular and elastic aortic media. SVA formation is associated with perimembranous ventricular septal defect, bicuspid aortic valve, aortic regurgitation, and coarctation of the aorta. SVAs originate from the right coronary sinus in 70% of patients, the noncoronary sinus in 25% of patients, and the left coronary sinus in only 5% of patients, and themale to female ratio is 4:1. SVAs are usually clinically silent and detected by routine 2-dimensional echocardiography.

Endovascular management of pseudo-aneurysms after previous surgical repair of congenital aortic coarctation

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?