The effect of levosimendan on the right ventricular function in patients with right ventricular dysfunction undergoing mitral valve surgery

Background: Right ventricular (RV) dysfunction is an important predictor of both immediate and long-term outcomes in valve surgeries. Levosimendan has proven beneficial in improving RV function. Aims: The objective was to study the effect of the addition of levosimendan to the conventional treatment on RV function in patients with RV dysfunction undergoing mitral valve (MV) surgeries. Setting and Design: Prospective randomized double-blinded controlled study at a tertiary care institution. Materials and Methods: Sixty adult patients aged 15� years, with preoperative transthoracic echocardiography (TTE) findings of RV dysfunction posted for elective MV surgery, were randomized into levosimendan (L) group and placebo (P) group. Patients in the L group were administered levosimendan at a rate of 0.1 mcg/kg/min after induction for 24 hrs, whereas patients in the P group were given multivitamin infusion at the same rate. Both the groups received standard inotropic therapy. The hemodynamic and echocardiographic parameters of RV function (RV size, Inferior vena cava (IVC) diameter, RV fractional area change (RVFAC) Tricuspid annular plane systolic excursion (TAPSE), and Systolic Pulmonary Artery Pressure (SPAP) were compared between the groups at 6 hrs, 24 hrs, and 7th day postoperatively. Results: All hemodynamic and echocardiographic parameters of RV function like RV size, IVC diameter, RVFAC, TAPSE, and SPAP improved from baseline to 24 hrs in both groups. Levosimendan caused a significant improvement in RV function compared to the P group at 24 hrs and 7th day postoperatively. Conclusions: The present study concludes that levosimendan is a promising option in patients with RV dysfunction undergoing MV surgeries.

Concomitant repair of moderate or less tricuspid regurgitation during mitral valve surgery improves early and mid-term prognosis of tricuspid valve and right heart function / 中国胸心血管外科临床杂志

@#Objective    To investigate the effect of concomitant tricuspid valve repair during mitral valve surgery on the early and mid-term prognosis of the tricuspid valve and right heart function in the patients with moderate or less tricuspid regurgitation. Methods    A retrospective study of 461 patients with mitral valve disease requiring cardiac surgery combined with moderate or less tricuspid regurgitation in our hospital from 2011 to 2014 was done. They were 309 males and 152 females with a median age of 53.00 (44.00, 60.00) years. According to whether they received tricuspid valve repair (Kay’s annuloplasty, DeVega’s annuloplasty or annular ring implantation), the patients were divided into a mitral valve surgery only group (a nTAP group, n=289) and a concomitant tricuspid valve repair group (a TAP group, n=172). At the same time, 43 patients whose tricuspid valve annulus diameter was less than 40 mm in the TAP group were analyzed in subgroups. Results    The median follow-up duration was 3.00 years (range from 0.10 to 9.30 years). There was no perioperative death. Three months after surgery, the anteroposterior diameter of the right ventricle in the TAP group was significantly improved compared with that in the nTAP group [–1.00 (–3.00, 1.00) mm vs. 0.00 (–0.20, 2.00) mm, P=0.048]. Three years after surgery, the improvement of right ventricular anteroposterior diameter in the TAP group was still significant compared with the nTAP group [–1.00 (–2.75, 2.00) mm vs. 2.00 (–0.75, 4.00) mm, P=0.014], and the patients in the TAP group were less likely to develop moderate or more tricuspid regurgitation (3.64% vs. 35.64%, P<0.001). Annuloplasty ring implantation was more effective in preventing regurgitation progression (P=0.044). For patients with a tricuspid annulus diameter less than 40 mm, concomitant tricuspid valve repair was still effective in improving the anteroposterior diameter of the right ventricle in the early follow-up (P=0.036). Conclusion     Concomitant tricuspid valve repair for patients with moderate or less tricuspid regurgitation during mitral valve surgery can effectively improve the tricuspid valve and right heart function in the early and mid-term after surgery. Annuloplasty ring implantation is more effective in preventing regurgitation progression. Patients whose tricuspid annulus diameter is less than 40 mm can also benefit from concomitant tricuspid repair.

