Pectoral muscle mass is not a robust prognostic factor for survival after left ventricular assist device (LVAD) implantation.

BACKGROUND: Left ventricular assist devices (LVAD) are an established treatment for end-stage left ventricular heart failure. Parameters are needed to identify the most appropriate patients for LVADs. This study aimed to evaluate pectoral muscle mass and density as prognostic parameters. METHODS: This single-center study included all patients with LVAD implantation between January 2010 and October 2017 and a preoperative chest CT scan. Pectoral muscle mass was assessed using the Pectoralis Muscle Index (PMI, surface area indexed to height, cm2/m2) and pectoral muscle density by Hounsfield Units (HU). Overall mortality was analyzed with Kaplan-Meier survival analysis and 1-year and 3-year mortality with receiver operating characteristic (ROC) curves and Cox regression models. RESULTS: 57 patients (89.5% male, mean age 57.8 years) were included. 64.9% of patients had end-stage left ventricular failure due to ischemic heart disease and 35.1% due to dilated cardiomyopathy. 49.2% of patients had preoperative INTERMACS profile of 1 or 2 and 33.3% received mechanical circulatory support prior to LVAD implantation. Total mean PMI was 4.7 cm2/m2 (± 1.6), overall HU of the major pectoral muscle was 39.0 (± 14.9) and of the minor pectoral muscle 37.1 (± 16.6). Mean follow-up was 2.8 years (± 0.2). Mortality rates were 37.5% at 1 year and 48.0% at 3 years. Neither PMI nor HU were significantly associated with overall mortality at 1-year or 3-year. CONCLUSIONS: The results of our study do not confirm the association between higher pectoral muscle mass and better survival after LVAD implantation previously described in the literature.

Percutaneous Cannulation of Femoral Vessels in Minimally Invasive Cardiac Surgery.

OBJECTIVE: Despite the recent trend of access miniaturization in minimally invasive cardiac surgery (MICS) surgical "cut down (CD)" for femoral cannulation remains the standard at many centers. Percutaneous vascular closure (PVC) devices have recently been introduced for minimizing invasiveness during interventional diagnostic and therapy. This report summarizes the initial experience with this new approach in the setting of MICS, with a special focus on safety and advantages. METHODS: Percutaneous cannulation with a standard protocol including preoperative computer tomography imaging and intraoperative point-of-care ultrasound guidance was performed in 93 consecutive patients from September 2018 until February 2020, while conventional "CD" procedure performed in 218 patients in the previous period. We analyzed patients' characteristics and compared access site complications of PVC group versus conventional "CD" group. RESULTS: As far as operative/postoperative outcome, the duration of intensive care unit stay as well as hospital stay was statistically shorter in PVC compared with CD (CD vs. PVC: 2.74 ± 3.83 vs. 2.16 ± 2.01 days, p < 0.01, 16.7 ± 8.75 vs. 13.0 ± 4.96 days, p < 0.001, respectively). Further, we found no femoral infection or lymphocele in the PVC group, whereas 4 cases of wound complications were observed in the CD group. CONCLUSION: According to our results, percutaneous closure system for femoral vessels in MICS seems to be beneficial with the assist of preoperative computed tomography and intraoperative Doppler guidance.

Impact of psoas muscle evaluation on clinical outcomes in patients undergoing left ventricular assist device implantation.

AIMS: The measurement of muscle mass reflects the physical components of frailty, which might affect postoperative outcomes in patients undergoing left ventricular assist device (LVAD) implantation. The aim of this study was to investigate the relationship between preoperative skeletal muscle evaluation and clinical outcomes in patients undergoing LVAD implantation. METHODS: From January 2010 to December 2017, a total of 63 patients were enrolled in this single-centre study. A retrospective analysis of preoperative abdominal computed tomography (CT) for psoas muscle index (PSMI) and Hounsfield-Units of the Psoas Muscle (PSHU) at the level of the mid-L4 vertebra was performed. RESULTS: Sixty-three patients (male; n = 49, 78%), with a mean age of 58.0 ±â€Š11.8 years, were treated with LVAD due to dilated (32%) or ischemic cardiomyopathy (68%). Among them, 43 patients (68.3%) were categorized in the Interagency Registry for Mechanically Assisted Circulatory Support profile I. The survival rate was 73.0% at 30 days and 44.4% at 1 year. Receiver-operating characteristic (ROC) curve analyses revealed that PSMI was a significant numeric predictor of 1-year mortality (P = 0.04). In contrast, PSHU displayed a significant predictive potential for pericardial effusion (P = 0.03) and respiratory insufficiency (P = 0.01). In addition, comparative ROC curve analysis revealed no significant difference in the predictive potential of PSMI and PSHU. CONCLUSION: Preoperative PSMI might be a predictor of 1-year mortality in patients undergoing LVAD implantation. In contrast, the PSHU seemed to potentially assume postoperative adverse events in this study. Thus, the evaluation of the preoperative psoas muscle using CT appears to be promising.

