Minimally invasive mitral valve repair in Barlow's disease: early and long-term results.

OBJECTIVE: Barlow's disease remains a challenging surgical pathology in patients presenting with mitral regurgitation. We reviewed our early and long-term results for patients with Barlow's disease who underwent minimally invasive mitral valve surgery. METHODS: Between 1999 and 2010, 145 patients with Barlow's disease underwent minimally invasive mitral valve repair at Leipzig Heart Center. Preoperative echocardiography and intraoperative valve analysis confirmed annular dilatation, bileaflet prolapse, and excessive leaflet tissue in all cases. We retrospectively reviewed mitral valve repair techniques, early and late postoperative clinical outcomes, and follow-up echocardiographic data. RESULTS: Successful mitral valve repair was performed in 94.5% of patients (n=137), initial mitral valve replacement was performed in 2.8% of patients (n=4), and mitral valve replacement after unsuccessful mitral valve repair was performed in 2.8% of patients (n=4). Mean aortic crossclamp time was 99±33 minutes, cardiopulmonary bypass time was 153±47 minutes, and total duration of surgery was 200±44 minutes. Mitral valve repair techniques consisted of ring annuloplasty and a variety of other methods (not mutually exclusive): "loop" neochordae (72% of patients), posterior mitral leaflet resection (28%), Alfieri stitch (17%), commissural plication (9%), chordal transfer (9%), and anterior mitral leaflet resection (7%). Concomitant procedures consisted of cryoablation for atrial fibrillation (28%), tricuspid valve repair (6%), and closure of an atrial septal defect/patent foramen ovale (12%). Thirty-day mortality was 1.4% (n=2), rethoracotomy for bleeding was required in 4.1% of patients (n=6), and conversion to sternotomy was required in 1 patient (0.7%). Long-term clinical follow-up was obtained in 100% of patients, and long-term echocardiographic data were obtained in 93.3% of surviving patients. Long-term survival was 94.7%±2.2% at 5 years and 88.3%±4.9% at 10 years. Freedom from mitral valve reoperation was 96.8%±1.6% at 5 years and 93.8%±2.6% at 10 years. Freedom from greater than 2+ grade mitral regurgitation was 90.2%±3.4% at 5 years and 88.4%±3.9% at 10 years. CONCLUSIONS: A wide variety of repair techniques can be used to perform successful minimally invasive mitral valve repair in the majority of patients with Barlow's disease, with good early and long-term results.

New concepts for mitral valve imaging.

The high complexity of the mitral valve (MV) anatomy and function is not yet fully understood. Studying especially the dynamic movement and interaction of MV components to describe MV physiology during the cardiac cycle remains a challenge. Imaging is the key to assessing details of MV disease and to studying the lesion and dysfunction of MV according to Carpentier. With the advances of computational geometrical and biomechanical MV models, improved quantification and characterization of the MV has been realized. Geometrical models can be divided into rigid and dynamic models. Both models are based on reconstruction techniques of echocardiographic or computed tomographic data sets. They allow detailed analysis of MV morphology and dynamics throughout the cardiac cycle. Biomechanical models aim to simulate the biomechanics of MV to allow for examination and analysis of the MV structure with blood flow. Two categories of biomechanical MV models can be distinguished: structural models and fluid-structure interaction (FSI) models. The complex structure and dynamics of MV apparatus throughout the cardiac cycle can be analyzed with different types of computational models. These represent substantial progress in the diagnosis of structural heart disease since MV morphology and dynamics can be studied in unprecedented detail. It is conceivable that MV modeling will contribute significantly to the understanding of the MV.

Cooling after successful resuscitation in cardiac surgery patients.

BACKGROUND: Despite many years of intensive research sudden cardiac death is one of the most common causes of death all over the world. The European Resuscitation Council (ERC) recommends the use of moderate therapeutic hypothermia for 12-24 hours to improve neurological outcome. However, the beneficial effect of this therapy on outcomes for cardiac surgery patients with In- Hospital- Resuscitation (IHR) has not been well studied.The purpose of this single center analysis was to investigate our first experience in a non - selected IHR population, where hypothermia was induced independent from initial heart rhythm disturbance. METHOD: A total of 20 resuscitated patients who were treated in our institution between January 2010 and December 2011 formed the study cohort. RESULTS: In all patients post- resuscitation course was significantly prolonged with severe low cardiac output syndrome in six patients (30%). Overall four patients (20%) sustained septicemia with the need for high dose inotropic support. The 30 day mortality was 30% (six of twenty). However, stroke with severe neurological impairment appeared in only four patients (20%) after resuscitation with subsequent therapeutic hypothermia. CONCLUSION: With our observation study we could demonstrate the benefits for neurological outcome due to therapeutic hypothermia in cardiac surgery patients after successful resuscitation. However post- resuscitation treatment should focus on sufficient therapeutic strategies to avoid the distinctive short term morbidity and mortality.

Interdisciplinary team approach for complicated type B aortic dissection with concomitant hematothorax by endovascular stent grafting and left side mini thoracotomy: a case report.

Due to high mortality rates in surgical treatment, total endovascular stent grafting has become a promising therapeutic option in patients with acute aortic dissection type B. In our case, a 76- year- old patient with acute ruptured aortic dissection type B and hematothorax achieved concomitant total endovascular stent grafting and left side mini thoracotomy. With moderate neurologic impairment he was discharged from hospital after 20 days.This case shows that early mortality of live threatening acute aortic dissection type B with hemorrhagic pleural effusion may be reduced by total endovascular stent grafting and concomitant mini thoracotomy.