Mitral Surgery for Severe Mitral Annular Calcification: Calcium Resection or Exclusion Procedure / 日本心臓血管外科学会雑誌

Background: Extensive calcification of the mitral annulus (MAC) represents a problem for mitral surgery due to a technical difficulty for implanting prosthetic valves, because the calcium does not allow placing direct sutures through the annulus and para-prosthetic leakage or cardiac rupture may result. We describe our experience with mitral valve surgery with or without decalcification of the annulus. Methods: Since 2005, we performed mitral valve operations in 1,327 patients and among them, severe mitral annular calcification was present in 25 (1.9%). Results: The mean age was 75±9 years and there were 6 men and 19 women, with hemodialysis in 4. Mitral valve replacement (MVR) was performed in all patients. A concomitant operation was aortic valve replacement in 19 and coronary artery bypass grafting in 4 patients. The MAC was resected in 14 (Group-R) and was excluded in 11 (Group-E). In-hospital mortality was four patients in Group-R. The cause of death was congestive heart failure in two, cerebellar infarction in one, and respiratory failure in one. Postoperative morbidity included one patient with reexploration and one with prolonged respiratory failure The aortic cross clamp time was a mean of 180±44 min (range 108∼266 min) in Group-R and 139±32 min (range 61∼186 min) in Group-E (p=0.009). The size of the prosthetic mitral valve was 24.3±1.0 mm in Group-R and 24.6±0.8 mm in Group-E (p=0.618). The postoperative echocardiography showed no abnormal mean pressure gradient of mitral valve prosthesis nor para-valvular leak in any patients in either group. Conclusions: The mitral valve replacement without annular decalcification in a severely calcified mitral annulus is a safe and an effective approach in an elderly patient.

Early clinical results of totally thoracoscopic repeat mitral valve surgery under hypothermic ventricular fibrillation / 中华胸心血管外科杂志

Objective:The aim of this study was to compare the perioperative outcomes of a totally thoracoscopic repeat mitral valve surgery under hypothermic ventricular fibrillation with those of a conventional median sternotomy approach for repeat mitral valve surgery and to explore the safety of the totally thoracoscopic repeat mitral valve surgery under hypothermic ventricular fibrillation.Methods:Patients requiring repeat mitral valve surgery admitted by the same surgeon at Cardiovascular Surgery, First Medical Center, Chinese PLA General Hospital from January 2018 to January 2022 were retrospectively enrolled. The patients were divided into the totally thoracoscopic group under hypothermic ventricular fibrillation and the conventional median sternotomy group according to the procedure, and the preoperative baseline data and perioperative outcomes were collected and statistically analyzed using SPSS 22.0.Results:A total of 91 patients matched the criteria for study enrollment, 25 in the totally thoracoscopic group and 66 in the median sternotomy group. There was no statistical difference in the preoperative baseline data between the two groups. The totally thoracoscopic group has advantages in mitral valvuloplasty rate(32.0% vs. 7.6%, P=0.008), transfusion rate(72.0% vs. 98.5%, P<0.001), mechanical ventilation time [(19.0±27.8)h vs.(43.3±58.3)h, P=0.009], chest drainage tube time [(2.2±1.9)days vs.(3.7±2.4)days, P=0.004], postoperative chest drainage volume [(489.6±319.1)ml vs.(913.6±568.4)ml, P=0.001], postoperative discharge time[(8.0±2.7)days vs.(13.9±12.8)days, P=0.026]. The totally thoracoscopic group had a longer cardiopulmonary bypass time [(180.8±41.7)min vs.(143.2±39.7)min, P<0.001], and it had an intraoperative ventricular fibrillation time of(100.2±42.5)min. There were no statistically significant differences in the postoperative complication rate(12.0% vs. 21.2%, P=0.481) and mortality(4.0% vs. 4.5%, P=1.000) between the two groups. Conclusion:The totally thoracoscopic approach has the characteristics of less invasion and faster recovery compared with the median sternotomy approach. Hypothermic ventricular fibrillation simplifies the procedure at the ascending aorta while reducing myocardial injury than conventional occlusion of the ascending aorta. Totally thoracoscopic mitral valve surgery under hypothermic ventricular fibrillation is a safe minimally invasive technique.