Predictive Value of Body Mass Index in Minimally Invasive Mitral Valve Surgery.

BACKGROUND: With this study we aimed to analyze if the separate consideration of body mass index (BMI) could provide any superior predictive values compared with the established risk scores in isolated minimally invasive mitral valve surgery (MIMVS). This might facilitate future therapeutic decision-making, e.g., regarding the question surgery versus transcatheter mitral valve repair (TMVr). METHODS: We assessed the relevance of BMI in non-underweight patients who underwent isolated MIMVS. The risk predictive potential of BMI for mortality and several postoperative adverse events was assessed in 429 consecutive patients. This predictive potential was compared with that of European System for Cardiac Outcome Risk Evaluation II (EuroSCORE II) and the Society of Thoracic Surgeons score (STS score) using a comparative receiver operating characteristic curve analysis. RESULTS: BMI was a significant numeric predictor of wound healing disorders (p = 0.001) and proved to be significantly superior in case of this postoperative adverse event compared with the EuroSCORE II (p = 0.040) and STS score (p = 0.015). Except for this, the predictive potential of BMI was significantly inferior compared with that of the EuroSCORE II and STS score for several end points, including 30-day (p = 0.029 and p = 0.006) and 1-year (p = 0.012 and p = 0.001) mortality. CONCLUSION: Therefore, we suggest that, in the course of decision-making regarding the right treatment modality for non-underweight patients with isolated mitral valve regurgitation, the sole factor of BMI should not be given a predominant weight.

Impact of standardized computed tomographic angiography for minimally invasive mitral and tricuspid valve surgery.

BACKGROUND: Femoral cannulation for extracorporeal circulation (ECC) is a standard procedure for minimally invasive cardiac surgery (MICS) of the atrio-ventricular valves. Vascular pathologies may cause serious complications. Preoperative computed tomography-angiography (CT-A) of the aorta, axillary and iliac arteries was implemented at our department. METHODS: Between July 2017 and December 2018 all MICS were retrospectively reviewed (n = 143), and divided into 3 groups. RESULTS: In patients without CT (n = 45, 31.5%) ECC was applied via femoral arteries (91.1% right, 8.9% left). Vascular related complications (dissection, stroke, coronary and visceral ischemia, related in-hospital death) occurred in 3 patients (6.7%). In patients with non-contrast CT (n = 35, 24.5%) only femoral cannulation was applied (94.3% right) with complications in 4 patients (11.4%). CT-angiography (n = 63, 44.1%) identified 12 patients (19.0%) with vulnerable plaques, 7 patients (11.1%) with kinking of iliac vessels, 41 patients (65.1%) with multiple calcified plaques and 5 patients (7.9%) with small femoral artery diameter (d ≤ 6 mm). In 7 patients (11.1%) pathologic findings led to alternative cannulation via right axillary artery, additional 4 patients (6.3%) were cannulated via left femoral artery. Only 2 patients (3.2%) suffered from complications. CONCLUSIONS: CT-A identifies vascular pathologies otherwise undetectable in routine preoperative preparation. A standardized imaging protocol may help to customize the operative strategy.

The analysis of left ventricular ejection fraction after minimally invasive surgery for primary mitral valve regurgitation.

