Interventional versus Surgical Treatment of Degenerated Freestyle Prosthesis.

BACKGROUND: Bioprosthetic stentless aortic valves may degenerate over time and will require replacement. This study aimed to evaluate early- and mid-term outcomes after isolated surgical redo aortic valve replacement (redo-SAVR) and transcatheter valve-in-valve implantation (TAVI-VIV) for degenerated stentless Freestyle bioprostheses. METHODS: We reviewed records of 56 patients at a single center. Overall, 37 patients (66.1%) received TAVI-VIV and 19 (33.9%) received redo-SAVR. RESULTS: Thirty-day survival was similar in both groups (100%). One-year survival was comparable between groups (97.3% in TAVI-VIV and 100% in redo-SAVR, p = 1.0). The difference in mid-term survival after adjusting for age and EuroScore II was not significant (p = 0.41). The incidence of pacemaker implantation after TAVI-VIV was higher than after redo-SAVR (19.4% vs. 0%, p = 0.08). CONCLUSION: The 30-day and 1-year survival rates after both procedures were outstanding, irrespective of baseline characteristics. Isolated redo-SAVR should be favored in young patients, as the pacemaker implantation rate is lower. TAVI-VIV for degenerated Freestyle prosthesis can be a method of choice in elderly patients and those with high operative risk.

Transcatheter mitral valve implantation versus conventional redo surgery for degenerated mitral valve prostheses and rings in a multicenter registry.

OBJECTIVES: Degeneration of mitral prostheses/rings may be treated by redo surgery, and, recently, by transcatheter valve-in-valve/ring implantation. This multicenter registry presents results of transcatheter valve-in-valve and repeat surgery for prostheses/rings degeneration. METHODS: Data provided by 10 German heart centers underwent propensity score-matched retrospective analysis. The primary endpoint was 30-day/midterm mortality. Perioperative outcome was assessed according to the Mitral Valve Academic Research Consortium criteria. Further, the influence of moderate or greater tricuspid regurgitation (TR) on 30-day/midterm mortality was analyzed. RESULTS: Between 2014 and 2019, 273 patients (79 transcatheter mitral valve-in-valve [TM-ViV] and 194 redo mitral valve replacement [Re-MVR]) underwent repeat procedure for mitral prosthesis/ring degeneration. Propensity score matching distinguished 79 patient pairs. European System for Cardiac Operative Risk Evaluation (EuroSCORE) II-predicted risk was 15.7 ± 13.7% in the TM-ViV group and 15.0% ± 12.7% in the Re-MVR group (P = .5336). TM-ViV patients were older (74.73 vs 72.2 years; P = .0030) and had higher incidence of atrial fibrillation (54 vs 40 patients; P = .0233). Severe TR incidence was similar (17.95% in TM-ViV vs 14.10%; P = .1741). Sixty-eight TM-ViV patients previously underwent mitral valve replacement, whereas 41 Re-MVR patients underwent valve repair (P < .0001). Stenosis was the leading degeneration mechanism in 42 TM-ViV versus 22 Re-MVR patients (P < .0005). The 30-day/midterm mortality did not differ between groups. Moderate or greater TR was a predictor of total (odds ratio [OR], 4.36; P = .0011), 30-day (OR, 3.76; P = .0180), and midterm mortality (OR, 4.30; P = .0378), irrespective of group. CONCLUSIONS: In both groups, observed mortality was less than predicted. Redo surgery enabled treatment of concomitant conditions, such as atrial fibrillation or TR. TR was shown to be a predictor of total, 30-day, and midterm mortality in both groups.

Treatment of a massive pseudoaneurysm originating from the ascending aorta with an off-the-shelf stent graft.

