Paola Colombo

Direct Aortic Access for Transcatheter Self- Expanding Aortic Bioprosthetic Valves Implantation

BACKGROUND Transcatheter aortic valve implantation (TAVI) has been designed to treat elderly patients with severe aortic stenosis at high risk for operation; however, these patients are also often affected by severe iliac-femoral arteriopathy that prohibits the transfemoral approach. METHODS From May 2008 to January 2012, 400 patients were evaluated for TAVI at our center; of these, 141 patients (64 men; mean age 81.3±8 years) with severe symptomatic aortic stenosis and no reasonable surgical option due to excessive risk were eligible for CoreValve (137 patients; Medtronic Inc, MN) or Sapien (Edwards Lifesciences, CA) implantation. Twenty-five patients (all affected by severe peripheral vasculopathy, including five re-do procedures), with a mean The Society of Thoracic Surgeons mortality score 11%±6%, underwent CoreValve implantation directly from the ascending aorta through a right anterior minithoracotomy. This case series was reviewed to evaluate the clinical outcomes of these patients. A combined team of cardiologists, cardiac surgeons with expertise in hybrid procedures, and anesthetists performed all the procedures. RESULTS In all patients after valve deployment, the mean aortic gradient immediately dropped to 5 mm Hg or less, and the angiographic grade aortic insufficiency was 1 or less in 22 patients. One patient was converted to the transfemoral approach due to an extremely fragile aortic wall, but the patient died of abdominal aorta aneurysm rupture on postoperative day 1. Procedural success was obtained in the remaining 24 patients. A left ventricle tear in 1 patient was successfully surgically treated. Four patients required a permanent pacemaker implantation. Thirty-day mortality was 8% (2 patients). All discharged patients improved their New York Heart Association functional class and functional capacity, and echocardiograms demonstrated good valve performance up to 2 years (mean valve gradient, 9 mm Hg). During follow-up, 1 patient died of cachexia and another of bone marrow aplasia. CONCLUSIONS TAVI with the direct aortic approach is safe and feasible, offering a new attractive option to treat selected high-risk patients with severe aortic stenosis and peripheral vasculopathy, including those requiring a re-do procedure, and has emerged as a valuable alternative route to transapical access.

Acute rejection after heart transplantation: noninvasive echocardiographic evaluation.

OBJECTIVES The purpose of this study was to assess the reliability of echocardiography in the noninvasive diagnosis of acute rejection in heart transplant recipients. BACKGROUND Although echocardiographic results seem to correlate well with allograft rejection, published data are limited and contradictory. METHODS In 130 transplant recipients, 1,400 serial echocardiograms were recorded within 24 h of endomyocardial biopsy. Increased wall thickness, myocardial echogenicity, pericardial effusion, shorter pressure half-time, isovolumetric relaxation time and a decrease in left ventricular ejection fraction were considered markers of rejection. RESULTS The distribution of echocardiographic markers revealed highly significant differences between bioptically graded moderate, mild and no rejection and between untreated and treated rejection episodes (both chi-square test, p < 0.0001). Specificity was 98.6% for two markers, but sensitivity was good (80%) for only moderate rejection because of the large number of false negatives in untreated patients with mild rejection. In untreated patients, there was a highly significant difference in the number of echocardiographic criteria between a benign and nonbenign outcome (chi-square test, p < 0.0001). In treated patients, the significant difference in the variation in echocardiographic criteria between favorable and unfavorable responses after 1 week was more pronounced after 2 weeks (t test, p < 0.01 vs. < 0.001). Diastolic indexes and pericardial effusion at 2 weeks seemed to be predictive of therapeutic response. CONCLUSIONS Poor sensitivity to mild rejection indicates that serial echocardiography cannot supplant endomyocardial biopsy in the early diagnosis of acute rejection, but it seems to be a reliable noninvasive means of identifying acute rejection requiring intensified immunosuppressive therapy and of evaluating outcome.

