Teodora Nisi

Long-Term Results (≤18 Years) of the Edge-to-Edge Mitral Valve Repair Without Annuloplasty in Degenerative Mitral Regurgitation Implications for the Percutaneous Approach

Background— To assess the long-term results of the edge-to-edge mitral repair performed without annuloplasty in degenerative mitral regurgitation (MR). Methods and Results— From 1993 to 2002, 61 patients with degenerative MR were treated with an isolated edge-to-edge suture without any annuloplasty. Annuloplasty was omitted in 36 patients because of heavy annular calcification and in 25 for limited annular dilatation. A double-orifice repair was performed in 53 patients and a commissural edge-to-edge in 8. Hospital mortality was 1.6%. Follow-up was 100% complete (mean length, 9.2±4.21 years; median, 9.7; longest, 18.1). Survival at 12 years was 51.3±7.75%. At the last echocardiographic examination, MR ≥3+ was demonstrated in 33 patients (55%). At 12 years, freedom from reoperation was 57.8±7.21% and freedom from recurrence of MR ≥3+ was 43±7.6%. Residual MR >1+ at hospital discharge was identified as a risk factor for recurrence of MR ≥3+ (hazard ratio, 3.8; 95% confidence interval, 1.7–8.2; P=0.001). In patients with residual MR ⩽1+ immediately after surgery, freedom from MR ≥3+ at 5 and 10 years was 80±6% and 64±7.58%, respectively. Conclusions— In degenerative MR, the overall long-term results of the surgical edge-to-edge technique without annuloplasty are not satisfactory. Early optimal competence (residual MR ⩽1+) was associated with higher freedom from recurrent severe regurgitation.

Long-term outcomes of tricuspid valve replacement after previous left-side heart surgery †

OBJECTIVES To assess long-term outcomes of tricuspid valve replacement (TVR) after previous left-side heart surgery. METHODS We reviewed reoperative TVR after left-side heart surgery performed at our institution between March 1997 and June 2012. In-hospital data were retrieved from our institutional database or medical records; follow-up was performed through telephone call, surviving patients being asked to provide a recent (≤6 months) echocardiogram. RESULTS Reoperative TVR was performed in 117 patients. Preoperative characteristics included: mean age 63.7 years, median logistic EuroSCORE (LES) 11.8, New York Heart Association (NYHA) class >2 in 79.5% of patients, right ventricle (RV) dysfunction >mild in 23.9% of patients and mean systolic pulmonary artery pressure (sPAP) 48.4 mmHg. A mechanical prosthesis was implanted in 5.1% of patients. A right thoracotomy was preferred to median sternotomy in 8.6% of cases. Isolated-TVR (I-TVR) was performed in 52.1% of patients, a beating-heart approach being used in 85.2% of I-TVR cases. Postoperative RV failure occurred in 46.1% of patients. Median length-of-stay was 11.5 days. Thirty-day mortality was 6.0% overall and 8.2% in the I-TVR group. Higher preoperative LES (P = 0.002), ascites (P = 0.004), RV dysfunction (P = 0.033) and sPAP (P = 0.046) were associated with acute mortality. No significant difference in acute outcomes was observed between beating and arrested-heart I-TVR, except for postoperative median length-of-stay (9 vs 28 days, respectively, P = 0.007). Among survivors median follow-up time was 5.1 years. Five-year and 10-year freedom from cardiac death were 79.4 and 61.0%, freedom from tricuspid reoperation were 97.3 and 87.5%, freedom from bioprosthesis degeneration were 92.8 and 74.3%, respectively. Five-year and 10-year survival in the I-TVR subgroup were respectively 74.4 and 61.6%. Higher preoperative sPAP was associated with increased follow-up mortality (P = 0.048). At the last follow-up, NYHA class I-II was found in 86.1% of surviving patients. CONCLUSIONS In selected cases, TVR is currently feasible with low acute mortality, especially if performed in the absence of ascites, significant RV dysfunction and pulmonary hypertension. Long-term mortality remains more difficult to predict, although it appeared to be also associated with higher preoperative pulmonary pressure. The global high-complexity profile of these patients is likely to impair long-term outcomes.