A 73-year-old patient who underwent an emergency coronary bypass surgery in our institution and who required postoperative extracorporeal membrane oxygenation support in December 2019 presented in August 2020 with a rapidly growing subxiphoidal, pulsating swelling. A computed tomography scan revealed a massive mediastinal pseudoaneurysm originating from an 8-mm Dacron graft that was sutured to the ascending aorta during the index surgery for arterial extracorporeal membrane oxygenation cannulation. Due to the location and extent of the pseudoaneurysm, an open surgical revision was deemed high risk. Because no bypass conduit originated from the ascending aorta, we decided to occlude the entry of the pseudoaneurysm with a stent graft. Also, urgency did not allow for the manufacturing of a custom-made device, so an off-the-shelf stent graft had to be implanted. Currently, the only off-the-shelf thoracic stent graft with a length suitable for the ascending aorta (<7 cm) is the Medtronic Valiant Navion prosthesis, of which 2 prostheses (37 mm × 52 mm; covered seal) were successfully implanted to exclude the pseudoaneurysm. A follow-up computed tomography scan performed 4 months postoperatively showed no perfusion and regression of the pseudoaneurysm. With the growing number of reports describing stent graft placement in the ascending aorta, more off-the-shelf stent grafts suitable for the ascending aorta are desirable.

Management of a Residual VSD 60 Years after One of the First Operations Worldwide.

Background Although surgical closure of ventricular septal defect (VSD) is the gold standard treatment, patients are subjected to deterioration in the following decades. We will present here the first case in literature surviving 60 years after surgical VSD closure with a residual VSD and presenting again for surgery. Case Description A 68-year-old male patient who underwent surgical closure of a perimembranous VSD in Berlin in 1959. Postoperatively, a small residual VSD was noticed, which was well tolerated over six decades. He presented 60 years postoperatively with severe aortic regurgitation, tricuspid regurgitation, and moderate mitral regurgitation.

3-dimensional printing for the diagnosis of left ventricular outflow tract obstruction after mitral valve replacement.

The objective of this study was to evaluate the use of the generation of 3D models and 3D prints of complex cases for physicians at the example of an intricate left ventricular outflow tract obstruction (LVOTO). LVOTO is a known complication of mitral valve surgery. A 38-year-old female patient with increasing dyspnoea after mitral valve replacement was referred to our centre. Echocardiography showed a strut of the bioprosthetic heart valve protruding into the left ventricular outflow tract. However, the diagnosis of a LVOTO was difficult based on echocardiography alone. Therefore, we fabricated a physical model of the left ventricular outflow tract, the mitral valve, the aortic valve and the left ventricle. With this physical model in hand, we were able to visualize the LVOTO and to discuss potential therapeutic options. Moreover, we were able to plan the subsequent redo surgery in detail using the model. This case shows the benefit of 3D printing technologies for surgeons and patients, not only for analysis, but also during the decision-making and pre-operative planning process.

What Is the Best Method to Achieve Safe and Precise Stent-Graft Deployment in Patients Undergoing TEVAR?

Thoracic endovascular aortic repair (TEVAR) for aortic pathologies requires sufficient landing zone of ideally more than 25 mm for safe anchoring of the stent-graft and prevention of endoleaks. In the aortic arch and at the thoracoabdominal transition, landing zone length is usually limited by the offspring of the major aortic side-branches. Exact deployment of the stent-graft to effectively use the whole length of the landing zone and to prevent occlusion of one of the side-branches is key to successful TEVAR. There are numerous techniques described to lower blood pressure and to reduce or eliminate aortic impulse to facilitate exact deployment of stent-grafts including pharmacologic blood pressure lowering, adenosine-induced asystole, inflow occlusion, and rapid pacing. Aim of this review was to assess the current literature to identify which of the techniques is best suited to prevent displacement and allow for precise placement of the stent-graft and safe balloon-molding.

Patient-Specific Instrument with a Cutting Template for Mitral Valve Repair by Resection.

Mitral valve regurgitation is one of the most common heart valve diseases and mitral valve repair is the favored therapy, in which a part of the mitral valve is resected. To improve preoperative planning of this challenging surgery, patient-specific mitral valve replicas have been developed on which the repair can be simulated. However, there is no possibility yet to transfer the planning from the replica to the surgery of the patient. To solve this problem, we developed a patient-specific instrument with a cutting template, intraoperatively visualizing the part of the mitral valve to be resected as planned on the replica. To realize this instrument, the surgeon first simulates mitral valve repair by resection on a patient-specific mitral valve replica. This postoperative mitral valve replica is then digitalized and from it and a preoperative mitral valve model the instrument with cutting template is automatically designed and then 3D printed. An expert heart surgeon successfully tested the functional principle of the instrument on a pig mitral valve.