Two Cases of Minimally Invasive Right Thoracotomy Approach and Microscope-Assisted Surgery for Mitral Re-Operation; Mechanical Valve Dysfunction in the Late Operative Period / 日本心臓血管外科学会雑誌

Case 1 of stuck valve was an 84 year old man, 25 years after mitral valve replacement (MVR) using a mechanical valve. Case 2 was a 67 year old woman, 18 years after the previous operation. These patients underwent re-do replacement of the prosthesis with a minimally invasive right thoracotomy approach using a microscope. Re-do cardiac surgery is commonly regarded high risk on account of difficulty in peeling the adhension, risk of injury to the heart, lung or large vessels, longer operation time, greater amount of transfusion, higher invasion and longer admission. In both cases however, because of microscope-assist and right thoracotomy MICS technique, we safely and successfully completed the operation without any unplanned troubles. We finally had a good course with a short admission, no perioperative transfusion or no perioperative complication.

Durabilidad a largo plazo de la cirugía reparadora de la válvula mitral con insuficiencia de tipo degenerativo / Long-term Durability of Mitral Valve Repair Surgery for Degenerative Regurgitation

RESUMEN Introducción: El objetivo del estudio es evaluar los resultados alejados de la reparación de la válvula mitral (VM) con insuficiencia de tipo degenerativo. Material y Métodos: Entre enero 2008 y diciembre 2019 se efectuó cirugía reparadora de la VM en 457 pacientes con insuficiencia mitral grave (IM). La edad promedio fue 64,9 ± 12,2 años, y 61,1% eran de sexo masculino. El seguimiento clínico mediana 3,0 (RIC 4,1 años) se completó en el 98,7% de los pacientes. Se efectuaron estudios ecocardiográficos de seguimiento en forma periódica, se analizó la sobrevida, la recurrencia de IM moderada-grave en forma global y según el tipo de valva afectada, y la necesidad de re intervención en el seguimiento alejado. Resultados: A 10 años de seguimiento la sobrevida alejada fue elevada sin diferencias significativas según la valva afectada: valva posterior 95 ± 2,1%, y valva anterior 94 ± 2,2% (p=0,54). El grupo de pacientes con clase funcional preoperatoria III/IV (n = 142) presentó mayor mortalidad al seguimiento: 13,9 ± 4,1% vs. 2,7% ± 1,2% (p = 0,001). El porcentaje de recurrencia de IM moderada-grave al finalizar el seguimiento para el grupo total de pacientes fue del 14,6 ± 4,3% y el periodo de libertad de recurrencia según valva afectada fue elevado sin diferencia significativas: valva posterior 90 ± 3,4% y valva anterior 80 ± 8,5 (p = 0,97). Por último, la necesidad de reintervención en el seguimiento post reparación fue del 4,7 ± 3,3 % Conclusiones: la sobrevida alejada post reparación de IM es elevada y la necesidad de reintervención poco frecuente. Existe un aumento progresivo en la recurrencia de IM en el seguimiento alejado.