Primary Anticoagulation With Bivalirudin for Patients With Implantable Ventricular Assist Devices

Bivalirudin is a direct thrombin inhibitor that is increasingly used in patients undergoing mechanical circulatory support as it presents many advantages compared with unfractionated heparin. The aim of this study was to describe our experience with bivalirudin as primary anticoagulant in patients undergoing ventricular assist device (VAD) implantation. An observational study was performed on 12 consecutive patients undergoing VAD implantation at our institution. Patients received a continuous infusion of bivalirudin, with a starting dose of 0.025 mg/kg/h; the target activated partial thromboplastin time (aPTT) was between 45 and 60 s. Patients never received heparin during hospitalization nor had a prior diagnosis of heparin-induced thrombocytopenia (HIT). All patients received a continuous flow pump except one. Preoperative platelets count was 134 000 ± 64 000 platelets/mm(3) . Mean bivalirudin dose was 0.040 ± 0.026 mg/kg/h over the course of therapy (5-12 days). Lowest platelets count during treatment was 73 000 ± 23 000 platelets/mm(3) . No thromboembolic complications occurred. Two episodes of minor bleeding from chest tubes that subsided after reduction or temporary suspension of bivalirudin infusion were observed. Intensive care unit stay was 8 (7-17) days, and hospital stay was 25 (21-33) days. Bivalirudin is a valuable option for anticoagulation in patients with a VAD and can be easily monitored with aPTT. The use of a bivalirudin-based anticoagulation strategy in the early postoperative period may overcome many limitations of heparin and, above all, the risk of HIT, which is higher in patients undergoing VAD implantation. Bivalirudin should no longer be regarded as a second-line therapy for anticoagulation in patients with VAD. [Correction added on 6 December 2013, after first online publication: The dose of bivalirudin in the Abstract to 0.025 mg/kg/h].

Mitral Valve Repair Without Repair of Moderate Tricuspid Regurgitation.

BACKGROUND The objective of this study was to assess the fate at long term of mild-to-moderate functional tricuspid regurgitation (TR) left untreated at the time of mitral valve repair in patients with dilated cardiomyopathy. METHODS We selected from our prospective hospital database 84 patients (age, 64 ± 9.6 years; ejection fraction, 0.31 ± 0.064) who underwent mitral repair for secondary mitral regurgitation in whom concomitant mild-to-moderate TR (nonlinear scale 1 to 4+) was left untreated. Tricuspid regurgitation was classified as mild in 61 patients (72.6%) and moderate in 23 patients (27.3%). Annular dilatation itself was not systematically measured and was not used as a trigger for tricuspid annuloplasty. Most of the patients were in New York Heart Association functional class III or IV (56 of 84; 66.7%). RESULTS At a median follow-up of 7.3 years (interquartile range, 4.5 to 9.3), 17 patients (20.2%) had moderate-to-severe TR and 21 patients (25%) showed a progression of at least two grades of their untreated preoperative TR. Freedom from moderate-to-severe TR or from progression of at least two grades of the baseline TR was 77% ± 5% at 5 years and 56.7% ± 8.4% at 10 years. Multivariate analysis identified preoperative right ventricular dysfunction (hazard ratio, 7.2; 95% confidence interval, 2.8 to 23; p = 0.001) and age (hazard ratio, 1; 95% confidence interval, 1.0 1.1; p = 0.03) as independent predictors of TR worsening. CONCLUSIONS A significant number of dilated cardiomyopathy patients with mild-to-moderate TR left untreated at the time of mitral repair show important TR at follow-up. In this setting, a more aggressive policy should be used taking into consideration the degree of annular dilatation and the function of the right ventricle and not simply the grade of TR.

