Tyler Wallen

Root Stabilization of the Repaired Bicuspid Aortic Valve: Subcommissural Annuloplasty Versus Root Reimplantation

BACKGROUND At our institution, type I bicuspid aortic valve (BAV) patients with aortic insufficiency (AI) who are candidates for valve preservation are stratified into two groups by aortic root pathology: nonaneurysmal root undergoing primary cusp repair+subcommissural annuloplasty (repair group) vs aneurysmal root undergoing primary cusp repair+root reimplantation (reimplantation group). We report outcomes of this surgical reconstructive strategy for the repaired type I BAV. METHODS A retrospective review was performed of 71 patients with a type I BAV undergoing primary valve repair from 2005 to 2012. The repair group (n=40) underwent annular stabilization by subcommissural annuloplasty, and the reimplantation group (n=31) underwent robust annular stabilization provided by root reimplantation. RESULTS Preoperative characteristics and root anatomy were similar, except for increased root dimensions in the reimplantation group (p<0.001). Mortality, stroke, valve reoperation, and pacemaker requirement were zero in both groups. Postoperative peak (19±10 vs 11±5 mm Hg, p<0.001) and mean gradients (10±5 vs 5±3 mm Hg, p<0.001) favored root reimplantation. Freedom from AI greater than 1+ was 100% in both groups. Mean follow-up was 40 months in the reimplantation group and 38 months in the repair group. At 5 years, overall survival was 100% in both groups. Freedom from aortic reoperation and AI exceeding 2+ were similar in both groups. Freedom from AI exceeding 1+ was significantly better in the reimplantation group (92%±6% vs 62%±10%, p=0.03). The 2-year peak (14±6 vs 19±9 mm Hg, p=0.009) and mean (7±4 vs 11±5 mm Hg, p=0.001) gradients favored root reimplantation. CONCLUSIONS Root stabilization with the reimplantation technique significantly improves the durability of the repaired type I BAV compared with subcommissural annuloplasty. It also provides improved and sustained valve mobility (transvalvular gradients).

Combined heart-liver transplant in a situs-ambiguous patient with failed Fontan physiology.

Combined heart–liver transplantation (CHLT) in patients with congenital heart disease (CHD) has been performed in the setting of heart–liver failure secondary to failed Fontan/single-ventricle physiology. Recently, referral of patients with failed Fontan physiology has increased at our institution. These patients now present—15 to 20 years post-Fontan palliation—with a ‘‘burned out’’singleventricle with ensuing liver failure.CHLTin these patients is challenging with regard to intraoperative techniques and postoperative care. CHLT in patients with situs inversus/ambiguous can be evenmore complex, requiring technicalmodifications and complex venous and arterial reconstruction.

Procedural and clinical outcomes of the valve‐in‐valve technique for severe aortic insufficiency after balloon‐expandable transcatheter aortic valve replacement

Objective: To describe the clinical and procedural outcomes of patients treated with the valve‐in‐valve technique for severe aortic insufficiency (AI) after balloon‐expandable transcatheter aortic valve replacement (TAVR). Background: Severe AI immediately after valve implantation is a notable complication of TAVR. It can be treated with a valve‐in‐valve technique which involves deploying a second valve within the first one to crush the leaflets of the first implant leaving a new functional valve. Methods: We analyzed data on 142 consecutive patients at our institution undergoing TAVR with the Sapien valve between November of 2007 and April of 2011. Etiologies of acute AI, procedural and intermediate term clinical outcomes were reported for those in whom a valve‐in‐valve procedure was necessary. Post‐hoc analysis of these cases with C‐THV imaging (Paieon Medical Ltd.) was performed to elucidate the mechanism for successful AI treatment. Results: A total of 5 of 142 (3.5%) patients were treated with the valve‐in‐valve technique. Etiologies of the aortic valve insufficiency included bioprosthesis malposition (n = 3), valve dysfunction (n = 1), and valve undersizing (n = 1). With placement of the second valve, the first valve dimensions increased to approach the nominal valve size while the second valve size remained less than nominal. Conclusions: The valve‐in‐valve technique is an appropriate bailout measure for patients with acute valvular AI after balloon‐expandable TAVR.

