Stefano Mastrobuoni

The Ross procedure in young adults: over 20 years of experience in our Institution

OBJECTIVES The aim of this study was to evaluate the long-term outcomes following the Ross procedure in young adults in our institution. METHODS All adult patients who received a Ross operation between 1991 and 2014 were included in the study. Survival analysis and regression analysis were performed. Survival of the Ross cohort was compared with the age-, gender- and calendar year-matched general population. RESULTS Three hundred-and-six patients (mean age: 41.7 ± 9.7, male: 74.8%, bicuspid aortic valve: 58.5%, valve stenosis: 68%) were included in the analysis. There were 7 perioperative deaths (2.3%). Nine patients were lost to follow-up from hospital and completeness of the follow-up was 94%. The median follow-up of the remaining 290 patients was 10.6 years. There were 21 late deaths of which only 3 were valve-related. The overall survival at 15 years since surgery is 88 ± 3% that is comparable with the matched population. Freedom from valve-related deaths was 96.8 ± 2% at 16 years. Freedom from autograft and pulmonary homograft reoperation was 74.5 ± 4.3% at 16 years. Preoperative aortic regurgitation was the only significant predictor of autograft failure over time. Freedom from the combined end point of bleeding/thromboembolism/endocarditis/reoperation was 69.2 ± 4% at 16 years. Perioperative mortality following reoperation was 2.6% and the autograft could be spared in 72% of reinterventions. CONCLUSIONS The Ross operation in young adults is associated with an excellent survival in the long term that is comparable with the general population. Although there is a risk of reoperation, incidence of other valve-related events is very low. The use of pulmonary autograft should be considered in any young adult patient requiring aortic valve replacement.

The role of annular dimension and annuloplasty in tricuspid aortic valve repair.

OBJECTIVES Valve sparing reimplantation can improve the durability of bicuspid aortic valve repair compared with subcommissural annuloplasty, especially in patients with a large basal ring. This study analyses the effect of basal ring size and annuloplasty on valve repair in the setting of a tricuspid aortic valve. METHODS From 1995 to 2013, 382 patients underwent elective tricuspid aortic valve repair. We included only those undergoing subcommissural annuloplasty, valve sparing reimplantation or no annuloplasty and in whom intraoperative transoesophageal echocardiography images were available for retrospective pre- and post-repair basal ring measurements (n = 323, subcommissural annuloplasty: 146, valve sparing reimplantation: 154, no annuloplasty: 23). In a subgroup of patients with available echocardiographic images, basal ring was retrospectively measured at the latest follow-up or prior to reoperation. subcommissural annuloplasty and valve sparing reimplantation were compared after matching for degree of aortic regurgitation and root size. RESULTS All three groups differed significantly for most of preoperative characteristics. Hospital mortality was 0.9%. The median follow-up was 4.7 years. At 8 years, overall survival was 80 ± 5%. Freedom from reoperation and freedom from aortic regurgitation >1+ were 92 ± 5% and 71 ± 8%, respectively. In multivariate analysis, predictors of aortic regurgitation >1+ were left ventricular end-diastolic diameter (P = 0.003), cusp repair (P = 0.006), body surface area (P = 0.01) and subcommissural annuloplasty (P = 0.05). In subcommissural annuloplasty, freedom from aortic regurgitation >1+ was lower for patients with basal ring ≥28 mm compared with patients with basal ring <28 mm (P = 0.0001). In valve sparing reimplantation, freedom from aortic regurgitation >1+ was independent of basal ring size (P = 0.38). In matched comparison between subcommissural annuloplasty and valve sparing reimplantation, freedom from aortic regurgitation >1+ was not significantly different (P = 0.06), but in patients with basal ring ≥28 mm, valve sparing reimplantation was superior to subcommissural annuloplasty (P = 0.04). Despite similar intraoperative reduction in basal ring size in subcommissural annuloplasty and valve sparing reimplantation, patients with subcommissural annuloplasty exhibited greater increase in basal ring size during the follow-up compared with the valve sparing reimplantation group (P < 0.001). CONCLUSIONS As with a bicuspid aortic valve, a large basal ring predicts recurrence of aortic regurgitation in patients with tricuspid aortic valve undergoing repair with the subcommissural annuloplasty technique. This recurrence is caused by basal ring dilatation over time after subcommissural annuloplasty. With the valve sparing reimplantation technique, large basal ring did not predict aortic regurgitation recurrence, as prosthetic-based circumferential annuloplasty displayed better stability over time. Stable circumferential annuloplasty is recommended in tricuspid aortic valve repair whenever the basal ring size is ≥28 mm.