Ultrasound-Accelerated Thrombolysis and Extracorporeal Membrane Oxygenation in a Patient With Massive Pulmonary Embolism and Cardiac Arrest

A 72-year-old man presented to the emergency department in cardiogenic shock; 4-days before he was diagnosed with right femoro-popliteal deep vein thrombosis after trauma. During routine monitoring and diagnostic workup, cardiac arrest with pulseless electric activity rapidly ensued and cardiopulmonary resuscitation was initiated. A transthoracic echocardiogram showed severe right ventricular dilatation and acute pulmonary embolism was suspected. No Return of Spontaneous Circulation was obtained after 10 minutes of cardiopulmonary resuscitation. The patient was transferred to the cardiac catheterization laboratory under resuscitation with autopulse (ZOLL, Chelmsford, MA) and femoro-femoral veno-arterial extracorporeal membrane oxygenation (ECMO; PLS Maquet GmbH, Rastett, Germany) was percutaneously initiated with a 23 French (Fr) venous cannula and 17 Fr arterial cannula with restoration of systemic blood flow and oxygen delivery (5 L/min, 4000 rpm). Baseline pulmonary angiography demonstrated a large amount of thrombus in both the right (Movie I in the online-only Data Supplement) and the left pulmonary arteries …

Mid-term outcomes of concomitant surgical ablation of atrial fibrillation in patients undergoing cardiac surgery for hypertrophic cardiomyopathy

OBJECTIVES Atrial fibrillation (AF) is common in patients with hypertrophic cardiomyopathy (HCM) and it is often poorly tolerated because of loss of atrial contraction and reduced filling time with rapid ventricular rates. Restoring sinus rhythm is of great clinical benefit to HCM patients. Very few data exist regarding surgical ablation of concomitant AF in this setting. The aim of this study was to evaluate the mid-term outcome of surgical AF ablation in patients who underwent cardiac surgery due to HCM. METHODS Thirty-one consecutive patients with primary HCM and drug-refractory symptomatic AF underwent surgical ablation with concomitant septal myectomy (77%) and/or mitral valve repair/replacement (39%). Follow-up was 97% complete with a median of 6.4 years [3.8-9.1]. RESULTS Hospital mortality was 6% and the overall survival at 7 years was 87 ± 6.1%. No stroke and thromboembolic events were documented at follow-up. The arrhythmia-free survival off antiarrhythmic drugs was 82 ± 7.3% at 1 year and 52 ± 10.2% at 6 years. The 1- and 6-year arrhythmia control (maintenance of sinus rhythm with or without antiarrhythmic drugs) was 96 ± 3.5 and 80 ± 8.1%, respectively. The recurrent arrhythmia was AF in all patients. No predictors of AF recurrence were detected. CONCLUSIONS Concomitant surgical ablation of AF is a reasonable treatment option for drug refractory AF in patients with HCM undergoing surgical myectomy and/or mitral valve surgery. However, chronic antiarrhythmic drugs are needed to achieve a satisfactory mid-term arrhythmia control.

Tricuspid Valve Disease: Surgical Techniques

Tricuspid valve disease remains an intricate and debated field in terms of pathophysiology, surgical indications and treatment options. In this chapter, surgical techniques, both for repair and replacement of the tricuspid valve will be described in details. Functional (secondary) and organic (primary) tricuspid regurgitation will be addressed and a challenging scenario, like late tricuspid regurgitation following previous mitral valve surgery, will be emphasized.

L'insufficienza tricuspidale funzionale: Un'entità clinica di crescente importanza

Functional tricuspid regurgitation (FTR) is the most frequent etiology of tricuspid valve pathology in Western countries. In the last years, many investigators have reported evidence in favor of a more aggressive surgical approach to FTR and interest has been growing in the physiopathology and treatment of FTR. The purpose of this editorial is to explore the anatomical basis, pathophysiology, therapeutic approaches and the perspectives of treatment.

Surgical Techniques for Tricuspid Valve Disease

Tricuspid valve disease affects millions of patients worldwide. It has always been considered less relevant than the left-side valves of the heart, but this “forgotten valve” still represents a great challenge for the cardiac surgeons, especially in the most difficult symptomatic scenarios. In this review we analyze the wide spectrum of surgical techniques for the treatment of a diseased tricuspid valve.

Evoluzione delle tecniche di chirurgia riparativa delle valvole cardiache: Implicazioni per il follow-up

The number of patients undergoing surgical heart valve repair has been increasing during the last years, particularly in high-volume centers. Several factors related to poor outcomes after surgical repair have been identified in different observational studies, leading to a better preoperative patient selection and improved long-term clinical and echocardiographic follow-up.