Management and Long-Term Prognosis of Spontaneous Coronary Artery Dissection

The optimal management and short- and long-term prognoses of spontaneous coronary artery dissection (SCAD) remain not well defined. The aim of this observational multicenter study was to assess long-term clinical outcomes in patients with SCAD. In-hospital and long-term outcomes were assessed in 134 patients with documented SCAD, as well as the clinical impact and predictors of a conservative rather than a revascularization strategy of treatment. The mean age was 52 ± 11, years and 81% of patients were female. SCAD presented as an acute coronary syndromes in 93% of patients. A conservative strategy was performed in 58% of patients and revascularization in 42%. On multivariate analysis, distal versus proximal or mid location of dissection (odds ratio 9.27) and basal Thrombolysis In Myocardial Infarction (TIMI) flow grade 2 or 3 versus 0 or 1 (odds ratio 0.20) were independent predictors of conservative versus revascularization strategy. A conservative strategy was associated with better in-hospital outcomes compared with revascularization (rates of major adverse cardiac events 3.8% and 16.1%, respectively, p = 0.028); however, no significant differences were observed in the long-term outcomes. In conclusion, in this large observational study of patients with SCAD, angiographic features significantly influenced the treatment strategy, providing an excellent short- and long-term prognosis.

Effect of Calories and Fat on Postprandial Gastro-oesophageal Reflux

Background: Gastro-oesophageal reflux (GOR) is commonly considered to be worsened by fatty food, but it has recently been shown that changing the fat content of equicaloric meals has no effect on GOR over a 3-h postprandial period. Our aims were to verify this finding over a longer postprandial period and test the hypothesis that increasing the caloric content of balanced meals increases GOR. Methods: Thirteen healthy subjects (6 men) aged 19-31 years underwent 6-h oesophageal pH monitoring after 3 solid/liquid meals of the same volume and osmolarity eaten on separate days in a randomized order: a) high fat (58% fat) 2.8 MJ; b) balanced (23% fat) 2.8 MJ; and c) balanced low calorie (25% fat) 1.6 MJ. Results: The mean percentage of time at pH < 4 and the mean number of reflux episodes after the balanced 2.8 MJ meal (3.0% and 11.5, respectively) were higher ( P < 0.05) than after the balanced 1.6 MJ meal (1.6% and 7.2) and similar to those after the equicaloric (2.8 MJ) high-fat meal (2.5% and 9.3). Acid clearance time was similar after all three meals. Conclusions: Our data suggest that advice on dietary habits in patients with GOR disease should be concentrated on decreasing the caloric load of meals rather than their fat content.

Direct aortic access through right minithoracotomy for implantation of self-expanding aortic bioprosthetic valves.

From the A De Gasperis Cardiology and Cardiac Surgery Department, and Cardiothoracic Anesthesia and Intensive-care, Niguarda Ca’ Granda Hospital, Milan, Italy. Disclosures: None. Received for publication Jan 18, 2010; accepted for publication Feb 20, 2010; available ahead of print April 15, 2010. Address for reprints: Giuseppe Bruschi, MD, A De Gasperis Cardiology & Cardiac Surgery Department, Niguarda Ca’ Granda Hospital, Piazza dell’Ospedale Maggiore 3, 20162 Milan, Italy (E-mail: giuseppe.bruschi@fastwebnet.it). J Thorac Cardiovasc Surg 2010;140:715-7 0022-5223/

Percutaneous Implantation of CoreValve Aortic Prostheses in Patients With a Mechanical Mitral Valve

36.00 Copyright 2010 by The American Association for Thoracic Surgery doi:10.1016/j.jtcvs.2010.02.030

Alternative approaches for trans-catheter self-expanding aortic bioprosthetic valves implantation: single-center experience

Concerns exist in the field of transcatheter aortic valve implantation regarding the treatment of patients with mechanical mitral valve for possible interference between the percutaneous aortic valve and the mechanical mitral prosthesis. We report our experience with percutaneous aortic valve implantation in 4 patients with severe aortic stenosis, previously operated on for mitral valve replacement with a mechanical prosthesis. All patients underwent uneventful percutaneous retrograde CoreValve implantation (CoreValve Inc, Irvine, CA). No deformation of the nitinol tubing of the prostheses (ie, neither distortion nor malfunction of the mechanical valve in the mitral position) occurred in any of the patients. All patients are alive and asymptomatic at a mean follow-up of 171 days.

Significance of pericardial effusion after heart transplantation.