Male-predominant plasma transfusion strategy for preventing transfusion-related acute lung injury: a systematic review.

Objectives:To assess 1) the effectiveness of male-predominant plasma transfusion strategy for preventing transfusion-related acute lung injury and related mortality; and 2) whether this effect varies across different patient subgroups. Design:Systematic Review and meta-analysis: Data were identified by querying MEDLINE and EMBASE (including proceedings of major conferences on blood transfusions), searching the Internet for hemovigilance reports, reviewing reference lists of eligible articles and contacting experts in the field. Eligible were all studies reporting transfusion-related acute lung injury incidence, all-cause mortality (primary outcomes), hospital length of stay, time to extubation, PaO2/FIO2-ratio or blood pressure changes (secondary outcomes) in recipients of plasma transfusions containing relatively more plasma from individuals at low risk of carrying leukocyte-antibodies (“male plasma”) than those receiving comparator plasma (“control plasma”). No limits were placed on study design, population or language. The only exclusion criteria were non-human subjects and lack of control group. Prespecified study quality indicators (including risk of bias assessment) and potential effect modifiers were tested using Cochran’s Q Test. Final analyses using random-effects models and I2 to assess heterogeneity were performed in the subset of studies judged to provide the best evidence and separately for significantly different subgroups using STATA 12.1 (StataCorp, College Station, TX). Setting:As per primary studies. Patients/Subjects:As per primary studies. Interventions:As per primary studies (generally: exposure to plasma containing relatively more male plasma than comparator plasma). Measurements and Main Results:From a total of 850 retrieved records, we identified 45 eligible studies. For transfusion-related acute lung injury incidence, final analysis was restricted to 13 cohort studies and one randomized controlled trial in which transfusion-related acute lung injury cases only involved plasma transfusions. Risk of transfusion-related acute lung injury and mortality in plasma recipients exposed to men when compared with control plasma were 0.27 (95% CI, 0.20–0.38; p < 0.001; I2 = 0%; n = 14; 286 events) and 0.89 (95% CI, 0.80–1.00; p = 0.04; I2 = 79%; n = 7; 5, 710 events), respectively. No other significant interactions were found. Secondary outcomes showed similar results but were less reported and the studies were more heterogeneous. Sensitivity analyses did not alter the results. There was no evidence of publication bias. Discussion:More than 800 million people in 17 countries are subject to male-predominant plasma transfusion policy and at least three more countries are planning or considering adoption of this strategy. On the basis of most observational data, judged to be of high quality, male-predominant plasma transfusion strategy reduces plasma-related transfusion-related acute lung injury incidence and possibly mortality. There was no evidence that the effect differs across patient subgroups, but power to detect such differences was low.

Over 20 years experience with aortic homograft in aortic valve replacement during acute infective endocarditis