ABSTRACT Objective: The aim of this study was to evaluate long-term results of degenerative mitral valve regurgitation (MR) repair. Methods: Between January 2008 and December 2019, 457 patients (mean age 64.9±12.2 years; 61.1% men) with severe MR underwent MV repair surgery. Median follow-up was 3.0 years (IQR 4.1 years) and was completed in 98.7% of patients. Periodic echocardiographic studies were performed, and long-term survival, the recurrence rate of moderate-severe MR and the need for reintervention were analyzed. Results: At 10-year follow-up, long-term survival was high without significant differences according to the affected leaflet: between posterior leaflet 95±2.1%, and anterior leaflet 94±2.2% (p=0.54). Patients with preoperative functional class III/IV (n=142) presented higher mortality at follow-up: 13.9±4.1% vs. 2.7%±1.2% (p=0.001). The risk of recurrence for moderatesevere MR at the end of follow-up for the total group of patients was 14.6±4.3% and freedom from recurrence according to the affected leaflet was high without significant difference: posterior leaflet 90±3.4% and anterior leaflet 80 ± 8.5 (p=0.97). Finally, the need for reoperation in post-repair follow-up was 4.7±3.3% Conclusions: Long-term survival after MV repair is high and the need for reoperation is infrequent. There is a progressive increase in MR recurrence at the long-term follow-up.

Valvuloplasty Without Prosthetic Ring or Band in Patients with Degenerative Mitral Regurgitation: Long-Term Results and Predictive Factors for Outcomes

Abstract Introduction: Mitral valvuloplasty including ring/band support is widely performed despite potential drawbacks of rings. Unsupported valvuloplasty is performed in only a few centers. This study aimed to report long-term outcomes of patients undergoing unsupported valvuloplasty for degenerative mitral regurgitation (MR) and to identify predictive factors for outcomes. Methods: This is a retrospective cohort including patients undergoing mitral valve repair for degenerative MR from 2000 to 2018. The main techniques were Wooler annuloplasty and quadrangular resection. Kaplan-Meier curves and Cox regression models were used for statistical analysis. Results: One hundred fifty-eight patients were included (median age: 64.0 years). In-hospital mortality was 2.5%. Maximum follow-up was 19.6 years, with a median of 4.7 years (992 patient-years). Overall survival at 5, 10, and 15 years was 91.0% (95% confidence interval [CI]: 85.7-96.3), 87.6% (95% CI: 80.7-94.5), and 78.1% (95% CI: 65.9-90.3), respectively. The European System for Cardiac Operative Risk Evaluation (EuroSCORE) II was an independent predictor of late death (hazard ratio [HR] 1.42; P=0.016). Freedom from mitral reoperation at 5, 10, and 15 years was 88.1% (95% CI: 82.0-94.2), 82.4% (95% CI: 74.6-90.2), and 75.7% (95% CI: 64.1-87.3), respectively. Left atrial diameter > 56 mm was associated with late reintervention in univariate analysis (HR 1.06; P=0.049). Conclusion: Degenerative MR can be successfully treated with repair techniques without annular support, thus avoiding the technical and logistical drawbacks of ring/band implantation while maintaining good long-term results. EuroSCORE II was a risk factor for late death, and larger left atrium was associated with late reoperation.

Early and mid-term outcomes of concomitant cryosurgical Cox-Maze Ⅳ procedure in minimally invasive mitral valve surgery / 中国胸心血管外科临床杂志

@#Objective    To analyze the early and mid-term safety and effectiveness of concomitant cryosurgical Cox-Maze Ⅳ procedure in minimally invasive mitral valve surgery. Methods    We retrospectively reviewed the clinical data of 68 patients (28 males and 40 females with a mean age of 38.7±9.3 years) who underwent concomitant cryosurgical Cox-Maze Ⅳ procedure in minimally invasive mitral valve and tricuspid surgery in the Department of Cardiovascular Surgery of the Second Xiangya Hospital from August 2013 to October 2017. The heart rhythm of the patients after surgery was supervised by 24 hour holter monitoring eletrocardiogram. Results    No death occurred during operation and follow-up. One patient underwent reexploration for bleeding. The rate of sinus rhythm restored at the time of discharge was 95.8%. The rate of sinus rhythm restored at 6 months, 12 months, 24 months, 36 months after surgery was 93.5%, 91.6%, 90.3% and 89.5% respectively. Conclusion    Concomitant cryosurgical Cox-Maze Ⅳ procedure in minimally invasive mitral valve surgery is quite safe and effective in treatment of rheumatic mitral valve disease and atrial fibrillation in the early and mid-term follow-up.

