Thomas Kuntze

Minimal invasive mitral valve repair for mitral regurgitation: results of 1339 consecutive patients

OBJECTIVE Some have expressed concern that minimal invasive mitral valve (MV) repair may not meet the standard of open surgical techniques. We therefore reviewed our results for minimal invasive MV repair for mitral regurgitation (MR). MATERIAL AND METHODS Between March 1999 and February 2007, a total of 1536 consecutive patients underwent minimal invasive MV surgery for MR at our institution using a right lateral mini-thoracotomy and femoral cannulation for cardiopulmonary bypass. Of these, a total of 1339 (87.2%) patients underwent MV repair and these form the focus of this study. The mean grade of preoperative MR was 3.3+/-0.6, age was 60.3+/-12.7 years, ejection fraction was 59.2+/-15.1% and 819 patients (61.2%) were male. RESULTS The procedure was successfully performed in all but four patients (0.3%) who required intraoperative conversion to full sternotomy. MV repair techniques consisted of ring annuloplasty with or without chordae-replacement or Carpentier-type leaflet resection. Concomitant procedures consisted of atrial fibrillation ablation in 351 patients (26.2%), tricuspid valve surgery in 80 patients (6.0%), and patent foramen ovale/atrial septal defect closure in 88 patients (6.6%). Mean duration of CPB was 121+/-38min and mean aortic cross-clamp time was 70+/-32min. Thirty-day mortality was 2.4%. Follow-up was performed in 99% of patients at an average of 28.1+/-23.9 months postoperatively. The Kaplan-Meier estimate for survival at 5 years was 82.6% (95% CI: 78.9-85.7%) and for freedom from MV reoperation was 96.3% (95% CI: 94.6-97.4%). CONCLUSIONS Minimal invasive MV repair, along with certain concomitant procedures, can be performed in the vast majority of patients with MR. Our large series demonstrates that these procedures can be performed with low perioperative complication rates and very good durability.

How does the use of polytetrafluoroethylene neochordae for posterior mitral valve prolapse (loop technique) compare with leaflet resection? A prospective randomized trial

OBJECTIVE Mitral valve surgery for posterior mitral leaflet prolapse consists mostly of leaflet resection, but implantation of premeasured polytetrafluoroethylene neochordae (ie, loops) is another option. The aim of this prospectively randomized trial was to determine how preservation of leaflet structure in combination with premeasured neochordae compares with the widely adopted technique of leaflet resection. METHODS A total of 129 patients with severe mitral regurgitation, with a mean mitral regurgitation grade of 3.6 +/- 0.6, underwent minimal invasive mitral valve surgery through a right lateral mini-thoracotomy. The mean age was 59.5 +/- 12 years, 90 patients were male, the mean preoperative ejection fraction was 65% +/- 8%, and the mean New York Heart Association functional class was 2.1 +/- 0.7. Posterior mitral leaflet prolapse was diagnosed in all patients. Randomization was performed preoperatively, and crossover was allowed if the surgeon deemed it medically necessary. Crossover from resection to loops occurred in 9 patients, and crossover from loops to resection occurred in 3 patients. RESULTS Mitral valve repair was accomplished in all patients (n = 129, 100%), and all patients received an annuloplasty ring. The mean number of loops implanted on the posterior mitral leaflet was 3.2 +/- 0.9, with a mean length of 13.3 +/- 2.2 mm. The mean duration of cardiopulmonary bypass was 135 +/- 37 minutes and the mean aortic crossclamp time was 82 +/- 26 minutes in all patients, with no significant difference between groups. Intraoperative transesophageal echocardiography showed a significantly longer line of mitral valve leaflet coaptation after implantation of loops (7.6 +/- 3.6 mm) than after resection (5.9 +/- 2.6 mm; P = .03). Thirty-day mortality was 1.6% for the entire group (2/129), with both deaths occurring in the loop group. Cause of death was massive pulmonary embolism in 1 patient and acute right heart failure in 1 patient. Early and mid-term echocardiographic follow-up revealed excellent valve function in the majority of patients, with no significant difference in mitral orifice area (3.6 +/- 1.0 cm(2) vs 3.7 +/- 1.1 cm(2), P = .4). CONCLUSION Both repair techniques for posterior mitral leaflet prolapse are associated with excellent results and appear comparable in the early postoperative course. The loop technique, however, results in a significantly longer line of leaflet coaptation and may therefore be more durable. Longer follow-up is required.