OBJECTIVES Despite the controversy, the aortic homograft is supposedly the best option in acute infective endocarditis (AIE), due to its resistance to reinfection. However, the technical complexity and the risk of structural deterioration over time have limited its utilization. The aim of this study was to evaluate the long-term results of aortic homograft for the treatment of infective endocarditis in our institution with particular attention to predictors of survival and homograft reoperation. METHODS The cohort includes 112 patients who underwent aortic valve replacement with an aortic homograft for AIE between January 1990 and December 2014. RESULTS Fifteen patients (13.4%) died during the first 30 days after the operation. Two patients were lost to follow-up after discharge from the hospital; therefore, 95 patients were available for long-term analysis. The median duration of follow-up was 7.8 years (IQR 4.7-17.6). Five patients (5.3%) suffered a recurrence of infective endocarditis (1 relapse and 4 new episodes). Sixteen patients (16.8%) were reoperated for structural valve degeneration (SVD; n = 14, 87.5%) or for infection recurrence (n = 2, 12.5%). Freedom from homograft reoperation for infective endocarditis or structural homograft degeneration at 10 and 15 years postoperatively was 86.3 ± 5.5 and 47.3 ± 11.0%, respectively. For patients requiring homograft reoperation, the median interval to reintervention was 11.6 years (IQR 8.3-14.5). Long-term survival was 63.6% (95% CI 52.4-72.8%) and 53.8% (95% CI 40.6-65.3%) at 10 and 15 years, respectively. CONCLUSIONS The use of aortic homograft in acute aortic valve endocarditis is associated with a remarkably low risk of relapsing infection and very acceptable long-term survival. The risk of reoperation due to SVD is significant after one decade especially in young patients. The aortic homograft seems to be ideally suited for reconstruction of the aortic valve and cardiac structures damaged by the infective process especially in early surgery.

Robotic mitral valve repair: a European single-centre experience

OBJECTIVES We report the outcomes of robotic valve repair for degenerative mitral regurgitation (MR) in our Institution. METHODS Between February 2012 and July 2016, 134 patients underwent robotic mitral valve (MV) repair with the da Vinci Si system. All the operations were performed through a mini-thoracotomy in the fourth right intercostal space, cardiopulmonary bypass and mild hypothermia. The clinical and echocardiographic follow-up was 100% complete. RESULTS There was no hospital death. The mean cross-clamp and cardiopulmonary bypass time were 112±23 and 159±33 min, respectively. Pre-discharge echocardiograms showed none-to-mild residual MR in all patients. Median follow-up was 24.1 months. We observed 1 early and 4 late reoperations on the MV for an overall freedom from reoperation of 98.2% and 94.1% at 12 and 36 months, respectively. Furthermore, echocardiographic follow-up revealed freedom from recurrence of MR greater than Grade 1+ of 92.5% and 80.7% at 12 and 36 months, respectively. Nevertheless freedom from recurrence of MR greater than Grade 2+ was 97.2% at 12 and 36 months. CONCLUSIONS Robotic MV repair is a feasible and safe option for the treatment of degenerative MR in selected patients with excellent perioperative outcomes. Early and midterm results are remarkable and are associated with low risk of late recurrence of MR and reoperation. Long-term follow-up is needed to confirm the durability of valve repair.

Aortic valve repair and Ross operation in children: the importance of patient selection and surgical technique.