BACKGROUND: Although minimally invasive mitral valve surgery (MIMVS) has become the first choice for primary mitral regurgitation (MR) in recent years, clinical evidence in this field is yet limited. The main focus of this study was the analysis of preoperative (Pre), postoperative (Post), and 1-year follow-up (Fu) data in our series of MIMVS to identify factors that have an impact on the left ventricular ejection fraction (LVEF) evolution after MIMVS. METHODS: We reviewed the perioperative and 1-year follow-up data from 436 patients with primary MR (338 isolated MIMVS und 98 MIMVS combined with tricuspid valve repair) to analyze patients' baseline characteristics, the change of LV size, the postoperative evolution of LVEF and its factors, and the clinical outcomes. RESULTS: The overall mean value of ejection fraction (EF) slightly decreased at 1-year follow-up (mean change of LVEF: -2.63 ± 9.00%). A significant correlation was observed for preoperative EF (PreEF) und EF evolution, the higher PreEF the more pronounced decreased EF evolution (in all 436 patients; r = -.54, p < .001, in isolated MIMVS; r = -.54, p < .001, in combined MIMVS; r = -.53, p < .001). Statistically significant differences for negative EF evolution were evident in patients with mild or greater tricuspid valve regurgitation (TR) (in all patients; p < .05, odds ratio [OR] = 1.64, in isolated MIMVS; p < .01, OR = 1.93, respectively). Overall clinical outcome in New York Heart Association classification at 1 year was remarkably improved. CONCLUSIONS: Our results suggest an excellent clinical outcome at 1 year, although mean LVEF slightly declined over time. TR could be a predictor of worsened follow-up LVEF in patients undergoing MIMVS.

Risk and Consequences of Postoperative Delirium in Cardiac Surgery.

BACKGROUND: Delirium is a common complication after cardiac surgery that leads to increased costs and worse outcomes. This retrospective study evaluated the potential risk factors and postoperative impact of delirium on cardiac surgery patients. METHODS: One thousand two hundred six patients who underwent open-heart surgery within a single year were included. Uni- and multivariate analyses of a variety of pre, intra-, and postoperative parameters were performed according to differences between the delirium (D) and nondelirium (ND) groups. RESULTS: The incidence of delirium was 11.6% (n = 140). The onset of delirium occurred at 3.35 ± 4.05 postoperative days with a duration of 5.97 ± 5.36 days. There were two important risk factors for postoperative delirium: higher age (D vs. ND, 73.1 ± 9.04 years vs. 69.0 ± 11.1 years, p < 0.001) and longer aortic cross-clamp time (D vs. ND, 69.8 ± 49.9 minutes vs. 61.6 ± 53.8 minutes, p < 0.05). We found that delirious patients developed significantly more frequent postoperative complications, such as myocardial infarction (MI) (D vs. ND, 1.43% [n = 3] vs. 0.28% [n = 2], p = 0.05), cerebrovascular accident (D vs. ND, 10.7% [n = 15] vs. 3.75% [n = 40], p < 0.001), respiratory complications (D vs. ND, 16.4% [n = 23] vs. 5.72% [n = 61], p < 0.001), and infections (D vs. ND, 36.4% [n = 51] vs. 16.0% [n = 170], p < 0.001). The hospital stay was longer in cases of postoperative delirium (D vs. ND, 23.2 ± 13.6 days vs. 17.4 ± 12.8 days, p < 0.001), and fewer patients were discharged home (D vs. ND, 56.0% [n = 65] vs. 66.8% [n = 571], p < 0.001). CONCLUSIONS: Because the propensity for delirium-related complications is high after cardiac surgery, a practical, preventative strategy should be developed for patients with perioperative risk factors, including higher age and a longer cross-clamp time.

The age-adjusted Charlson comorbidity index in minimally invasive mitral valve surgery.

OBJECTIVES: Mitral valve repair is the preferred method used to address mitral valve regurgitation, whereas transcatheter mitral valve repair is recommended for high-risk patients. We evaluated the risk-predictive value of the age-adjusted Charlson comorbidity index (aa-CCI) in the setting of minimally invasive mitral valve surgery. METHODS: The perioperative course and 1-year follow-up of 537 patients who underwent isolated or combined minimally invasive mitral valve surgery were evaluated for 1-year mortality as the primary end point and other adverse events. The predictive values of the EuroSCORE II and STS score were compared to that of the aa-CCI by a comparative analysis of receiver operating characteristic curves. Restricted cubic splines were applied to find optimal aa-CCI cut-off values for the increased likelihood of experiencing the predefined adverse end points. Consequently, the perioperative course and postoperative outcome of the aa-CCI ≥8 patients and the remainder of the sample were analysed. RESULTS: The predictive value of the aa-CCI does not significantly differ from those of the EuroSCORE II or STS score. Patients with an aa-CCI ≥8 were identified as a subgroup with a significant increase of mortality and other adverse events. CONCLUSIONS: The aa-CCI displays a suitable predictive ability for patients undergoing minimally invasive mitral valve surgery. In particular, multimorbid or frail patients may benefit from the extension of the objectively assessed parameters, in addition to the STS score or EuroSCORE II. Patients with an aa-CCI ≥8 have a very high surgical risk and should receive very careful attention.

