Early- and Long-Term Outcomes of Mitral Valve Repair in a Low-Volume Centre in the Caribbean

Abstract Introduction: This study examines early- and long-term outcomes of mitral valve repairs in a low-volume cardiac surgery centre in the Caribbean. Methods: Ninety-six consecutive patients underwent mitral valve repair from April 2009 to December 2018. Patients were divided into two groups: functional mitral regurgitation requiring simple mitral annuloplasty (FMR, n=63) or structural degenerative mitral regurgitation requiring more complex repair (DMR, n=33). Data collected prospectively were retrospectively analysed from the unit-maintained cardiac surgery database. Results: Thirty-day mortality in the whole series was 2.1%, with 3% in the FMR group and 0% in the DMR group. Early post-operative echocardiography in the FMR group demonstrated 51 patients (83.6%) without mitral regurgitation, 8 patients (13.1%) with trivial to mild regurgitation, and 2 patients (3.3%) with moderate regurgitation. However, at a mean follow-up of 98.2±50.8, only 21 patients (42.8%) were in NYHA class I, with 7 (14.2%) in class II, 16 (32.6%) in class III, and 5 (10.2%) in class IV. There were 9 cardiac-related deaths at final follow-up, with freedom from re-operation and survival of 98% and 75.6%, respectively. In the DMR group, early post-operative echocardiography demonstrated 29 patients (87.9%) without mitral regurgitation, 3 patients (9.1%) with trivial regurgitation and 1 patient (3.0%) with mild regurgitation. At a mean follow-up of 114.1±25.4 months, there was a good functional post-operative status in this group with 93.3% in NYHA class I, and 6.7% in class II. No patient required reintervention, 96.3% of patients had mild or no mitral regurgitation and survival was 90.9%. Conclusion: Despite challenges of maintaining skills in a low-volume centre, mitral valve repair can be performed safely with good early- and long-term results.

Early- and Long-Term Outcomes of Mitral Valve Repair in a Low-Volume Centre in the Caribbean.

INTRODUCTION: This study examines early- and long-term outcomes of mitral valve repairs in a low-volume cardiac surgery centre in the Caribbean. METHODS: Ninety-six consecutive patients underwent mitral valve repair from April 2009 to December 2018. Patients were divided into two groups: functional mitral regurgitation requiring simple mitral annuloplasty (FMR, n=63) or structural degenerative mitral regurgitation requiring more complex repair (DMR, n=33). Data collected prospectively were retrospectively analysed from the unit-maintained cardiac surgery database. RESULTS: Thirty-day mortality in the whole series was 2.1%, with 3% in the FMR group and 0% in the DMR group. Early post-operative echocardiography in the FMR group demonstrated 51 patients (83.6%) without mitral regurgitation, 8 patients (13.1%) with trivial to mild regurgitation, and 2 patients (3.3%) with moderate regurgitation. However, at a mean follow-up of 98.2±50.8, only 21 patients (42.8%) were in NYHA class I, with 7 (14.2%) in class II, 16 (32.6%) in class III, and 5 (10.2%) in class IV. There were 9 cardiac-related deaths at final follow-up, with freedom from re-operation and survival of 98% and 75.6%, respectively. In the DMR group, early post-operative echocardiography demonstrated 29 patients (87.9%) without mitral regurgitation, 3 patients (9.1%) with trivial regurgitation and 1 patient (3.0%) with mild regurgitation. At a mean follow-up of 114.1±25.4 months, there was a good functional post-operative status in this group with 93.3% in NYHA class I, and 6.7% in class II. No patient required reintervention, 96.3% of patients had mild or no mitral regurgitation and survival was 90.9%. CONCLUSION: Despite challenges of maintaining skills in a low-volume centre, mitral valve repair can be performed safely with good early- and long-term results.

Rupture of sinus of Valsalva aneurysm: case report and review of contemporary literature.

Sinus of Valsalva aneurysm rupture is a rare condition with a great potential for morbidity and mortality if not promptly diagnosed and managed. We present an unusual non-infected sinus of Valsalva aneurysm rupture in a 47-year-old female. This case report, a likely presentation of a late congenital heart defect, highlights the need for a high index of suspicion in a patient with atypical history of congestive cardiac failure.

Developing a cardiac surgery unit in the Caribbean: A reflection.