OBJECTIVE Trans-catheter aortic valve implantation has emerged and rapidly gained credibility as a valuable alternative to treat patients with severe aortic stenosis and no surgical option; however, these patients are often affected also by severe iliac-femoral arteriopathy, rendering the transfemoral approach unemployable. From May 2008, 92 patients with severe, symptomatic aortic stenosis and no reasonable surgical option because of excessive risk underwent trans-catheter aortic valve implantation at our center. Eighty patients (34 male) with mean age 82 ± 8 years were eligible for CoreValve percutaneous femoral implantation. Twelve patients, mean age 81 ± 8 years, were excluded from percutaneous femoral CoreValve implantation because of iliac-femoral arteriopathy. METHODS These 12 patients underwent trans-catheter aortic valve implantation through the left axillary artery in six cases, the other six directly from the ascending aorta through a right anterior mini-thoracotomy. Procedures were performed by a combined team of cardiologists, cardiac surgeons, and anesthetists. RESULTS Procedural success was obtained in 11 cases; all these patients were discharged in asymptomatic status, with midterm good prosthesis performance. Three patients required the implantation of a permanent pacemaker. One patient needed a subclavian covered stent implantation to treat a post-implant artery dissection. One patient of the direct aortic access group was converted to the femoral approach due to an extremely fragile aortic wall, but died in the intensive care unit of abdominal aortic aneurysm rupture. All discharged patients improved their New York Heart Association (NYHA) functional class and functional capacity, and echocardiograms evidenced good valve performance at 2 years. CONCLUSIONS Trans-catheter aortic valve implantation with surgical subclavian or direct aortic approach seems safe and feasible, offering a new attractive option to treat selected high-risk patients with severe aortic stenosis and peripheral vasculopathy, and has emerged as a valuable alternative route to trans-apical procedures.

Mechanical Circulatory Support for Cardiogenic Shock Complicating Acute Myocardial Infarction: An Experimental and Clinical Review

The aim of this study was to evaluate the clinical significance of pericardial effusion after heart transplantation and to assess its correlation with acute rejection. One hundred fifty transplanted patients were followed up for the first year: serial echocardiographic studies were performed on the same day as were the endomyocardial biopsies; hemodynamic studies and coronary angiographies were performed 1 year after transplant. Ten days after surgery, pericardial effusion was absent in 77 patients, small in 52, moderate in 14, and large in 7, and was significantly related to severe postoperative bleeding (p < 0.001). Patients were classified according to the presence and the course of pericardial effusion in group A (absence or disappearance of previous pericardial effusion within 1 month, 107 patients) and in group B (onset, persistence, or increase in pericardial effusion, 43 patients). One hundred nineteen patients experienced > or = 1 acute rejection episode. The evolution of pericardial effusion was different (p < 0.0001) according to the number of acute rejection episodes and biopsy specimens showing acute rejection, histologic grading and time of the first episode, and histologic grading of the most severe acute rejection episode. Furthermore, there was a significant correlation with the cumulative duration of acute rejection episodes (p < 0.005) and the presence of previous cardiac surgical history (p < 0.007), but no correlation with cardiac transplant vasculopathy or with a positive weight mismatch. This study suggests that pericardial effusion in transplant recipients is associated with a higher incidence and more severe histologic grading of acute rejection episodes; its presence indicates the need for stricter monitoring of acute rejection.

Direct Transatrial Transcatheter SAPIEN Valve Implantation Through Right Minithoracotomy in a Degenerated Mitral Bioprosthetic Valve

Cardiogenic shock (CS) occurs in 7% to 10% of cases after acute myocardial infarction and remains the most common cause of death in these patients. Despite aggressive treatment regimens such as fibrinolysis and percutaneous transluminal coronary angioplasty, mortality rates from CS remain extremely high. It has been shown that intra-aortic balloon pumping can result in initial hemodynamic stabilization. However, in the majority of studies, death was merely delayed. In recent years, efforts have been made to develop ventricular devices (LVAD) capable of providing complete short-term hemodynamic support. Seventeen major studies of LVAD support for CS complicating acute myocardial infarction are reported in the literature, with a mean weaning and survival rate of 58.5% and 40%, respectively. Patients considered in these studies are difficult to compare in terms of demographic and anatomic data, but taking these considerations into account, LVAD support seems to give no survival improvement in these patients compared with early reperfusion alone or associated with intra-aortic balloon pumping. Data emerging from experimental studies of acute myocardial infarction supported with LVAD are intriguing. In this review, we report the LVAD experience in the CS setting, starting from percutaneous extracorporeal support up to bridge therapy with implantable devices.