Virtual Reality Analysis of Three-Dimensional Echocardiographic and Cardiac Computed Tomographic Data Sets.

BACKGROUND: Three-dimensional echocardiographic (3DE) imaging and cardiac computed tomographic (CCT) imaging are important cardiac imaging tools. Despite the three-dimensional nature of these image acquisitions and reconstructions, they are visualized on two-dimensional monitors with shading and coloring to create the illusion of three dimensions. Virtual reality (VR) is a novel tool that allows true three-dimensional visualization and manipulation. The aims of this study were to test the feasibility of converting 3DE and CCT data into three-dimensional VR models, compare the variability of measurements performed in VR and conventional software, assess the diagnostic quality of VR models, and understand the value of VR over conventional viewing. METHODS: Custom software with clinically relevant postprocessing tools (interactively adjustable visualization parameters, multiplanar reconstructions, cropping planes, and nonplanar measurements) was developed to convert 3DE and CCT data into VR models. Anatomic measurements of 15 3DE and 15 CCT data sets of the mitral valve were compared using conventional software and in the VR environment. Additionally, the diagnostic quality of the VR models created from 3DE and CCT data sets was assessed. RESULTS: The 3DE and CCT data sets were successfully converted into VR models in <3 min. The measurement variabilities were reduced by 40% (20.1% vs 12.2%) for 3DE imaging and 34% (15.3% vs 10.1%) for CCT imaging by using VR. The mean time needed for measurements was reduced by 31% (from 61 to 42 sec) for 3DE imaging and 39% (from 37 to 23 sec) for CCT imaging. Most users reported facile manipulation of VR models, diagnostic quality visualization of the anatomy, and high confidence in the measurements. CONCLUSIONS: This study demonstrates the feasibility of converting 3DE and CCT data into diagnostic-quality VR models. Compared with conventional imaging, VR analysis is associated with faster navigation and accurate measurements with lower variability.

Valve-in-valve transcatheter aortic valve replacement in a young patient with a suspected COVID-19 infection: a surgical dilemma in the era of the COVID-19 pandemic.

We report on a case of a 57-year-old male patient, who underwent full root replacement in 2005 and now presented with high grade aortic insufficiency. On admission, the patient underwent a computed tomography scan which demonstrated interstitial infiltration in the left lung, highly suspicious for a COVID-19 infection that could not be confirmed by reverse transcription polymerase chain reaction (RT-PCR) testing. As there usually is a delay between infection and positive RT-PCR test results, the initial decision was to perform additional testing. However, the patient deteriorated quickly in spite of optimal medical therapy making urgent aortic valve replacement necessary. We decided to perform transcatheter aortic valve replacement to avoid cardiopulmonary bypass with shorter operative times, presumably shorter ventilation times and duration of intensive care unit stay, and thus a lesser risk for pulmonary complications.

The cardiotomy reservoir - a preliminary evaluation of a new cell source for cardiovascular tissue engineering.

OBJECTIVES: Cell sources for cardiovascular tissue engineering (TE) are scant. However, the need for an ideal TE cardiovascular implant persists. We investigated the cardiotomy reservoir (CR) as a potential cell source that is more accessible and less ethically problematic. METHODS: CR (n = 10) were removed from the bypass system after surgery. Isolation was performed using different isolation methods: blood samples were taken from the cardiopulmonary bypass and centrifuged at low density. The venous filter screen was cut out and placed into petri dishes for cultivation. The spongelike filter was removed, washed and treated in the same way as the blood samples. After cultivation, cell lines of fibroblasts (FB) and endothelial cells (EC) were obtained for analysis. The cells were seeded on polyurethane patches and analyzed via scanning electron microscopy (SEM), Life/Dead assay and immunohistochemistry. RESULTS: No correlation between age, time of surgery and quality of cells was observed. The successful extraction of FB and was proven by positive staining results for TE-7, CD31 and vWF. Cell morphology, cytoskeleton staining and quantification of proliferation using WST-1 assay resembled the cells of the control group in all ways. The topography of a confluent and vital cell layer after cell seeding was displayed by SEM analysis, Life/Dead Assay and immunohistochemistry. The establishment of an extracellular matrix (ECM) was proven by positive staining for collagen IV, laminin, fibronectin and elastin. CONCLUSIONS: Viable FB and EC cell lines were extracted from the CR after surgery. Easy access and high availability make this cell source destined for widespread application in cardiovascular tissue engineering.