BACKGROUND AND AIM: Access to specialized cardiac surgery is a problem in emerging countries. Here, we reflect on the approach we used to establish a cardiac surgery unit in Trinidad and Tobago. METHODS: The program started in 1993 with monthly visits by a team from Bristol Heart Institute. A group of local doctors, nurses, and perfusionists were identified for training, and a senior nurse moved to the island to start a teaching program. The visiting support was gradually reduced, and the local team gained independence in managing the service in 2006. RESULTS: The initial low volume surgery increased to around 380 cases a year with the implementation of comprehensive service in 2006. Most patients required coronary artery bypass graft (CABG). In-hospital mortality declined from 5% in the nascent years to below 2% thereafter. In the last 5 years (2015-2019), 1764 patients underwent surgery (mean age 59.6 ± 10.8 years, 66% male). The majority were East-Indian-Caribbean (79.1%) or Afro-Caribbean (16.7%), half had diabetes, and two-thirds hypertension (EuroScore II 1.8 ± 1.9). The majority (1363 patients) underwent CABG (99.5% off-pump; conversion to on-pump 1.5%). The mean number of grafts was 2.5 ± 0.7 with 98.5% and 23.1% receiving one and two or more arterial grafts, respectively. In-hospital mortality was 1.1%, re-exploration for bleeding 2%, stroke 0.1%, mediastinitis 0.2%. The length of the postoperative hospital stay was 5.8 ± 2 days. CONCLUSION: Frequent outside visits complemented by training in an overseas center, and transfer of knowledge proved to be an effective strategy to develop a cardiac surgery unit in an emerging country with results comparable to accepted international standards.

Adult cardiac surgery in Trinidad and Tobago during the COVID-19 pandemic: Lessons from a developing country.

BACKGROUND AND AIM: The coronavirus disease 2019 (COVID-19) pandemic has seen the cancellation of elective cardiac surgeries worldwide. Here we report the experience of a cardiac surgery unit in a developing country in response to the COVID-19 crisis. METHODS: From 6th April to 12th June 2020, 58 patients underwent urgent or emergency cardiac surgery. Data was reviewed from a prospectively entered unit-maintained cardiac surgery database. To ensure safe delivery of care to patients, a series of strict measures were implemented which included: a parallel healthcare system maintaining a COVID-19 cold site, social isolation of patients for one to 2 weeks before surgery, polymerase chain reaction testing for COVID-19, 72 hours before surgery, discrete staff assigned only to cardiac surgical cases socially isolated for 2 weeks as necessary. RESULTS: The mean age at surgery was 59.7 ± 11 years and 41 (70.7%) were male. Fifty-two patients were hypertensive (90%), and 32 were diabetic (55.2%). There were three emergency type A aortic dissections. Forty-seven patients underwent coronary artery bypass graft surgery with all but three performed off-pump. Fourteen cases required blood product transfusion. One patient had postoperative pneumonia associated with chronic obstructive pulmonary disease. The median length of stay was 5.7 ± 1.8 days. All patients were discharged home after rehabilitation. There were no cases of COVID-19 infection among healthcare workers during the study period. CONCLUSION: These strategies allowed us to maintain a service for urgent and emergency procedures and may prove useful for larger countries when there is decrease in COVID-19 cases and planning for the restart of elective cardiac surgery.

Transfusion related acute lung injury with massive pulmonary secretion during cardiac surgery. A case report.

A Indo-Caribbean patient undergoing cardiac surgery developed Transfusion Related Acute Lung Injury (TRALI) with massive endobronchial secretion of clear fluid mimicking severe pulmonary edema. Hypoxemia and lung stiffness were so severe that didn't allow closure of the sternum on completion of surgery. The patient was treated with invasive ventilation, high positive pressure and % FiO2 and aggressive endotracheal suction. After several hours, secretions reduced spontaneously and the patient made an uneventful recovery.

Double patch repair through a single ventriculotomy for ischemic ventricular septal defects.

We present a novel postinfarction ventricular septal defect repair, through a single ventriculotomy, using a biseptal double patch and gelatin-resorcinol-formaldehyde glue. This technique reduces the postoperative recurrence of ventricular septal defects by reducing the tension on the patch sutures and by preventing blood from infiltrating into the suture lines within the ventricular septal defect cavity.

Ventricular fibrillation in acute mitral valve insufficiency caused by chordae tendineae rupture: report of a surgically corrected case.

In this report, we present the case of a previously healthy 80-year-old woman who was referred to surgery after a cardiac arrest due to ventricular fibrillation successfully resuscitated; the following evaluation revealed acute mitral regurgitation due to chordae tendineae rupture. After mitral valve repair, a single-chamber cardioverter-defibrillator was implanted for secondary prevention of sudden cardiac death. After 16 months of follow-up, the patient is asymptomatic without any further episodes of ventricular arrhythmias reported, underlying the pivotal role of mitral valve repair in the prevention of potentially lethal ventricular arrhythmias.