Relevance of Leaflet Prolapse to the Indication Policy for Aortic Valve-Sparing Root Replacement.

BACKGROUND: In aortic root replacement, "preexisting" or "induced" aortic leaflet prolapse is related to advanced aortic root pathology and can indicate valve repair. Efforts should be made to perform root replacement before leaflet prolapse is in its maximum extent. MATERIALS AND METHODS: Thirty-nine patients with chronic aortic root dilatation and aortic valve regurgitation (AR) underwent a reimplantation procedure. Contrary to 32 of the 39 patients (group A), 7 of the 39 patients (group B) underwent cusp plication for prolapse. For both groups, data related to the diameter at the level of maximal tubular extension, sinotubular junction, sinus of Valsalva, aorto-ventricular junction (AVJ), and aortic annulus were obtained from preoperative computed tomography scans and analyzed comparatively. RESULTS: Group B showed a higher mean AR grade (P = .007), a higher mean diameter at the level of the aortic annulus (P = .038), AVJ (P = .037), and aortic sinus (P <.001) and a higher sinus dilatation index (existing-to-predicted diameter ratio) (P <.001) than group A. The sinus of Valsalva displayed the best predictive value regarding a plicature-indicating prolapse (P <.001; 95% confidence interval [CI]: 0.809-1.013). A diameter >40 mm was accompanied by an odds ratio (OR) of 24.6 (95% CI: 1.29-496.02). During the follow-up period of 29.0 ± 18.4 months (range: 6-62 months), 1 patient (group A) required reoperation 5 years postoperatively for progressive AR. CONCLUSION: The sinus of Valsalva diameter seems to have the greatest prognostic value for the development of prolapse. Our data suggest that root repair should be considered earlier in time before leaflet prolapse is complete, which most likely occurs when root dilatation becomes an aneurysm.

Transfer of a minimally invasive mitral valve repair program from a high-volume center to a very low volume center: how many cases are necessary to maintain acceptable results?

OBJECTIVE: To investigate whether minimally invasive mitral valve repair (MIMVR) can be transferred from a high-volume center into a very small volume center and to clarify how many cases are necessary for maintenance of this program, early outcomes of MIMVR in Asahikawa Medical University were compared with those results in patients operated by a single surgeon in Duesseldorf University Hospital. METHODS: Sixty-five patients who underwent MIMVR in Asahikawa Medical University (group A) between May 2014 and July 2018 and 134 patients who underwent MIMVR in Duesseldorf University Hospital (group D) between September 2009 and January 2014 by a surgeon who started MIMVS later in Asahikawa were retrospectively analyzed. RESULTS: In group D, there were more patients with ischemic mitral valve regurgitation and with annular calcification than in group A. Survival rate at 6 months and 1 year was 98.5% and 98.5% in group A and 92.9% and 91.3% in group D, respectively. EuroSCORE II was significantly higher in patients dead within 30 days and within the first year. CONCLUSIONS: The present study demonstrated that MIMVR programs can be transferred with acceptable early results into very low volume centers, if the team is developed by surgeons who are well trained and experienced in MIMVR. Moreover, the present study suggested that case number for maintenance of acceptable results may be obviously less than the previous recognition that this kind of specialized surgery could be maintained with at least 50 cases annually. However, meticulous preparations for surgery are essential for satisfactory surgical outcomes.

TAVI as Therapy of Choice for Aortic Valve Disease in Osteogenesis Imperfecta.

Osteogenesis imperfecta (OI) is a syndrome that is often associated with dysfunction of the aortic valve. Because of the resultant fragile vessels and impaired hemostasis, surgical therapy to treat OI is challenging. Previous reports have suggested that transcatheter aortic valve implantation (TAVI) might be a suitable treatment for this condition. To the best of the authors' knowledge, the present case is the first to describe a young patient who underwent successful TAVI to treat osteogenesis imperfecta. The proposal of transfemoral TAVI serving as first-line therapy for aortic valve stenosis in patients suffering from osteogenesis imperfect was confirmed.