First successful transcatheter double valve replacement from a transapical access and nine-month follow-up.

AIMS: While TAVI is the treatment of choice in patients with aortic stenosis considered inoperable or at high risk, interventional replacement of the mitral valve is still in the preclinical or early clinical phase. Our aim was to report on the first transcatheter double valve replacement into native valves from a transapical access. METHODS AND RESULTS: A 67-year-old, highly symptomatic female patient considered inoperable due to severe calcification of the mitral annulus and comorbidities was scheduled for transcatheter double valve replacement by the local Heart Team. Preoperative planning was carried out by multiplanar reconstruction from cardiac CT. Through a transapical access, the mitral valve was replaced first by an inverted 29 mm Edwards SAPIEN 3 prosthesis, then the aortic valve by a 23 mm SAPIEN 3, both during rapid pacing. Both prostheses revealed excellent function in angiography and echocardiography. The patient was extubated early after surgery and transferred to the normal ward the following day. After five months, she exhibited signs of cardiac failure again. Migration of the mitral prosthesis was detected, and the mitral valve was replaced surgically. CONCLUSIONS: Transcatheter double valve replacement can be performed through a transapical access. The key to success is thorough preoperative planning based on CT, not only for sizing, but also for estimating the anatomical relationship of the prostheses. However, late migration can be expected and may lead to LVOT obstruction.

The Use of Bilateral Internal Mammary Artery Grafting in Different Degrees of Obesity.

Background Obesity is a limiting factor for the use of bilateral internal mammary arteries (BIMAs). Therefore, we assessed the safety of their use in different degrees of obesity. Patients and Methods We studied two groups of patients with obesity using propensity matching. The first group received single internal mammary artery and saphenous vein grafts (SIMA group, 526 patients) and the second group received bilateral internal mammary arteries (BIMA group, 526 patients). Patients were classified further according to their body mass index (BMI) into overweight (BMI = 25-29.9 kg/m2), obese (BMI = 30-34.9 kg/m2), and severely obese (BMI ≥ 35 kg/m2). Results Preoperative data were similar regarding age (62.78 ± 9.96 vs. 62.98 ± 9.66 years; p = 0.734), female sex (17.5 vs. 18.6%; p = 0.631), diabetes mellitus (26.3 vs. 27.2%; p = 0.74), EuroSCORE (3.21 ± 2.23 vs. 3.18 ± 2.41; p = 0.968), and COPD (16 vs. 16%; p = 1). No significant differences were noticed between the two groups regarding the number of peripheral anastomoses (3.09 ± 0.84 vs. 3.12 ± 0.83; p = 0.633), myocardial infarction (1.7 vs. 1.7%; p = 1), reexploration (1.3 vs. 2.1%; p = 0.34), deep sternal wound infection (DSWI) (2.1 vs. 2.9%; p = 0.43), and 30-day mortality (0.8 vs. 1.1%; p = 0.53). Multivariate analysis identified BMI and intensive care unit stay as independent predictors for DSWI. However, postoperative blood loss (694.56 ± 631.84 vs. 811.67 ± 688.73 mL; p < 0.001) and the incidence of pneumothorax (1 vs. 2.7%; p = 0.037) were higher in BIMA group. Conclusion Patients with obesity can benefit from BIMA grafting. However, postoperative blood loss and the incidence of pneumothorax can be higher using this technique.

The Use of Bilateral Internal Mammary Arteries for Coronary Revascularization in Patients with COPD: Is It a Good Idea?