Massa Valvar Mitral em Paciente com Suspeita de Lúpus Sistêmico: Tumor, Endocardite ou Ambos? / Mitral Valve Mass in a Patient Suspected of Systemic Lupus: Tumor, Endocarditis or Both?

Resumo Apresentamos o relato de caso de uma paciente com mixoma valvar mitral infectado e uma revisão da literatura sobre o assunto. Uma mulher de 33 anos apresentou histórico de febre e dispneia com evolução de alguns dias. Na hospitalização, ela apresentava uma síndrome semelhante ao lúpus, com hemoculturas positivas para Haemophilus spp . O ecocardiograma revelou uma massa gigante envolvendo ambos os folhetos mitrais associada à regurgitação grave, necessitando de troca valvar mitral biológica. A microscopia revelou mixoma infectado e a paciente recebeu alta assintomática após o término da antibioticoterapia. Ela apresentou bons resultados no seguimento. Este é o sexto caso de mixoma valvar mitral infectado relatado na literatura e o terceiro caso de mixoma cardíaco infectado pelo grupo HACEK. Devido à alta incidência de eventos embólicos, a antibioticoterapia precoce aliada à pronta intervenção cirúrgica são decisivos para a redução da morbimortalidade. O tempo para o diagnóstico foi muito mais breve do que o geralmente relatado em casos de endocardite por HACEK. A troca valvar foi a intervenção mais comum e todos os pacientes em relatos de caso anteriores apresentaram bons resultados no seguimento.

Abstract We present a case report of a patient with an infected mitral valve myxoma and a literature review on the subject. A 33-year-old female presented with a history of fever and dyspnea evolving over a few days. On admission, she had a lupus-like syndrome with positive blood cultures for Haemophilus species . Echocardiogram revealed a giant mass involving both mitral leaflets causing severe regurgitation, requiring biological mitral valve replacement. Microscopy showed an infected myxoma and the patient was discharged asymptomatic upon completion of antibiotics. She did well on follow-up. This is the sixth case of an infected mitral valve myxoma reported in the literature and the third case of a cardiac myxoma infected by the HACEK group. Exceedingly high incidence of embolic events makes prompt imaging, antibiotic therapy and surgery crucial for better outcomes. Time to diagnosis was much briefer than usually reported in other cases of HACEK endocarditis. Valve replacement was the most common surgical procedure and all patients from previous reports did well on follow-up.

Reparación de una disección de aurícula izquierda: presentación de un caso / Repair of left auricular dissection: case report

Resumen Introducción: La disección de la aurícula izquierda es una complicación infrecuente, pero potencialmente fatal de la cirugía cardíaca. Es frecuentemente asociada a cirugías de la válvula mitral, tanto su reparación el reemplazo, con una incidencia de 0,16%. Sin embargo, otros procedimientos como intervenciones percutáneas también presentan este riesgo. Objetivos: Presentar la resolución quirúrgica de un caso de disección de aurícula izquierda y aportar a la casuística nacional. Materiales y Método: Registro clínico, imagenológico y fotográfico del episodio clínico. Resultados: Una paciente que fue sometida a ablación por radiofrecuencia por vía retrógrada, y cursa durante el periodo postintervencional con insuficiencia cardíaca y su estudio identifica una disección auricular. Se realiza reparación del anillo mitral, plastía del aparato subvalvular y parche de pericardio, la paciente presenta evolución clínica y ecográfica favorable. Discusión: El tratamiento de esta entidad debe analizarse caso a caso, ya que la etiología relacionada a procedimientos percutáneos es diferente a la causada por cirugía valvular mitral. Conclusión: La reparación de una disección auricular con parche es una buena alternativa de tratamiento en estos casos.