Preconditioning by Levosimendan is Mediated by Activation of Mitochondrial Ca2+-Sensitive Potassium (mBKCa) Channels.

PURPOSE: Activation of mitochondrial large-conductance Ca2+-sensitive potassium (mBKCa)-channels is a crucial step for cardioprotection by preconditioning. Whether activation of these channels is involved in levosimendan-induced preconditioning is unknown. We investigated if cardioprotection by levosimendan requires activation of mBKCa-channels in the rat heart in vitro. METHODS: In a prospective blinded experimental laboratory investigation, hearts of male Wistar rats were randomized and placed on a Langendorff system, perfused with Krebs-Henseleit buffer at a constant pressure of 80 mmHg. All hearts were subjected to 33 min of global ischemia and 60 min of reperfusion. Before ischemia, hearts were perfused with different concentrations of levosimendan (0.03-1 µM) for determination of a dose-effect curve. In a second set of experiments, 0.3 µM levosimendan was administered in combination with the mBKCa-channel inhibitor paxilline (1 µM). Infarct size was determined by TTC staining. RESULTS: In control, animal's infarct size was 58 ± 7%. Levosimendan at a concentration of 0.3 µM reduced infarct size to 30 ± 7% (P < 0.05 vs. control). Higher concentrations with 1 µM levosimendan did not confer stronger protection. Paxilline completely blocked levosimendan-induced cardioprotection while paxilline alone had no effect on infarct size. CONCLUSIONS: This study shows that activation of mBKCa-channels plays a pivotal role in levosimendan-induced preconditioning.

Conversion of Atrial Fibrillation after Cardiosurgical Procedures by Vernakalant® as an Atrial Repolarization Delaying Agent (ARDA).

BACKGROUND: Postoperative, new-onset atrial fibrillation (POAF) is one of the most common complications after cardiosurgical procedures. Vernakalant has been reported to be effective in the conversion of POAF. The aim of this study was to evaluate the efficacy and safety of vernakalant for atrial fibrillation after cardiac operations, and to investigate predictors for the success of vernakalant treatment. Patients and Methods: Post-cardiac surgery patients with new-onset of atrial fibrillation (AF) were consecutively enrolled in this study. Demographic data as well as intraoperative and postoperative parameters were analyzed. Vernakalant administration was primarily started 5.5 hours after new-onset POAF: 3 mg/kg intravenously over 10 min, and in case of non-conversion, a second dose of 2 mg/kg intravenously over 10 min. Results: 129 consecutive patients (70.2 ± 9.1 years) were included: 61 patients with coronary artery bypass graft (CABG) surgery, 49 patients with isolated valve procedures, and 19 patients with combined procedures (CABG and valve). Conversion in sinus rhythm was achieved after the first vernakalant dose in 57 patients (44%), and after the second dose in 41 patients (32%). The mean time to conversion was 13.7 ± 14.1 min. The patients receiving valve procedures depicted a significantly lower conversion rate. The following variables lowered conversion rate: no preoperative beta blocker, postoperative troponin levels >500 ng/L, and systolic blood pressure >140 mmHg. At the first follow-up, 92% of the converted patients showed sinus rhythm, while 80% of the non-responders showed sinus rhythm (P < .01). Conclusions: The POAF was effectively converted by vernakalant. The conversion rate of POAF after valve surgery was lower when compared to isolated CABG.

Previous Sternotomy as a Risk Factor in Minimally Invasive Mitral Valve Surgery.

BACKGROUND: Cardiac redo surgery, especially after a full sternotomy, is considered a high-risk procedure. Minimally invasive mitral valve surgery (MIMVS) is a potential therapeutic approach. However, current developments in interventional cardiology necessitate additional discussion regarding the therapy of choice in high-risk patients. In this context, it is necessary to clarify the perioperative and postoperative risks induced by the factor previous sternotomy in the setting of MIMVS. Thus, we present a comparative study analyzing the outcome of MIMVS after previous sternotomy vs. primary operation. METHODS: We identified 19 patients who received isolated or combined mitral valve (MV) surgery via the MIMVS approach after previous full sternotomy (PS group) and compared the results to those of a group of 357 patients who received primary MIMVS (non-PS group). After a propensity score analysis, groups of n = 15 and n = 131, respectively, were subjected to a comparative evaluation. A 1-year follow-up analysis of functional cardiac parameters and clinical symptoms was performed, accompanied by a Kaplan-Meier analysis. RESULTS: Except for the rate of realized MV reconstructions (PS group: 53.8% vs. non-PS group: 85.5%; p = 0.011), no significant differences were to be noted within the intraoperative and early postoperative course. However, patients in the PS group experienced an increased intensive care unit stay length (PS group: 2 days, 95% CI, 1-8 vs. non-PS group: 1 day, 95% CI, 1-2; p = 0.072). The follow-up examinations revealed excellent functional and clinical outcomes for both groups. The Kaplan-Meier analysis displayed no significant difference regarding the postoperative mortality (p = 0.929) related to the patients at risk. CONCLUSION: A previous sternotomy remains a risk factor for MIMVS and demands special attention in the early postoperative period. Nevertheless, the early- and late-term results concerning the functional and clinical outcomes suggest that the MIMVS procedure is satisfactory, even after a full sternotomy.