Surgical risk of preoperative malperfusion in acute type A aortic dissection

OBJECTIVE Patients who have type A dissection with preoperative malperfusion syndromes are believed to be at extremely high surgical risk. Our aim was to evaluate perioperative and long-term results of patients with preoperative malperfusion. METHODS A total of 276 patients (174 men; mean age 59.5 +/- 13.4 years) underwent surgery for acute type A dissection between October 1994 and January 2008. Preoperative malperfusion syndromes were diagnosed in 93 (33.7%) patients (group I) and involved coronary circulation in 41 (15%) patients, central nervous system in 39 (14%) patients, limb ischemia in 32 (11.6%) patients, and mesenteric circulation in 8 (3%) patients. Postoperative results were compared between patients with preoperative malperfusion and those without this complication (group II, n = 183). RESULTS In-hospital mortality was 29.0% in group I versus 13.6% in group II (P = .002). The postoperative intensive care unit stay was longer (11.4 +/- 9.7 vs 7.7 +/- 6.9 days; P = .04) in the malperfusion group. A total of 6 (75%) patients with mesenteric malperfusion died. Long-term follow-up (range, 1-122 months postoperatively) was available in 100% of survivors. One-year and 5-year overall survivals were 49.8% +/- 11.8% and 41.8% +/- 12.6% in group I versus 70.4% +/- 7.6% and 56% +/- 10.4% in group II (P = .005). Cox regression analysis identified preoperative malperfusion as a significant risk factor for long-term mortality after surgery for type A dissection (hazard ratio, 1.7; 95% confidence intervals, 1.2-3.1). CONCLUSIONS Preoperative malperfusion is a significant risk factor influencing perioperative and long-term survival after surgery for acute type A dissection. Percutaneous interventional procedures and delayed surgery should be considered in patients with clinically apparent mesenteric malperfusion because of the dismal prognosis of immediate surgical therapy.

Secondary surgical procedures after endovascular stent grafting of the thoracic aorta: successful approaches to a challenging clinical problem.

OBJECTIVE To evaluate the results of open surgical repair for complications after endovascular thoracic aorta stenting. METHODS A total of 14 patients (8 male, mean age 59.8 +/- 14.8 years) underwent conventional surgical therapy at our institution over a 5-year period after previous thoracic aortic stent implantation. The indications for surgery, intraoperative strategy, and perioperative and follow-up results were analyzed. RESULTS The indication for stent implantation was type B aortic dissection in 10 patients, expanding degenerative thoracic aneurysm in 3 patients, and pseudoaneurysm in 1 patient. The median interval to conventional surgery after stent implantation was 4.5 months (range 0.1-49 months). The indication for surgery was persistent type I endoleak with progressive aneurysm enlargement in 7 patients, aortoesophageal fistula in 2 patients, retrograde type A dissection in 2 patients, infection of the endoprosthesis in 2 patients, and aortic valve insufficiency caused by perforation of noncoronary and right coronary cusps in 1 patient. The endograft had to be removed in 9 (64%) patients, and 5 (36%) patients required replacement of the thoracoabdominal aorta. In-hospital mortality was 7% (1 patient). No patients had a postoperative stroke or paraparesis. Eleven (79%) patients are alive after a mean follow-up of 13.5 +/- 10.1 months (range 1-36 months). CONCLUSIONS Secondary surgical procedures after stenting of the thoracic aorta can be performed with very good results, despite the challenging clinical scenarios. Identification of successful surgical strategies for this difficult clinical problem is important in the era of increasing endovascular therapy.