Successful surgical treatment of a giant coronary aneurysm communicating with the right atrium.

Aneurysms of the coronary arteries are rare events. In most cases, such abnormalities are clinically silent and, when they cause symptoms, there are dyspnea and/or angina. Our report describes a case presenting with dyspnea; the admission electrocardiogram demonstrated largely spread ischemia in the lower-lateral leads and myocardial necrosis in the inferior wall. Selective coronary angiography disclosed severe three-vessel disease; aortic angiography revealed a large vascular neoformation, partly thrombosed, with multilobes and a wide communication with the ascending aorta; the oxygen run showed a slight, non-significant 'jump' at the level of the right atrium, confirming a possible left-to-right shunt. On open chest surgery, these alterations were confirmed. The principal aneurysm (6-7 cm) originating in right auricle gave rise to a localized pseudoaneurysm above the superior vena cava; the other three aneurysmal structures were situated along the course of the right coronary artery. After 2 years of clinical and echocardiographic control, the patient is symptom-free under conventional medical treatment.

Intracoronary infusion of levosimendan to treat postpericardiotomy heart failure.

Systemic hypotension limits the intravenous use of levosimendan, particularly in coronary disease. Published reports show that the intracoronary administration of levosimendan in animal models causes an increase of coronary blood flow without systemic hypotension. In this case report, the intracoronary administration of levosimendan bolus in a 74-year-old man with postpericardiotomy heart failure elicited beneficial cardiac effects, increasing both systolic and diastolic functions and blood flow in all of the grafts. No changes of heart rate and systemic arterial blood pressure were observed.

Overreduction of the posterior annulus in surgical treatment of degenerative mitral regurgitation.

BACKGROUND: The concept of overreduction of the posterior annulus was applied in surgical treatment of degenerative mitral valve disease. METHODS: From April 1993 to November 2004, 141 patients underwent overreduction of the posterior annulus of the mitral valve in mitral valve repair for degenerative disease. Mean scallop involvement per patient was 2.3 and increased to 3.0 in the last period. Correction of the prolapse of the posterior leaflet included resection with focal sliding (n = 100), or application of artificial chordae (n = 28), with (n = 11) or without (n = 17) plication of one or more scallops. The anterior leaflet prolapse was corrected with edge-to-edge technique (n = 20) or chordal replacement (n = 28). An overreducting ring, 40 (n = 81) or 50 (n = 60) mm long (autologous pericardium in 64 cases and Sovering Miniband [Sorin, Saluggia, Italy] in 77) was used in all the patients. RESULTS: Three patients died in the early period (2.1%) and 3 (2.1%) were reoperated on from 3 to 24 months due to endocarditis (2 cases) and failure of repair (1 case). Ten-year freedom from death any cause was 91.6%, from reoperation 96.4%, from death any cause and reoperation 87.7%, from death any cause, reoperation, and New York Heart Association class III-IV 79.8%. Sixty-four patients out of 68 who survived more than 2 years (94.1%) at a mean follow up of 4.2 +/- 2.5 years had no or 1+ residual mitral regurgitation. CONCLUSIONS: Although the complexity of mitral valve repair for degenerative disease increased, results of surgery remained stable. Apposition of a posterior overreductive ring was useful to cover any mistake performed during the correction.

Use of the inferior epigastric artery for CABG.

Presentation of the inferior epigastric artery as conduit for coronary artery bypass grafting (CABG): harvesting, use and results.

Single versus bilateral internal mammary artery for isolated first myocardial revascularization in multivessel disease: long-term clinical results in medically treated diabetic patients.