Introduction: Left atrial dissection is an infrequent but potentially fatal complication of cardiac surgery. It is frequently associated with mitral valve surgery, both its repair and replacement, with an incidence of 0.16%. However, other procedures such as percutaneous interventions can also be predisposing factors. Objectives: To report the surgical resolution of a left atrial dissection case and contribute to the national casuistry. Materials and Method: Clinical, imaging and photographic record of the clinical episode. Results: A patient who underwent retrograde radiofrequency ablation during the post-interventional period with heart failure and whose study identifies an atrial dissection. Mitral ring repair, subvalvular apparatus repair and pericardial patch was performed, the patient evolves with favorable clinical and sonographic evolution. Discussion: The treatment of this entity should be analyzed case by case, the etiology related to percutaneous procedures is different to that caused by mitral valve surgery and this should be considered when choosing a therapeutic option. Conclusion: Repairing an atrial dissection with a patch is a good alternative in these cases.

Efficacy comparison between robot-assisted and conventional mitral valve surgery: A systematic review and meta-analysis / 中国胸心血管外科临床杂志

@#Objective    Through comparing the therapeutic efficacy of robot-assisted surgery (RS) and conventional surgery (CS) for mitral valve disease by meta-analysis to guide the choice of clinical operation. Methods    Databases including The Cochrane Library, PubMed, EMbase, China National Knowledge Infrastructure (CNKI), China Biology Medicine disc (CBMdisc) and Wanfang Database were searched by computer from inception to June 2020. The literature of efficacy comparison between RS and CS was collected. Two reviewers independently screened the literature according to inclusion and exclusion criteria, extracted the data, and evaluated the quality of the literature. Meta-analysis was performed using RevMan 5.4 software. Results    We identified 11 studies of RS versus CS with 4 330 patients. Among them, 2 212 patients underwent RS and 2 118 underwent CS. Meta-analysis demonstrated that compared with the CS, RS had longer cross-clamp time (MD=25.00, 95%CI 15.04 to 34.95, P<0.000 01), cardiopulmonary bypass time (MD=44.11, 95%CI 29.26 to 58.96, P<0.000 01) and operation time (MD=46.40, 95%CI 31.55 to 61.26, P<0.000 01). However, ICU stay (MD=–22.13, 95%CI –31.88 to –12.38, P<0.000 01) and hospital stay (MD=–1.81, 95%CI –2.69 to –0.92, P<0.000 01) were significantly shorter in the RS group; and the incidences of blood transfusion (OR=0.38, 95%CI 0.16 to 0.89, P=0.03) and complications (OR=0.73, 95%CI 0.57 to 0.94, P=0.01) were significantly lower in the RS group. Conclusion    Although RS has a longer operation time than CS, it has less damage, less bleeding, faster recovery and better curative efficacy.

Comparison of quality of life and long-term outcomes following mitral valve replacement through robotically assisted versus median sternotomy approach / 南方医科大学学报

OBJECTIVE@#To compare the mid- and long-term outcomes of patients receiving mitral valve replacement through robotically assisted and conventional median sternotomy approach.@*METHODS@#The data of 47 patients who underwent da Vinci robotic mitral valve replacement in our hospital between January, 2007 and December, 2015 were collected retrospectively (robotic group). From a total of 286 patients undergoing mitral valve replacement through the median thoracotomy approach between March, 2002 and June, 2014, 47 patients were selected as the median sternotomy group for matching with the robotic group at a 1:1 ratio. The perioperative data and follow-up data of the patients were collected, and the quality of life (QOL) of the patients at 30 days and 6 months was evaluated using the Quality of Life Short Form Survey (SF-12). The time of returning to work postoperatively and the patients' satisfaction with the surgical incision were compared between the two groups.@*RESULTS@#All the patients in both groups completed mitral valve replacement successfully, and no death occurred during the operation. In the robotic group, only one patient experienced postoperative complication (pleural effusion); in median sternotomy group, one patient received a secondary thoracotomy for management of bleeding resulting from excessive postoperative drainage, and one patient died of septic shock after the operation. The volume of postoperative drainage, postoperative monitoring time, ventilation time, and postoperative hospital stay were significantly smaller or shorter in the robotic group than in the thoracotomy group (@*CONCLUSIONS@#Robotically assisted mitral valve replacement is safe and reliable. Compared with the median sternotomy approach, the robotic approach is less invasive and promotes faster postoperative recovery of the patients, who have better satisfaction with the quality of life and wound recovery.