The influence of gender on mortality in patients after thoracic endovascular aortic repair.

OBJECTIVES: The aim of this study was to determine if gender affects mortality in patients after thoracic endovascular aortic repair (TEVAR). METHODS: We retrospectively analyzed 286 consecutive patients undergoing TEVAR at our institution during a 12-year period (female 29%, median age 69 years). Chronic health conditions, risk factors, as well as early and long-term outcome were assessed. Follow-up data were available in all patients. RESULTS: For female gender, 1-year survival and 5-year survival was 84% and 56% versus 83% and 60% for male gender. No significant gender influence was observed (odds ratio (OR) 0.96, 95% confidence interval (CI) 0.59-1.56). Furthermore, no significant gender influence could be observed according to the individual indication--atherosclerotic aneurysms (OR 0.78 95%CI 0.41-1.47), acute type B dissections (OR 0.78 95%CI 0.21-2.83), penetrating atherosclerotic ulcers/intramural hematoma (OR 1.48 95%CI 0.53-4.19), and traumatic aortic lesions (OR 1.48 95%CI 0.53-4.19). Age (OR 3.6 95%CI 1.24-10.45) and chronic obstructive pulmonary disease (COPD; OR 3.09 95%CI 0.98-9.73) were independent predictors of mortality in females. CONCLUSIONS: Gender does not affect mortality in patients after TEVAR irrespective of the underlying indication, atherosclerotic aneurysms, acute type B dissections, penetrating ulcers/intramural hematoma, and traumatic aortic lesions. Classical risk factors such as age and the presence of COPD at the time of TEVAR remain the most important risk factors in females.

Risk factors of mortality in different age groups after thoracic endovascular aortic repair.

BACKGROUND: The aim of this study was to determine risk factors for mortality in different age groups after thoracic endovascular aortic repair (TEVAR). METHODS: We retrospectively analyzed 226 consecutive patients undergoing TEVAR at our institution during a 12-year period (female 28%; median age 67 years). Fifty-six patients were more than 75 years of age at the time of TEVAR. Follow-up data were available in all patients. RESULTS: Patients more than 75 years old had a higher incidence of extracardiac arteriopathy (79% versus 58%; p = 0.006) and were more likely to be unsuitable for open surgery (84% versus 47%; p < 0.001). Multivariate logistic regression analysis revealed the combined endpoint of perioperative myocardial infarction and neurologic injury (p = 0.023, odds ratio 13.9, 95% confidence interval: 1.44 to 134.6) as well as persisting type I and III endovascular leaks (p = 0.042, odds ratio 2.81, 95% confidence interval: 1.04 to 7.58) as independent predictors of mortality in patients less than 75 years old. Emergency TEVAR was the only independent predictor of mortality among patients more than 75 years old (p = 0.041, odds ratio 3.65, 95% confidence interval: 1.06 to 12.64). CONCLUSIONS: Different age groups exhibit different risk factors after TEVAR. The prognosis for younger patients is substantially limited by perioperative myocardial infarction and neurologic injury as well as persisting endovascular leak formation, as these patients may be more likely to experience aortic-related complications. Emergency TEVAR-most often being associated with hemodynamic instability-is the limiting factor for elderly patients, reflecting their frail physiology. Adhering to strict indications and broad screening, thereby reducing the incidence of emergency procedures, will help to further improve outcome after TEVAR.

Translocation of the supra-aortic vessels and stent grafting of the aortic arch.

This is a report on the combined surgical and endovascular treatment of a very large aortic arch aneurysm. In the first step, total arch rerouting was performed with an inversed bifurcated Dacron prosthesis. Brachiocephalic trunk and left subclavian artery were inserted into the two branches of the prosthesis via an end-to-end anastomosis and left common carotid was reinserted into the branch to the left subclavian. In the second step, thoracic endovascular aortic repair was performed. By this combined concept a stable and durable result could be achieved.

Endovascular and conventional treatment of thoracic aortic aneurysms: a comparison of costs.

BACKGROUND: The purpose of this study is to compare costs of conventional surgical therapy with costs of endovascular stent-graft placement in patients with thoracic aortic aneurysms. METHODS: Fifteen patients undergoing either conventional surgical therapy or endovascular stent-graft placement of thoracic aortic aneurysms were analyzed. A catalog of costs was then created for both procedures and this catalog was applied individually to each patient. RESULTS: Total costs of the service provision of endovascular stent-graft placement including anesthesia were 38.220.98 euros considering 1.7 stent-grafts per patient and including 5900.00 euros (Euros) for days of care. In conventional surgical therapy, adding the costs of the service provision of left heart catheterization, conventional surgical therapy including anesthesia, as well as intraoperative echocardiography a sum of 19.534.12 euros was calculated. Days of care accounted for 31.230.00 euros and total costs of 50.764.12 euros were calculated. The difference between total costs of the two procedures was 12.543.14 euros. CONCLUSIONS: Costs of endovascular stent-graft placement in patients with thoracic aortic aneurysms compare favorably with conventional surgical therapy, revealing a cost benefit of 24.7%. Higher procedural costs are outweighed by a lower number of days of care. Nevertheless, aneurysm-related secondary endovascular or surgical procedures may balance the benefit of endovascular therapy. Which strategy to choose, conventional or endovascular, should remain to be based on age, comorbidity, and technical feasibility.