Wilder et al. [1] have reported an important series of 90 children operated for significant aortic regurgitation in recent years in a single institution. The children received either aortic valve repair (51%), the Ross procedure (23%) or valve replacement with a prosthesis [aortic valve replacement (AVR), 26%]. The series was quite heterogeneous and included children with root dilatation and valve insufficiency (AI), or with congenital malformation or iatrogenic lesions following balloon dilatation. Furthermore, up to 52% of the kids had some degree of aortic stenosis. During a mean follow-up of 6 years, the authors found that aortic valve repair procedures were associated with a higher rate of recurrent AI, a higher left ventricle outflow tract peak pressure and a greater annular dilatation. Moreover, the rate of freedom from reoperation was only 51% for AVR and 64% for aortic valve (AV) repair compared with 100% with the pulmonary autograft (the Ross procedure) at 6 years. Further analysis revealed AVR to be a significant risk factor for reoperation. Nevertheless, when excluding the cases of bioprosthesis degeneration, AV repair became a significant predictor of reoperation over time. However, when transcathether procedures were also taken into consideration, the authors found no difference in the rate of reintervention between the three groups. The authors concluded that, in their experience, AV repair might not offer any advantage over valve replacement with the pulmonary autograft for older children with significant AI. Despite the limitations of a retrospective analysis of a limited number of cases with a broad spectrum of lesions and most likely a significant selection bias that makes the comparison between the three groups difficult, the study highlights some important points that deserve consideration. From our 20 years of experience with aortic valve repair in adults and children [2], we have learned that the twomost important determinants of repair durability are: (i) the quality and quantity of the leaflet tissue the surgeon has to deal with during the procedure and (ii) the quality of the immediate result in terms of leaflet coaptation, motion, coaptation height and residual AI, as assessed by intraoperative transoesophageal echocardiography (TOE) after weaning from cardiopulmonary bypass. Moreover, similar to mitral valve repair, annular stabilization improves the long-term result, preventing further dilatation and recurrence of AI. We have seen in adults that a detailed identification of the mechanism of aortic regurgitation by means of preoperative TOE is of paramount importance to predict valve reparability and to choose the most appropriate repair technique [3]. In children, the congenital lesions of the aortic valve may be classified from a surgical point of view in lesions with enough or an excess of leaflet tissue (or in any case with good quality of leaflets; such as dilatation of the ascending aorta or root, bicuspid valves without restrictive raphe), and lesions with a lack of tissue (such as unicuspid, rheumatic and post-balloon valvotomy valves). In the first instance, the excess of leaflet tissue usually allows a successful repair by means of free margin shortening (with either plication or resuspension) without the need of exogenous material such as the pericardial patch. In these cases, excellent and durable results are expected. It is noteworthy that, in this series by Wilder et al., 43% of the children who underwent AV repair showed some degree of valve stenosis and up to 85% of them needed pericardial leaflet extension. Although some children received commissuroplasty with the Trusler stitch, a central plication of the free margin or triangular resection was not applied in any case. This reveals that the quality of these valves was probably quite poor from the beginning and hence the suboptimal results with repair. Nevertheless, if the pericardial patch was overused, these results demonstrate that one should avoid its use as much as possible. The authors have also shown through an impressive number of follow-up echoes that the children in the repair group presented with a significant dilatation of the annulus over time with a mean size of 2.4–2.5 cm at 5–7 years after surgery. We have also learned that annular stabilization with either subcommissural or circumferential annuloplasty is an important determinant of repair durability over time [4]. This study further reveals that progressive annular dilatation is possible in children and is associated with recurrence of AI. Therefore, annular stabilization should be considered also in children to increase repair durability. Although AV repair may have a certain risk of failure over time, as the authors have correctly pointed out, repair techniques may delay a further valve replacement regardless of a prosthesis or a pulmonary autograft was used. This time gain is very valuable in children, allowing, on the one hand, one to avoid the oral anticoagulation associated with a mechanical prosthesis for some years

Endovascular resection of the native aortic valve before transcatheter aortic valve implantation: state of the art and review

Transcatheter aortic valve implantation was introduced into clinical practice in 2002 as a rescue approach in patients presenting with symptomatic severe aortic stenosis but not eligible for conventional aortic valve replacement. This technique allows implantation of a balloon expandable bioprosthesis without resection of the native aortic valve. Several complications are described as a consequence of the residual highly calcified valve being squeezed against the aortic wall by the stent of the implant. This can result in deformation of the metal stent and paravalvular leakage, risk of occlusion of the coronary ostia, or central and peripheral embolization of valvular debris. To avoid these complications, many authors suggest the possibility to resect and remove the native aortic valve before transcatheter aortic valve implantation. In this field, different authors have described possible techniques and different sources of energy to resect the calcified valve. In this article, we review the development of these experimental techniques and discuss future prospects in this field.