Minithoracotomy vs. conventional mitral valve surgery for rheumatic mitral valve stenosis: a single-center analysis of 128 patients

Abstract Objective: To compare the in-hospital outcomes of a right-sided anterolateral minithoracotomy with those of median sternotomy in patients who received a mitral valve replacement (MVR) because of rheumatic mitral valve stenosis (RMS). Methods: This is a retrospective analysis of 128 patients (34% male) with RMS between 2011 and 2015. The median age was 53 years (45; 56). The mean ejection fraction was 58.4±6.3%. All the subjects were divided into two groups - Group 1 contained 78 patients who underwent MVR via minithoracotomy (MT-MVR), while Group 2 contained 50 patients who underwent MVR via median sternotomy (S-MVR). Results: In the MT-MVR group, a mechanical prosthesis was implanted in 72% of cases, while it was implanted in 90% of cases in the S-MVR group (P=0.01). The duration of myocardial ischemia was similar (MT-MVR, 77±24 min; S-MVR, 70±18 min) (P=0.09). However, the cardiopulmonary bypass time was lower in the S-MVR group than in the MT-MVR group (99±24 min and 119±34 min, respectively) (P≤0.001). There was no difference in the duration of mechanical ventilation, intensive care unit stay, and hospitalization period. Postoperative blood loss was lower in the MT-MVR group (P≤0.001) than in the S-MVR group. There are no statistically significant differences in postoperative complications (superficial wound infection, stroke, delirium, pericardial tamponade, pleural puncture, acute kidney insufficiency, and implantation of pacemaker). The overall in-hospital mortality was 3.9% (P=0.6) Conclusion: The minimally invasive approach for RMS is feasible and has an excellent cosmetic effect without increasing the risk of surgical complications.

Catéter de Swan Ganz con marcapasos en la cirugía mini-invasiva mitral / Pacing Swan-Ganz Catheter in Minimally Invasive Mitral Valve Surgery

RESUMEN Introducción: La cirugía mediante mini-toracotomía lateral presenta ventajas comparativas sobre el acceso convencional como menor trauma quirúrgico, reducida morbimortalidad y un resultado estético superior, pero plantea dificultades en caso de necesitar estimulación eléctrica temporal. Objetivo: Valorar el empleo terapéutico del catéter de Swan-Ganz con marcapasos incorporado como solución a dicho problema y analizar sus complicaciones. Material y métodos: Se incluyeron pacientes programados para cirugía mini-invasiva mitral mediante mini-toracotomía lateral. Se definió empleo terapéutico del catéter al uso debido a bradiarritmias o trastornos de conducción o necesidad de incrementar la frecuencia cardíaca con fines hemodinámicos. Pacientes intervenidos de urgencia o emergencia, fueron excluidos del estudio. Resultados: Fueron incluidos 517 pacientes (289 de sexo masculino, con edad promedio de 68,3 ± 10,4 años); se efectuaron 115 (22,2%) reemplazos y 402 (77,7%) plásticas mitrales. Simultáneamente, se realizaron 294 (56,9%) procedimientos de Maze, 182 (35,2%) cierres de orejuela izquierda, 9 (1,7%) cierres de defectos septales y 14 (2,7%) plásticas tricuspídeas. Ciento sesenta y dos (313%) pacientes necesitaron ser marcapaseados; debido a bradiarritmias, 85 (52,47%) pacientes; por trastornos de conducción, 50 (30,86%) pacientes; mientras que otros 27 (16,66%) requirieron incrementar su frecuencia debido a bajo volumen minuto. La mortalidad resultó de 12 (2,32%) casos. Catorce (2,7%) pacientes presentaron pérdida de captura y se resolvieron con el reposicionamiento del catéter, mientras que 2 (0,6%) pacientes presentaron atrapamiento y requirieron reintervención. Conclusiones: Casi un tercio de los pacientes intervenidos mediante mini-toracotomía lateral requirieron del empleo terapéutico del catéter de Swan-Ganz con marcapasos. Dos pacientes presentaron atrapamiento y requirieron resolución quirúrgica.