Transforming Growth Factor-Beta Receptor Type II Mutation in a Patient With Bicuspid Aortic Valve Disease and Intraoperative Aortic Dissection

We report on a patient with familial bicuspid aortic valve disease operated on for proximal aortic aneurysm. The surgery was complicated by intraoperative aortic dissection. Multi-generational genetic analysis demonstrated a mutation in the transforming growth factor-beta receptor type II gene. This case confirms the clinical hypothesis that the proximal aortic disease has a genetic origin in some bicuspid aortic valve patients.

Circulating Vascular Cell Adhesion Molecules VCAM-1, ICAM-1, and E-Selectin in Dependence on Aging

Background: Elevated levels of circulating cell adhesion molecules (cCAMs) such as vascular cell adhesion molecule-1 (VCAM-1), intercellular adhesion molecule-1 (ICAM-1), and endothelial leukocyte adhesion molecule-1 (E-selectin) are found in subjects with vascular diseases and in subjects with several risk factors for atherosclerosis. However, data evaluating cCAMs and biological age are limited. Objective: The purpose of this study was to assess in subjects with different cardiovascular risk profiles the levels of cVCAM-1, cICAM-1, and cE-selectin in dependence on age. Methods: The following groups of subjects were included in the study: 282 apparently healthy subjects of the average population aged 18–89 years, 77 vegetarians who are characterized by a favourable global cardiovascular risk profile, 94 patients with coronary heart disease, and 181 patients with peripheral arterial occlusive disease. Blood samples were obtained after an overnight fast for measurement of cCAMs, lipoproteins, and other clinical/biochemical parameters. The cCAM levels were determined by the use of monoclonal antibody based enzyme-linked immunosorbent assays. Results: Amongst the cCAMs, cVCAM-1 is uniquely elevated in elderly persons with different risks for atherosclerosis, including subjects of the average population, vegetarians with a favourable risk profile, and patients with both coronary heart disease and peripheral arterial occlusive disease. With respect to cICAM-1, an age-dependent elevation was found in the control subjects included in the study. The cE-selectin levels were not correlated with age. Moreover, no associations of cCAMs with serum lipid and lipoprotein levels were found. Conclusion: The results of the present study indicate that cVCAM-1 is an age-dependent parameter independent of cardiovascular risk.

Distal Aortic Reinterventions After Root Surgery in Marfan Patients

BACKGROUND Distal aortic disease may evolve in Marfan patients after aortic root surgery. The aim of this study was to analyze the results of distal aortic reoperations in Marfan patients after proximal aortic surgery. METHODS A total of 95 Marfan patients (56 male; mean age 34.5 +/- 10.9 years) have been followed or operated on at our institution between October 1994 and December 2007. Results of patients who required distal aortic reinterventions after root surgery were collected and analyzed. RESULTS Fifteen Marfan patients (9 male; mean age 39.1 +/- 7.5 years) underwent distal aortic reinterventions after aortic root surgery. The indications for distal reoperations consisted of dissecting aneurysm after type A dissection surgery in 12 patients (80%) and nondissecting aneurysm in 3 patients (20%). Type A dissection during initial aortic root surgery was the only independent predictor of distal aortic reoperation (hazard ratio 3.8). One patient (6.7%) died perioperatively. Neurologic morbidity consisted of 1 patient with paraplegia and 1 with temporary paraparesis, and no strokes. Two patients died during a mean follow-up of 36.2 +/- 25.5 months. Survival was 91.7% +/- 1.6% at 1 and 5 years postoperatively. Three patients undergoing reoperative arch procedures required additional interventions on the distal aorta during follow-up. CONCLUSIONS Distal aortic reoperations in Marfan patients are more common among those presenting with type A dissection. Although technically challenging, such procedures can be performed with good short- and long-term results. Complete aortic arch replacement with an elephant trunk technique, if it can be safely performed, should be considered for Marfan patients presenting with type A dissection.