Management of coronary obstruction following transcatheter aortic valve replacement

Although occlusion of the coronary arteries during transcatheter aortic valve replacement is rare, the mortality is high. In this review, we discuss the prevention and management of this complication. Occlusion of coronary ostia is a very rare, but serious, complication of transcatheter aortic valve replacement (TAVR). Although reported as only occurring in <1% of TAVR cases, it carries a high risk of fatality, with some series reporting a mortality rate as high as 40%. We present the management of an occluded left coronary artery after a self‐expanding TAVR, and review the incidence, prevention, and management of this complication.

Two-stage surgical strategy for aortoesophageal fistula: emergent thoracic endovascular aortic repair followed by definitive open aortic and esophageal reconstruction.

DISCUSSION PV stenosis appears frequently in neonates or infants with congenital heart disease such as total anomalous pulmonary venous connection. PV stenosis can be repaired using several surgical procedures, including a sutureless technique, patchplasty, excision of the stenosis, and reimplantation of the PV with direct anastomosis. The sutureless technique has evolved as a method to treat patients with recurrent PV stenosis developing after repair of total anomalous pulmonary venous connection. This technique requires no direct suturing of the PVs, enabling aggressive resection of the anterior wall of the segmental PV. Thus, the PV confluence can be created as wide as possible, even in complicated cases such as redo procedures. Additionally, oblique incision of the LAAp is key to creating a large atriopericardial anastomosis. Although various congenital cases have been documented, to the best of our knowledge, only 1 adult case has been previously reported. In a 43-year-old man with PV stenosis caused by idiopathic mediastinal fibrosis, pericardial patchplasty was performed for repair. After that report, we used conventional patchplasty for the first time. Subsequently, the sutureless technique was indicated for recurrent PV stenosis. However, a recent study reported that no significant difference could be found in the primary outcomes between the primary sutureless technique and conventional patchplasty in patients with a total anomalous pulmonary venous connection. Accordingly, our strategy was considered reasonable and proper for the present patient. Currently, more than 40,000 cases of catheter ablation are attempted each year in the United States. PV stenosis induced by ablation occurs in 1% to 3% of patients, and

Minimally Invasive Port Access Approach for Reoperations on the Mitral Valve

BACKGROUND In patients requiring a second-time or more operation on the mitral valve (MV), we assessed whether the outcomes of the minimally invasive port access approach (port access group) were equivalent to those of the traditional redo sternotomy approach (redo sternotomy group). METHODS In a retrospective review (1998-2011), 409 patients had previous MV operations requiring a second-time or more MV reintervention. Of those, 67 patients had the port access approach, and 342 had the redo sternotomy approach. Of the latter, 220 met the inclusion criteria because emergencies, patients with endocarditis, and those requiring concomitant procedures involving aortic valve and aorta were excluded. RESULTS New York Heart Association class 2 or above, age, atrial fibrillation, and surgical indications were similar in both groups. The port access group had more patients with previous MV repair (78% [n = 52] vs 41% [n = 90], p < 0.01) than with MV replacement (19% [n = 13) vs 53% [n = 116], p < 0.01). Concomitant procedures were similar (20% [n = 14] vs 27% [n = 59], p = 0.4). The MV re-repair rates were similar (19% [n = 10] vs 22% [n = 20], p = 1). The cardiopulmonary bypass times (153 ± 42 minutes vs 172 ± 83 minutes, p = 0.07) and aortic cross-clamping times (104 ± 38 minutes versus 130 ± 71 minutes, p < 0.01) were lower in the port access group. Mortality was lower in the port access group, although not significantly (3.0% [n = 2] vs 6.0% [n = 13], p = 0.5). The rates of postoperative stroke were similar (3.0% [n = 2] vs 3.2% [n = 7], p = 1). On postoperative echocardiography, freedom from mitral regurgitation >2+ was 100% in the port access group and 99% in the redo sternotomy group. The mean hospital length of stay was 11 ± 15 days versus 14 ± 12 days (p = 0.07). CONCLUSIONS The port access approach can be safely adopted for reoperations on the MV without compromising postoperative mortality or MV function.