BACKGROUND: We evaluated our experience to investigate if the use of bilateral internal mammary artery (BIMA) grafting, with or without complementary saphenous vein grafts (SVG), increases the quality of the results of coronary bypass grafting in medically treated diabetic patients who undergo first myocardial revascularization, when compared with the use of a single left internal mammary artery (LIMA) and SVG. METHODS: From October 1991 to December 2001, 558 diabetic patients with multivessel coronary disease had first isolated myocardial revascularization using LIMA and SVG (group LIMA) in 217 cases and BIMA +/- SVG (group BIMA) in 341. Propensity score analysis identified 400 patients, 200 for each group, with similar preoperative characteristics. Thirty-day outcome and 8-year freedom from death from any cause, cardiac death, acute myocardial infarction (AMI), AMI in a grafted area, redo/percutaneous transluminal coronary angioplasty (PTCA), redo/PTCA in a grafted area, target cardiac events, and any event were evaluated. Follow-up ranged from 2.0 to 12.2 years (mean 6.0 +/- 2.0). RESULTS: There was no difference between groups except the cardiac deaths, which were significantly higher in the LIMA group (7 versus 0, p = 0.015). The BIMA group showed better 8-year freedom from death any cause (86.7 +/- 3.2 versus 79.5 +/- 4.1, p = 0.0274), cardiac death (96.3 +/- 1.4 versus 88.4 +/- 4.0, p = 0.0406), acute myocardial infarction (99.5 +/- 0.5 versus 92.0 +/- 3.9, p = 0.0092), and acute myocardial infarction in a grafted area (99.5 +/- 0.5 versus 93.4 +/- 3.7, p = 0.0204). Cox analysis confirmed that the use of LIMA and SVG was an independent predictor for lower freedom from death (hazard ratio [HR] = 1.8, p = 0.0310), cardiac death (HR = 1.9, p = 0.0426), AMI (HR = 9.7, p = 0.0033) and AMI in a grafted area (HR = 8.2, p = 0.0410). CONCLUSIONS: In diabetic patients with multivessel disease who undergo first myocardial revascularization, BIMA +/- SVG provides higher freedom from death, any cause, and cardiac-related death, if compared with LIMA + SVG. It plays a protective role in reducing the incidence of late AMI.

Bilateral internal thoracic artery grafting with and without cardiopulmonary bypass: six-year clinical outcome.

OBJECTIVES: We sought to evaluate whether early and late results in patients who underwent off-pump or on-pump myocardial revascularization with bilateral internal thoracic artery grafting were similar. METHODS: From November 1994 through December 2001, 1835 patients underwent isolated myocardial revascularization with bilateral internal thoracic artery grafting. By applying propensity score pairwise matching, 1194 patients were selected and operated on either off pump (n = 597) or on pump (n = 597). RESULTS: The overall 30-day mortality was 1.5% (1.2% in the off-pump group and 1.8% in the on-pump group, P = .342). There was no difference for all the other complications between the 2 groups. Mean follow-up was 5.2 +/- 1.8 years. Forty-two patients died over the follow-up period (22 in the off-pump group and 20 in the on-pump group), 15 of them of cardiac causes (7 in the off-pump group and 8 in the on-pump group). Six-year outcomes (freedom from death, cardiac death, acute myocardial infarction and reoperation in all or in the grafted area, target cardiac events, and any other event) were similar for both categories. After a mean of 30.7 +/- 20.1 months, 202 patients had a postoperative angiography showing similar results. CONCLUSIONS: Our results with extensive arterial revascularization clearly show that with the technical improvements achieved in the most recent years, off-pump operations can be performed safely with the same quality of late results as those obtained with on-pump operations.

Reoperative coronary artery bypass grafting: analysis of early and late outcomes.

BACKGROUND: The purpose of this study was to evaluate early and late results of reoperative coronary artery bypass grafting compared with those of first coronary artery bypass grafting. METHODS: From November 21, 1994, to December 31, 2001, 4,381 patients underwent isolated coronary revascularization: among these patients, 274 (6.3%) underwent a redo. Applying the propensity score, 239 redo patients (group R) were matched with 239 who underwent the first revascularization (group F). RESULTS: Early mortality was 2.1% (group F) and 4.2% (group R), not significantly different. Group R showed significantly higher creatine kinase myocardial band release, length of intensive care unit stay, and incidence of incomplete myocardial revascularization than group F. In group R, off-pump patients showed higher incidence of incomplete revascularization. Redo was a risk factor for abnormal (>19 IU/L) creatine kinase myocardial band release (odds ratio, 1.7; p = 0.0066) and incomplete myocardial revascularization (odds ratio, 2.4; p = 0.0060). Five-year clinical outcome was significantly worse in group R, except for freedom from redo or percutaneous transluminal coronary angioplasty. Redo was an independent variable for lower freedom from death of any cause, cardiac death, acute myocardial infarction, cardiac events, and any event. Patients with higher creatine kinase myocardial band release or incomplete myocardial revascularization showed lower freedom from cardiac-related events. Incidence of incomplete myocardial revascularization and creatine kinase myocardial band release were significantly higher in group R by both univariate and multivariate analysis. This could explain the worse late outcome of redo patients. CONCLUSIONS: Complete revascularization without damaging the heart, whichever technique is used, is the target of redo surgery, to achieve the same quality of results obtained in the first operation.