BACKGROUND: The use of bilateral internal mammary arteries (BIMA) is limited worldwide, especially in patients with chronic obstructive pulmonary disease (COPD). Thus, we assessed the safety of the use of BIMA in COPD patients. METHODS: From cohorts of 8846 patients operated on at our center for primary isolated multi-vessel coronary bypass operations between 2002 and 2012, we studied two propensity-matched groups of patients with COPD who received either single internal mammary artery and saphenous vein grafts (SIMA group: 137 patients) or exclusively BIMA (BIMA group: 137 patients). Preoperative data were similar regarding age (63.59 ± 10.62 versus 65.55 ± 9.61 years; P = .10), body mass index (BMI) (28.6 ± 4.71 versus 28.42 ± 3.86 kg/m2; P = .72), diabetes mellitus (32% versus 27%; P = .08), EuroSCORE (4.34 ± 2.23 versus 4.8 ± 2.52; P = .09) and ejection fraction (58.7 ± 13.08% versus 60.29 ± 14.13%; P = .32). RESULTS: No significant differences were noticed between the two groups regarding the number of peripheral anastomoses (3.07 ± 0.77 versus 3.06 ± 0.85; P = .90), total operation time (192.17 ± 43.06 versus 200.63 ± 39.24 min; P = .08), postoperative stroke (0.7% versus 0%; P = .29), myocardial infarction (2.92% versus 3.6%; P = .81), reintubation (2.9% versus 4.4%; P = .66), reexploration (0.7% versus 2.2%; P = .32), deep sternal wound infection (2.9% versus 3.6%; P = .81) and 30-day mortality (2.2% versus 2.9%; P = .77). However, postoperative blood loss (726.1 ± 468.35  versus 907 ± 890.58 mL; P = .03) was higher in the BIMA group. CONCLUSION: COPD patients can benefit from coronary artery revascularization with BIMA; however, postoperative blood loss can be higher using this technique.

Medtronic Freestyle aortic bioprosthesis: a potential option for haemodialysis patients†.

OBJECTIVES: End-stage renal disease patients on regular haemodialysis are at higher risk of calcification. Therefore, many surgeons have concerns regarding the implantation of bioprostheses in such patients. The haemodynamic advantages of stentless aortic bioprostheses support their use; however, these have not been studied yet in end-stage renal disease patients. We studied accordingly the early and mid-term outcomes of aortic valve replacement (AVR) using Medtronic Freestyle stentless aortic bioprostheses in this subset of patients in comparison with stented aortic bioprostheses. METHODS: We retrospectively studied two groups of consecutive patients on regular haemodialysis who required AVR between 2007 and 2013. Non-Freestyle (NFS) group received stented aortic bioprostheses (36 patients) and Freestyle (FS) group received Medtronic Freestyle aortic bioprostheses (48 patients). Follow-up ranged from 2 to 76 months with a mean follow-up of 36.3 ± 25 months. RESULTS: Patients in both groups showed similar demographic characters regarding age (76.4 ± 8.1 vs 74.9 ± 7.2 years; P = 0.35), male gender (58 vs 60%; P = 0.57) and diabetes mellitus (42 vs 48%; P = 0.57). Smaller aortic bioprostheses were implanted in the NFS (23.3 ± 1.2 vs 25.4 ± 2.1; P < 0.001) with consequently higher postoperative mean gradients (14.1 ± 4.1 vs 11.9 ± 5.3 mmHg; P = 0.004). No significant differences were noted regarding postoperative neurological disorder (8 vs 12%; P = 0.73), deep sternal wound infection (3 vs 4%; P = 0.68), re-exploration (8 vs 8%; P = 0.91) and in-hospital mortality (6 vs 4%; P = 0.92). Mid-term follow-up showed higher prosthetic valve calcification and/or sclerosis in NFS group (25 vs 6%; P = 0.015), whereas no significant differences were noticed between the two groups regarding stroke (0 vs 8%; P = 0.13), endocarditis (0 vs 4%; P = 0.50), 36- and 72-month survival (51 ± 2%, 14 ± 4% vs 55 ± 2%, 19 ± 3%, respectively; P = 0.45). CONCLUSIONS: Aortic bioprostheses are a good option for haemodialysis patients requiring AVR, offering acceptable mid-term survival. The Medtronic Freestyle aortic bioprostheses could allow the implantation of larger bioprostheses inferring consequently lower mean gradients, with a potentially higher resistance to calcification and sclerosis in haemodialysis patients.