Focal induction of ROS-release to trigger local vascular degeneration.

Reactive oxygen species (ROS) play an important role in the process of cardiovascular degeneration. We evaluated the potential of a controlled, local induction of ROS-release by application of rose bengal (RB) and photo energy to induce atherosclerosis-like focal vascular degeneration in vivo. After injection of RB, rats fed with a pro-degenerative diet underwent focal irradiation of the abdominal aorta by a green laser (ROS group), while the controls received irradiation without RB. Aortic tissue was analyzed by histology and immunohistochemistry at 0, 2, 4, 8, 28 and 56 days (n = 5). The intimal surface topography was analyzed by scanning electron microscopy. In the ROS group, an initial thrombus formation had disappeared by day 8. Similarly, ROS-derived products displayed the highest concentrations at day 0. Relative matrix metalloproteinase (MMP) activity achieved a maximum after 8 days (ROS group vs. CONTROL GROUP: 1.60 ± 0.11 vs. 0.98 ± 0.01; p < 0.001). After 28 days, no significant differences in any aspect were found between the ROS group and the controls. However, after 56 days, the aortic tissue of ROS animals exhibited relative media-pronounced thickening (ROS vs. CONTROL: 2.15 ± 0.19 vs. 0.87 ± 0.10; p < 0.001) with focal calcification and reduced expression of alpha smooth muscle actin (aSMA). The ROS-releasing application of RB and photo energy allowed for the induction of vascular degeneration in a rodent model. This protocol may be used for the focal induction of vascular disease without systemic side effects and can thereby elucidate the role of ROS in the multifactorial processes of vessel degeneration and atherogenesis.

Isolated Tricuspid Valve Surgery: A Single Institutional Experience with the Technique of Minimally Invasive Surgery via Right Minithoracotomy.

Background Minimally invasive cardiac surgery via right lateral minithoracotomy is a well-described approach. However, reports on isolated tricuspid valve surgery (TVS) in this technique are rare. Therefore, we like to give a contribution by reporting our experience. Methods We retrospectively reviewed 25 tricuspid valve operations via right lateral minithoracotomy with femoral cannulation between August 2009 and September 2013 (18 repairs, 7 replacements, and 72% repair rate). Three patients (12%) presented for a re-do operation, and nine patients (36%) suffered from active endocarditis at admission. All patients underwent TVS as single valve procedure. Ten patients received additional procedures such as removal of infected leads, resection of atrial tumors, or closure of atrial septal defects. An annuloplasty ring was inserted in 12 cases. We investigated the short-term morbidity and mortality with regard to the surgical procedure. Results Repair rate was 72%. Thirty-day and 1-year mortality were 4 and 20%, respectively. The only patient with early mortality received the surgical procedure on the tricuspid valve as fourth cardiac-related surgery and postoperative mortality was due to intracranial air embolism. Perioperative morbidity included reoperation for bleeding (8%) and stroke (4%). No disturbance of wound healing occurred. Durations of intensive care unit stay and hospital stay were 2.3 ± 2.4 and 17.4 ± 13.1 days, respectively. Endocarditis-caused surgery did not reveal any significant difference in the intra- or perioperative course compared with other indications. Conclusion Minimally invasive TVS via right lateral minithoracotomy is feasible with good results. Even in a cohort of patients suffering from elevated rate of active endocarditis, a high repair rate can be achieved.

Implantation of a SAPIEN 3 Valve in a Patient with Pure Aortic Regurgitation.