ABSTRACT Background: The use of a lateral mini-thoracotomy presents several advantages over the standard access, such as less surgical trauma, reduced morbidity and mortality, shorter recovery time and better cosmetic results, but presents difficulties if temporary pacing is required. Objective: The aim of this study was to evaluate the therapeutic use of a Swan-Ganz catheter with pacing capabilities and analyze its complications. Methods: Patients undergoing scheduled minimally invasive mitral valve surgery through lateral mini-thoracotomy were included in the study. Therapeutic use of the pacing catheter was defined as the need for pacing due to bradyarrhythmias or conduction disorders or need of increasing heart rate in case of hemodynamic instability. Patients undergoing urgent or emergency surgery were excluded from the study. Results: A total of 517 patients were included in the study; mean age was 68.3 ± 10.4 years and 289 (55.9%) were men; 115 patients (22.2%) underwent mitral valve replacement and 402 (77.7%) mitral valve repair. The following concomitant procedures were carried out: 294 (56.9%) Maze procedures, 182 (35.2%) left atrial appendage closures, 9 (1.7%) atrial septal defect closures and 14 (2.7%) tricuspid valve repair surgeries. In the postoperative period 162 (31.3%) patients required pacing due to bradyarrhythmias in 85 cases (52.47%), conduction disorders in 50 (30.86%), and need to increase heart rate in 27 (16.66%) patients with low cardiac output syndrome. Postoperative mortality was 2.32% (n=12). Fourteen (2.7%) patients presented loss of capture that was resolved with catheter repositioning, while 2 (0.6%) patients presented catheter entrapment requiring reintervention. Conclusion: Almost one-third of the patients undergoing lateral mini-thoracotomy required therapeutic use of the pacing Swan-Ganz catheter. Two patients presented catheter entrapment and required surgical reintervention.

Experiencia inicial en un centro único del uso de neocuerdas preformadas en reparación mitral / Experience with Premeasured Chordal Loops for Mitral Valve Repair: A Uselful and Reproducible Technique?

RESUMEN Introducción: La reparación de la válvula mitral ha demostrado superioridad por sobre el reemplazo valvular en el tratamiento de la insuficiencia mitral degenerativa. Objetivo: El propósito de este trabajo es demostrar la utilización de neocuerdas de politetrafluoroetileno expandido preformadas para la realización de una plástica mitral exitosa. Material y métodos: Entre marzo y diciembre del 2018 se intervinieron 13 pacientes con insuficiencia mitral grave quirúrgica por enfermedad degenerativa con criterios quirúrgicos a los cuales se les implantó cuerdas nuevas preformadas para la reparación mitral en el Hospital Universitario Austral. Resultados: Se repararon en forma exitosa la insuficiencia mitral grave a los 13 pacientes colocando neocuerdas preformadas en la valva posterior en 6 pacientes; en la valva anterior, en 4 pacientes; y, en ambas valvas, en 3 pacientes. Conclusiones: Las neocuerdas de politetrafluoroetileno permitieron realizar la plástica reparadora de la insuficiencia mitral en forma satisfactoria, segura y reproducible para el prolapso de cualquier segmento valvular mitral.

ABSTRACT Background: Mitral valve repair has demonstrated better outcomes compared with valve replacement for the treatment of degenerative mitral regurgitation. Objective: The aim of this study is to show the experience with premeasured expanded polytetrafluoroethylene chordal loops for successful mitral valve repair. Methods: Between May and December 2018, 13 patients with severe mitral regurgitation caused by degenerative disease with indication for surgery underwent mitral valve repair at the Hospital Universitario Austral. Results: The procedure was successful in the 13 patients. Chordal loops were applied to the anterior leaflet in 4 patients, to the posterior leaflet in 6 patients and to both anterior and posterior leaflets in 3 patients.