Outcome after mitral valve operations with depressed left ventricular function.

We retrospectively investigated 42 patients (27 men, 15 women; mean age, 67 years) with severe mitral valve incompetence and endstage cardiomyopathy (ejection fraction<30%) who were operated on between January 2002 and March 2009. Of these, 14 were in New York Heart Association class IV, and 27 were in class III. The etiology was ischemic in 18 patients and idiopathic dilated in 24. Mitral valve repair was performed in 25 patients, and 17 had mitral valve replacement. The mean logistic EuroSCORE was 33.41. The mean follow-up was 44.52 months. There were no perioperative deaths. Three patients died within 30 days postoperatively. Thirty-day mortality was lower than predicted by EuroSCORE (7.14% vs. 33.41%). The median functional class improved from 3 to 2 during follow-up. Ejection fraction improved from 24% to 42% at 6 weeks, then decreased to 33%. The midterm survival rate was 86%, and 81% after 1 and 2 years. Freedom from reoperation at 2 years was 85%; 6 patients needed reoperation for recurrent mitral regurgitation. Despite high operative risk, mitral valve surgery can be performed successfully with acceptably low mortality in patients with endstage cardiomyopathy. Patients experience substantial clinical improvement and a moderate recovery of left ventricular function.

Takotsubo cardiomyopathy with concurrent multivessel obstructive coronary artery disease: proposition for a new clinical entity and first case surgical experience.

We present a seldom seen case of Takotsubo cardiomyopathy (TCM) with concurrent obstructive coronary artery disease (OCAD) and its first case surgical experience. We propose that TCM and OCAD can coexist and that the presence of OCAD should not be an exclusion criterion for the diagnosis of TCM.

Restoration of the thoracic aorta in Type A dissection with hybrid prosthesis.

Following successful repair of Type A dissection, late morbidity and mortality depend on the progression of residual chronic Type B dissection. To avoid the development of late aneurysms of the descending thoracic aorta, a persistent aortic false lumen around the stent-graft can be prevented by remodeling the thoracic aorta. Ten consecutive patients (mean age: 56 years) with acute Type A dissection underwent a "frozen elephant trunk operation" with the E-vita hybrid prosthesis, under deep hypothermic circulatory arrest, between October 2009 and April 2010. The thoracic aorta was restored to its original size. Computed tomography was used to size the aortic diameter. All patients survived and were routinely discharged. Postoperative computed tomography showed no remaining false lumen and no distal organ ischemia in any patient. No new neurological complication was recorded. Two patients suffered postoperative pulmonary arterial embolism; one underwent embolectomy. Restoration of the thoracic aorta is a safe procedure to close the false lumen during the primary operation for acute Type A dissection. However, the diameter of the stent should reflect the overall aortic size, independent of the diameter of the true lumen.

Should intentional endovascular stent-graft coverage of the left subclavian artery be preceded by prophylactic revascularisation?

Thoracic endovascular aortic repair (TEVAR) has emerged as a promising therapeutic alternative to conventional open aortic replacement but it requires suitable proximal and distal landing zones for stent-graft anchoring. Many aortic pathologies affect in the immediate proximity of the left subclavian artery (LSA) limiting the proximal landing zone site without proximal vessel coverage. In patients in whom the distance between the LSA and aortic lesion is too short, extension of the landing zone can be obtained by covering the LSA's origin with the endovascular stent graft (ESG). This manoeuvre has the potential for immediate and delayed neurological and vascular symptoms. Some authors, therefore, propose prophylactic revascularisation of the LSA by transposition or bypass, while others suggest prophylactic revascularisation only under certain conditions, and still others see no requirement for prophylactic revascularisation in anticipation of LSA ostium coverage. In this review about LSA revascularisation in TEVAR patients with coverage of the LSA, we searched the electronic databases MEDLINE and EMBASE historically until the end date of May 2010 with the search terms left subclavian artery, covering, endovascular, revascularisation and thoracic aorta. We have gathered the most complete scientific evidence available used to support the various concepts to deal with this issue. After a review of the current available literature, 23 relevant articles were found, where we have identified and analysed three basic treatment concepts for LSA revascularisation in TEVAR patients (prophylactic, conditional prophylactic and no prophylactic LSA revascularisation). The available evidence supports prophylactic revascularisation of the LSA before ESG LSA coverage when preoperative imaging reveals abnormal supra-aortic vascular anatomy or pathology. We further conclude that elective patients undergoing planned coverage of the LSA during TEVAR should receive prophylactic LSA transposition or LSA-to-left-common-carotid-artery (LCCA) bypass surgery to prevent severe neurological complications, such as paraplegia or brain stem infarction.