Use of a plant-based polysaccharide hemostat for the treatment of sternal bleeding after median sternotomy.

BACKGROUND: In cardiac surgery profuse or persistent sternal bleeding after sternotomy is routinely controlled with bone wax. However, bone wax should be avoided, especially in high-risk patients for nonunion of the sternum and infections. Purpose of this study was to evaluate an alternative technique to control bleeding after medium sternotomy using a plant based absorbable polysaccharide hemostat. METHODS: A consecutive series of 38 patients requiring median sternotomy for coronary artery bypass surgery (21 OPCAB, 17 CABG) had sternal bleeding control with the polysaccharide hemostat, STARSIL® HEMOSTAT. This hemostat is a hydrophilic powder, which achieves hemostasis after topical application at the surgical wound site. Initially it dehydrates blood rapidly, thus accelerating aggregation of platelets and blood solids. Thereafter, it forms a gelled adhesive matrix, which serves as a mechanical barrier against further bleeding. The polysaccharide is completely resorbed within 48 to 72 hours. RESULTS: Satisfactory control of sternal bleeding was observed in 37 patients (97%). No product-related complications were observed or any other major adverse events in an observation period of 3 months. CONCLUSION: Polysaccharide hemostats appear to be safe and effective for bleeding control of the sternum.

Repair of left atrioventricular disruption after mitral valve replacement using extracorporeal life support system for effective ventricular unloading.

Atrioventricular (AV) disruption is a rare but fatal complication after prosthetic mitral valve replacement. Surgical management is controversial and ranges from epicardial tissue sealing to open repair using autologous or xenogenic patch techniques to autotransplantation of the heart. We report the successful repair of an AV disruption Type I using an extracorporeal life support (ECLS) system for effective ventricular unloading followed by epicardial patch closure. The surgical management of AV disruption benefits from the use of ECLS, as it allows effective decompression of the heart without requiring full heparinization.

Three-dimensional printing in cardiac surgery and interventional cardiology: a single-centre experience.

OBJECTIVES: In individual cases, routine preoperative imaging might not be sufficient for optimal planning of cardiovascular procedures. Three-dimensional printing (3D), a widely used technique to build life-like replicas of anatomical structures that has proven value in different medical disciplines, might overcome these shortcomings. However, data on 3D printing in cardiovascular medicine are limited to single reports. This stimulated us to present our single-centre experience with 3D printing models in cardiac surgery and interventional cardiology. METHODS: Between the years 2006 and 2013, we fabricated 3D printing models using preoperative computed tomography or magnetic resonance imaging data in paediatric and adult cardiac surgery, as well as interventional cardiology. We present the 8 most representative cases. RESULTS: The models were very helpful for perioperative planning and orientation, as well as simulation of procedures due to the exact and life-like illustration of the cardiovascular anatomy. CONCLUSIONS: The fabrication of 3D printing models is feasible for perioperative planning and simulation in a variety of complex cases in paediatric and adult cardiac surgery, as well as in interventional cardiology. Further studies including more patients and providing more data are expected to demonstrate that the use of 3D printing may decrease morbidity and mortality of complex, non-routine procedures in cardiovascular medicine.

Three-dimensional printing for perioperative planning of complex aortic arch surgery.

PURPOSE: In this study, we show the use of three-dimensional printing models for preoperative planning of surgery for patients with complex aortic arch anomalies. DESCRIPTION: A 70-year-old man with an extensively arteriosclerotic aneurysm reaching from the ascending aorta to the descending aorta was referred to our center for complete aortic arch replacement. We visualized and reconstructed computed tomography data of the patient and fabricated a flexible three-dimensional model of the aortic arch including the aneurysm. EVALUATION: This model was very helpful for the preoperative decision making and planning of the frozen elephant trunk procedure owing to the exact and lifelike illustration of the native aortic arch. CONCLUSIONS: Three-dimensional models are helpful in preoperative planning and postoperative evaluation of frozen elephant trunk procedures in patients with complex aortic anatomy.