Management and Outcome of Prosthetic Vascular Graft Infections: A Single Center Experience:

Background: Prosthetic vascular graft infection (PVGI) remains a severe and challenging complication in vascular surgery with high morbidity and mortality rates. Incidence has been reported between 1% and 6%. The aim of this study was to report our experience in terms of general and surgical management as well as outcome, over 15 years. Methods: A retrospective consecutive study was conducted of all patients treated in our department for PVGI between January 2000 and December 2015. We analyzed all data relative to primary operation, duration interval between initial surgery and infections signs, infection site, type of microorganism involved, and surgical treatment modality, as well as evaluation of short- and long-term results. Results: Sixty-two patients were admitted for PVGI. Primary revascularization procedures consisted of a peripheral bypass in 42 (68%) patients and an aortic bypass in the remaining 20 (32%) patients. Median interval between primary procedure and reintervention was 3 months (interquartile range 17 [IQR 17]) in the peripheral group and 48 months (IQR 70.5) in the aortic group. Complete excision of the prosthetic graft was carried out in 85% of the cases. Thirty-day mortality was 0% and 9.5% in the aortic and peripheral group, respectively. The overall survival rate was 62.3% at 2-years, 46.4% in the aortic group, and 69.7% in the peripheral group. Conclusions: Prosthetic vascular graft infection needs a multidisciplinary management with appropriate antibiotherapy, radical removal of the infected graft, and in situ reconstruction. This strategy gives satisfactory results in terms of mortality, morbidity, patency rates, and infection control.

Re-repair of the failed mitral valve: insights into aetiology and surgical management

OBJECTIVES Mitral valve (MV) repair is the gold standard for treatment of degenerative mitral regurgitation. A variety of surgical techniques allow surgeons to achieve a high rate of MV repair even with MV diseases of other aetiologies. However, a certain number of repairs fail over time. The aim of this study was to review our single-centre experience of MV re-repair and analyse the mode of repair failure, re-repair safety and efficiency in relation to the initial aetiology. METHODS Between 1997 and 2015, 91 patients underwent redo MV re-repair. The first MV repair was performed in our institution in 59% of cases. Follow-up information was available for 93% of our patients. The median follow-up was 56 months. RESULTS The initial aetiology was degenerative disease in 40 (44%) patients, rheumatic disease in 25 (27.5%), endocarditis in 10 (11%), ischaemic in 6 (7%), severe mitral annulus calcification in 5 (5.5%), congenital disease in 4 (4%) and unknown in 1 (1%). The mean age was 58 ± 15 years. The median delay between the 1st and 2nd repair was 49 months with 6 early re-repairs. Re-repair was urgent or emergent in 19% of cases; indications for surgery were mitral regurgitation in 48%, stenosis in 19%, endocarditis in 19%, mitral disease in 11%, ring thrombosis in 2% and systolic anterior motion in 1%. The main mechanisms of failure included technical error (30%), progression of disease (35%), new disease (29%) and unknown (6%.) Re-repair was performed through a median sternotomy in 96% of cases, and 34% of patients had concomitant procedures. Eight (9%) postoperative deaths (4 of mitral annulus calcification, 2 of endocarditis, 1 of degenerative disease, 1 of ischaemia) and 5 (6%) early failures occurred (3 of rheumatic disease, 1 of degenerative disease, 1 of a congenital condition), requiring MV replacement in 4 and new repair in 1. Overall survival at 5 and 10 years was 76% and 57%, 83% and 49% in patients with degenerative diseases and 95% and 95% in patients with rheumatic disease. Overall freedom from reoperation at 5 and 10 years was 82% and 61%, 94% and 87% with degenerative disease and 60% and 45% with rheumatic disease. CONCLUSIONS MV re-repair is feasible and has good mid-term results in patients with degenerative MV disease. Rheumatic MV disease is associated with a certain risk of failure over time; nevertheless, these patients show excellent survival after re-repair.

Valve sparing-aortic root replacement with the reimplantation technique in acute type A aortic dissection.

A 56-year-old man presented to the emergency department of our institution complaining of sudden onset chest pain, shortness of breath and palpitations. His past medical history was significant for hypertension and paroxysmal atrial fibrillation. Physical examination revealed a blood pressure of 150/80 mmHg, heart rate of 120 bpm, normal heart sounds and lungs auscultation and normal distal arterial pulses. An urgent computed tomography (CT) scan of the chest and abdomen revealed an acute type A aortic dissection extending from the ascending aorta till the origin of the superior mesenteric artery with a maximum diameter of 51 mm at the level of the ascending aorta. The patient was therefore referred for emergency surgery.