Geometric orientation of the aortic neoroot in patients with raphed bicuspid aortic valve disease undergoing primary cusp repair and a root reimplantation procedure

OBJECTIVES Primary cusp repair + aortic root reimplantation in bicuspid aortic valve (BAV) disease presenting with root aneurysm with aortic insufficiency (AI) is an effective surgical treatment. We assessed whether the geometric orientation of the repaired BAV into its reimplanted neoroot affects outcomes-180°/180° orientation was compared with the 150°/210° orientation. METHODS From 2005 to 2012, 66 BAV repairs were performed. This is a retrospective review of all types of Ib/II BAV AI patients undergoing root reimplantation (n = 26) at two different geometric orientations: 180°/180° (n = 11) vs 150°/210° (n = 15). In the 180°/180° group, reimplantation into the neoroot was such that both conjoint and non-conjoint cusps occupied 180° of the annular circumference. In the 150°/210° group, the repaired valve was configured to the more typical native orientation of a type I BAV: the non-conjoint cusp occupied 150°, and the conjoint cusp occupied 210° of the annular circumference. RESULTS Preoperative characteristics were similar in both groups. In-hospital mortality, stroke, reoperation, renal failure and pacemaker rates were zero in both groups. No patient left the operating room with >1+ AI and one had a peak gradient >20 mmHg. Transvalvular gradients were higher in the 180°/180° group, but not significant (P > 0.05). M.ean follow-ups for the 180°/180° and 150°/210° group were 48 and 33 months, respectively. Actuarial freedom from AI >2+ at 5 years was 100% in both groups. Freedom from AI >1+ at 5 years was 90 ± 10% in the 150°/210° group and 86 ± 13% in the 180°/180° group (P = 0.71). Freedom from peak gradient >20 mmHg was 80% (n = 8) in the 180°/180° group and 100% in the 150°/210° group at 1-year follow-up. Transvalvular gradients were higher in the 180°/180° group (16 ± 8 vs 10 ± 4 mmHg, P = 0.02; 9 ± 3 vs 5 ± 3 mmHg, P = 0.01). Five-year actuarial survival and freedom from aortic reoperation have remained at 100% in the entire cohort. CONCLUSION Cusp repair + root reimplantation for BAV type Ib/II AI can be safely performed at either geometric orientation. Conceptually, 150°/210° orientation respects the natural type I BAV anatomy with regard to cusp surface area and leaflet insertion perimeter. The 180°/180° group may have higher transvalvular gradients and smaller coaptation zones than the 150°/210° group. Further follow-up may reveal the superiority of one geometric orientation over the other.

The role of extracorporeal membrane oxygenator therapy in the setting of Type A aortic dissection

Patients presenting with type A aortic dissection (TAAD) present with a wide clinical spectrum ranging from hemodynamic stability to multiorgan malperfusion with cardiovascular collapse. Extracorporeal membrane oxygenator (ECMO) therapy is increasingly being utilized as salvage therapy in patients with acute cardiopulmonary failure and for post‐cardiotomy shock. We sought to determine the utility of ECMO implementation post‐TAAD repair.

Concomitant antegrade stent grafting of the descending thoracic aorta during transverse hemiarch reconstruction for acute DeBakey I aortic dissection repair improves aortic remodeling

Concomitant endovascular stent grafting of the descending thoracic aorta during open repair for acute DeBakey I aortic dissection can be performed in patients with extensive dissection and malperfusion. We analyzed the effects of this strategy on distal aortic remodeling.

Tricuspid valve endocarditis in the era of the opioid epidemic

We reviewed our institutional experience with tricuspid valve endocarditis to understand the impact of the opioid epidemic on the incidence of right heart endocarditis.