Transcatheter aortic valve implantation (TAVI) is an emerging treatment for high-risk patients with aortic stenosis. Aortic regurgitation is considered to be a relative contraindication for transcatheter procedures, as a non-calcified aortic annulus poses the risk of an insufficient anchoring of the transcatheter aortic valve prosthesis. Herein is described the case of a patient who suffered from recurrent aortic valve regurgitation after valve-sparing repair, and which was successfully treated by the transcatheter implantation of an Edwards SAPIEN 3™ prosthesis. This case report demonstrated the suitability of this prosthesis to treat pure aortic valve regurgitation, without excessive oversizing of the valve.

Comparison of Manual and Automated Preprocedural Segmentation Tools to Predict the Annulus Plane Angulation and C-Arm Positioning for Transcatheter Aortic Valve Replacement.

BACKGROUND: Preprocedural manual multi-slice-CT-segmentation tools (MSCT-ST) define the gold standard for planning transcatheter aortic valve replacement (TAVR). They are able to predict the perpendicular line of the aortic annulus (PPL) and to indicate the corresponding C-arm angulation (CAA). Fully automated planning-tools and their clinical relevance have not been systematically evaluated in a real world setting so far. METHODS AND RESULTS: The study population consists of an all-comers cohort of 160 consecutive TAVR patients with a drop out of 35 patients for technical and anatomical reasons. 125 TAVR patients underwent preprocedural analysis by manual (M-MSCT) and fully automated MSCT-ST (A-MSCT). Method-comparison was performed for 105 patients (Cohort A). In Cohort A, CAA was defined for each patient, and accordance within 10° between M-MSCT and A-MSCT was considered adequate for concept-proof (95% in LAO/RAO; 94% in CRAN/CAUD). Intraprocedural CAA was defined by repetitive angiograms without utilizing the preprocedural measurements. In Cohort B, intraprocedural CAA was established with the use of A-MSCT (20 patients). Using preprocedural A-MSCT to indicate the corresponding CAA, the levels of contrast medium (ml) and radiation exposure (cine runs) were reduced in Cohort B compared to Cohort A significantly (23.3±10.3 vs. 35.3 ±21.1 ml, p = 0.02; 1.6±0.7 vs. 2.4±1.4 cine runs; p = 0.02) and trends towards more safety in valve-positioning could be demonstrated. CONCLUSIONS: A-MSCT-analysis provides precise preprocedural information on CAA for optimal visualization of the aortic annulus compared to the M-MSCT gold standard. Intraprocedural application of this information during TAVR significantly reduces the levels of contrast and radiation exposure. TRIAL REGISTRATION: ClinicalTrials.gov NCT01805739.

Single-centre experience of mitral valve surgery via right lateral mini-thoracotomy in octogenarians.

OBJECTIVES: According to demographic changes in the industrialized world, the average age of patients referred to cardiac surgery is increasing. These patients typically display numerous comorbidities, associated with increased perioperative risk. Therefore, the indication for a catheter-based therapy is progressively extended, including interventions on the mitral valve (MV). In this context, we evaluated a contemporary series of octogenarians undergoing minimally invasive MV surgery at our institution using right lateral minithoracotomy to elucidate the preoperative risk profile and the postoperative course in this particular cohort. METHODS: Between October 2009 and October 2014, 34 patients aged 80 years and older (82.5 ± 2.0) undergoing minimally invasive MV surgery were identified with a subgroup of 15 patients (44.1%) receiving concomitant surgery on the tricuspid valve (TV). We analysed the preoperative profile, perioperative course and functional outcome. RESULTS: Preoperative comorbidities included insulin-dependent diabetes mellitus (17.6%), COPD (17.6%), active endocarditis (2.9%) and previous neurological events (2.9%). The mean left ventricular ejection fraction was 59.7 ± 6.9%. Mean European System for Cardiac Outcome Risk Evaluation II was 5.2 ± 5.3%. The repair rate of all treated MVs and TVs in isolated and combined procedures was 81.6% (73.5% for MV and 100.0% for TV surgery). Postoperatively, 4 patients (11.8%) required new-onset intermittent haemodialysis. Prolonged ventilation (>12 h) was necessary in 9 patients (26.5%). The 30-day mortality rate was 5.9%. CONCLUSIONS: Minimally invasive right lateral MV surgery in octogenarians results in favourable outcomes. Therefore, MV surgery represents a valid option in this cohort, providing established and durable concepts of valve reconstruction.