Sasa Borovic

Mitral valve replacement with posterior transposition of the anterior mitral leaflet which covers and buttresses partially decalcified posterior mitral annular bed.

Mitral valve replacement (MVR) in the presence of the extensive calcification of the mitral annulus is a technical challenge. The heavily calcified annulus can cause great difficulty in the insertion of a prosthetic valve and periprosthetic leakage later on. Vigorous annular decalcification may cause circumflex coronary artery injury, atrioventricular rupture and thromboembolic events. We herein describe a surgical technique for MVR in such cases while focusing on partial decalcification of the posterior mitral annulus and its reinforcement and buttressing with the transferred anterior mitral leaflet (AML). At the same time, the transferred AML supports the posterior annular region and maintains ventricular-annular continuity, thus preserving the left ventricular function.

A refined flanged Bentall technique using Valsalva tube graft: does it really wrap all of the proximal anastomosis line?

We read with great interest the article by Koshiyama et al. [1] regarding reinforcement of the proximal anastomosis during composite graft replacement of the aortic root, using one of the modifications of the Bentall and DeBono technique [2]. Modified Bentall procedures have many beneficial effects such as prevention of excessive bleeding and development of false aneurysm, avoidance of the kinking of coronary arteries, as well as reduced tension on ‘button’ coronary anastomoses. However, a major weakness in the composite graft replacement of the ascending aorta is haemostasis at the proximal suture line. A refined, flanged Bentall technique using Vasalva tube graft reported by Koshiyama et al. [1] is similar to the flanged technique reported by Yakut [3], previously. The Valsalva sinus portion of the graft is resected, leaving 10 mm in length as the flange and is everted outwards using Koshiyama’s technique [1], whether a segment (several millimetres in a length) of the proximal end of vascular graft is everted outwards to form the flange of the graft using Yakut’s technique [3]. The polypropylene running suture (3–0 or 4–0) is used to anastomose the cuff of the prosthetic valve to the bottom border of the chosen conduit. Subsequently, the flange is returned to its original position. In both techniques, the homemade composite conduit is seated on the aortic annulus, using continuous 3–0 polypropylene suture [3], or everting pledgeted 2–0 polyester sutures [1], which are passed through the flange below the sewing cuff of the prosthetic valve. Koshiyama et al. [1] stated that using 3–0 polyprolene suture to sew the flange and the margin of the residual proximal aortic wall enabled them to wrap tightly all of the proximal anastomosis line. However, as it can be easily seen on figure 1D of their manuscript [1], only the pledgets of the tied everting pledgeted 2–0 polyester sutures are covered, while the knots of these sutures are still ‘naked’, outside, on the flange, between the flange and prosthetic tube, thus leaving pinholes of the everting mattress sutures as the potential sites of bleeding. On the contrary, Chen et al. [4] modified the composite graft by adding a short skirt (which was made of a part of the distal end of the prosthetic tube) to a standard composite graft root. After the proximal end of the modified composite conduit was secured in the aortic annulus, the short skirt was sewn to the remaining native proximal aortic wall to really wrap all of the proximal anastomosis line. However, we have to point out that Copeland et al. [5] reported an elegant, easily reproducible, and efficient technique to reduce bleeding from the proximal anastomosis after the Bentall procedure. After the composite conduit is seated into the aortic annulus and the sutures are tied, an additional 3–0 polypropylene suture is used to sew the cut edge of the proximal aortic wall and the prosthetic sewing cuff or the prosthetic tube, thus reinforcing and really completely covering all of the proximal anastomosis line.

Myocardial Na+ K+-ATPase and SERCA: Clinical and Pathological Significance From a Cytological Perspective

Structure and functions of Na+/K+-ATPase and SERCA are described with details on their subunits, isoforms, and intracellular localization. Main regulatory mechanisms are summarized. Molecular mechanisms of cell death and heart failure are explained with the analysis of the role of Na+/K+-ATPase and SERCA in these processes. Facts are considered from a cytological, pathological, and clinical perspective with an accent to new therapeutic strategies. The aim of this contribution is an overview of functional results in a structural context.

Interventional or surgical management of iatrogenic ostial coronary dissections

Results 6 cases happened at our institution (4 on interventional and 2 on diagnostic procedures) and 1 was urgently transferred from a secondary center without on site surgery following coronary intervention. Of 7 cases, 2 happened with radial approach and 5 with femoral. Ostial LM was dissected in 4 cases and RCA in 3. Aortic propagation less than 2.5 cm was seen in 2 pts. Five patients underwent interventional revascularization and 2 surgical (1 was stable (RCA) and 1 unstable (LM)). All 5 interventions were successful with prolonged hospital stay and uneventful f-up. Surgical intervention on RCA dissection was successful with uneventful f-up, patient with LM dissection underwent rescue surgery with double SV grafting, but died however at 4 postoperative day of intractable heart failure due to large myocardial infarction. Of 4 LM dissections, 2 were treated with 1 ostial stent, one with 2 sequential stents, and one with 2 stents in LM (culotte stenting). Two RCAs was stented with 1 stent, and one needed 3 stents to seal and prevent further aorto-ostial propagation. Conclusions Interventional treatment of IOCD dissection is feasible requiring skills and experienced team work. Surgical treatment is good alternative if delivered immediately and if basic hemodynamics could be maintained up to the operation theater.

Early surgical revascularization after acute myocardial infarction

Methods A total of 62 consecutive patients underwent CABG therapy within 14 days after the onset of myocardial infarction between September 2009 and January 2013 at our institution. Prospectively recorded preoperative, intraoperative, and postoperative data were retrospectively screened for in-hospital mortality and major adverse postoperative events (low cardiac output syndrome, prolonged mechanical ventilation, prolonged intensive care stay, hospital stay >7 days).

Utilisation of sphericity indices in the assessment of left ventricular shape and function after surgical ventricular restoration in patients recovered from anterior myocardial infarction

Background Surgical ventricular restoration (SVR) after anterior myocardial infarction with post infarction aneurysm, significantly improves left ventricular (LV) performance. To describe mid-term postoperative changes of shape and performance of the newly created LV and mitral valve function through the classical (SI) and apical (ASI) left ventricular sphericity index, and determinants of mitral regurgitation.

Concomitant mitral valve repair and resynchronization therapy

Background Functional mitral regurgitation (MR) affects 90% of cardiac resynchronization therapy (CRT) candidates, with moderate–severe/severe MR being present in 35%. The purpose was to assess the outcome of CRT candidates with severe MR undergoing concomitant mitral valve repair and resynchronization therapy. Methods