Functional Aortic Root Parameters and Expression of Aortopathy in Bicuspid Versus Tricuspid Aortic Valve Stenosis.

BACKGROUND The correlation between bicuspid aortic valve (BAV) disease and aortopathy is not fully defined. OBJECTIVES This study aimed to prospectively analyze the correlation between functional parameters of the aortic root and expression of aortopathy in patients undergoing surgery for BAV versus tricuspid aortic valve (TAV) stenosis. METHODS From January 1, 2012 through December 31, 2014, 190 consecutive patients (63 ± 8 years, 67% male) underwent aortic valve replacement ± proximal aortic surgery for BAV stenosis (n = 137, BAV group) and TAV stenosis (n = 53, TAV group). All patients underwent pre-operative cardiac magnetic resonance imaging to evaluate morphological/functional parameters of the aortic root. Aortic tissue was sampled during surgery on the basis of the location of eccentric blood flow contact with the aortic wall, as determined by cardiac magnetic resonance (i.e., jet sample and control sample). Aortic wall lesions were graded using a histological sum score (0 to 21). RESULTS The largest cross-sectional aortic diameters were at the mid-ascending level in both groups and were larger in BAV patients (40.2 ± 7.2 mm vs. 36.6 ± 3.3 mm, respectively, p < 0.001). The histological sum score was 2.9 ± 1.4 in the BAV group versus 3.4 ± 2.6 in the TAV group (p = 0.4). The correlation was linear and comparable between the maximum indexed aortic diameter and the angle between the left ventricular outflow axis and aortic root (left ventricle/aorta angle) in both groups (BAV group: r = 0.6, p < 0.001 vs. TAV group r = 0.45, p = 0.03, z = 1.26, p = 0.2). Logistic regression identified the left ventricle/aorta angle as an indicator of indexed aortic diameter >22 mm/m(2) (odds ratio: 1.2; p < 0.001). CONCLUSIONS Comparable correlation patterns between functional aortic root parameters and expression of aortopathy are found in patients with BAV versus TAV stenosis.

Correlation between systolic transvalvular flow and proximal aortic wall changes in bicuspid aortic valve stenosis

OBJECTIVES The purpose of this study was to analyse the correlation between preoperative systolic transvalvular flow patterns and proximal aortic wall lesions in patients undergoing surgery for bicuspid aortic valve (BAV) stenosis. METHODS A total of 48 consecutive patients with BAV stenosis (mean age 58 ± 9 years, 65% male) underwent aortic valve replacement (AVR) ± proximal aortic surgery from January 2012 through February 2013. Preoperative cardiac phase-contrast cine magnetic resonance imaging (MRI) assessment was performed in all patients in order to detect the area of maximal flow-induced stress in the proximal aorta. Based on these MRI data, two aortic wall samples (i.e. area of the maximal stress (jet sample) and the opposite aortic wall (control sample)) were collected during AVR surgery. Aortic wall changes were graded based on a summation of seven histological criteria (each scored from 0 to 3). Histological sum score (0-21) was separately calculated and compared between the two aortic samples (i.e. jet sample vs control sample). RESULTS An eccentric transvalvular flow jet hitting the proximal aortic wall could be identified in all 48 (100%) patients. The mean histological sum score was significantly higher in the jet sample vs control sample areas of the aorta (i.e. 4.1 ± 1.8 vs 2.2 ± 1.5, respectively) (P = 0.02). None of the patients had a higher sum score value in the control sample. CONCLUSIONS Our study demonstrates a strong correlation between the systolic pattern of the transvalvular flow jet and asymmetric proximal aortic wall changes in patients undergoing AVR for BAV stenosis.

Aortic Dissection After Previous Aortic Valve Replacement for Bicuspid Aortic Valve Disease

The effect of bicuspid aortic valve (BAV) phenotype on the future risk of type A aortic dissection is unknown. On the basis of previous data [(1)][1], we hypothesized that the risk of post–aortic valve replacement (AVR) aortic dissection might be different in BAV insufficiency versus BAV stenosis