Late results of first myocardial revascularization in multiple vessel disease: single versus bilateral internal mammary artery with or without saphenous vein grafts.

OBJECTIVE(S): We evaluated our experience to investigate if the use of bilateral internal mammary artery (BIMA) grafting, with or without complementary saphenous vein grafts (SVGs), if compared to the use of single IMA and SVG(s), increases the quality of the results of coronary bypass grafting in patients younger than 75 years who undergo first myocardial revascularization. METHODS: From September 1986 to December 1999, 1602 patients younger than 75 years underwent first myocardial revascularization using left internal mammary (LIMA) to left anterior descending (LAD) and SVG(s) (n=576) or BIMA (one IMA on the LAD) with or without SVG(s) (n=1026). Propensity score analysis was used to select 1140 patients with the same preoperative and operative characteristics. Thirty day outcome was evaluated as well as 10-year freedom from death by any cause, cardiac death, acute myocardial infarction (AMI), AMI in a grafted area (GA), redo/PTCA, redo/PTCA in a GA, target cardiac events (death from cardiac cause, AMI in a GA, redo/PTCA in a GA), and any event. Follow-up ranged from 3.5 to 16.8 years (mean 7.3+/-4.8 years). RESULTS: Thirty day mortality was 2.8% in Group LIMA and 2.1% in Group BIMA, P n.s.; incidence of major complications was, respectively, 7.0 versus 5.4%, P n.s. Group BIMA showed better 10-year freedom from cardiac death (96.5+/-0.8 versus 91.3+/-1.4, P=0.0288), AMI (98.0+/-0.6 versus 94.3+/-1.2, P=0.0180), AMI in a GA (98.4+/-0.6 versus 94.7+/-1.1, P=0.0057) and target cardiac events (93.9+/-1.1 versus 86.3+/-1.8, P=0.0388). Cox analysis confirmed that LIMA+SV(s) was an independent risk factor from lower freedom from cardiac death, AMI, AMI in a GA and cardiac events. CONCLUSIONS: As freedom from cardiac events is a main target of any revascularization procedure, we think that, when a patient undergoes a first coronary surgery and is younger than 75 years, BIMA grafting should not be denied, especially if his life expectancy is higher than 10 years.

Partial clamping of the brachiocephalic trunk for total ascending aorta replacement without circulatory arrest: early and midterm results.

BACKGROUND: The aim of this study was to evaluate in elective patients the early and midterm results of partial clamping of the brachiocephalic trunk (BCT) for total ascending aorta replacement (TAAR) without circulatory arrest. Contraindications to the procedure were BCT/aortic arch calcifications and chronic aortic dissection. METHODS: The right radial artery was cannulated to monitor the systemic pressure after the BCT was partially clamped. A specially designed clamp was applied obliquely to occlude approximately 50% of the BCT and part of the aortic arch. The distal tip of the clamp was positioned in front of the left subclavian artery. From January 2002 to October 2003, 92 patients underwent TAAR. In 62 patients (67.4%), partial clamping of the BCT was used. Twenty of these patients underwent isolated TAAR, 27 underwent aortic valve replacement and TAAR, 11 had a Bentall operation, and 2 had a Cabrol operation. The aortic valve was spared in the remaining 2 patients. The mean (+/- SD) aortic cross-clamping and cardiopulmonary bypass times were 96 +/- 31 minutes and 116 +/- 43 minutes, respectively. RESULTS: Early mortality was 1.6% (1 patient). No cerebrovascular accidents occurred, demonstrating the safety of the technique. The major complications were acute respiratory insufficiency in 2 cases and acute renal failure in 5. The mean follow-up time was 9.0 +/- 6.5 months. The mean 18- month and event-free survival rate was 96.6% +/- 0.9%. CONCLUSION: Partial clamping of the BCT for TAAR without circulatory arrest provides good early and midterm clinical results. Aortic arch clamping is not associated with cerebrovascular accidents.

Midterm results after septal reshaping for anteroseptal scars.

BACKGROUND: Midterm clinical and morphologic results of the septal-reshaping exclusion of anteroseptal dyskinetic or akinetic areas were evaluated. METHODS: From January to June 2003, 44 patients with myocardial infarction following left anterior descending coronary artery (LAD) occlusion underwent septal reshaping. The mean (+/- SD) New York Heart Association (NYHA) class of the patients at admission was 2.7 +/- 0.9. Angina was referred in 21 cases. The incision was started at the apex and directed parallel to the LAD toward the base of the heart. The septum was rebuilt with 1 or 2 U-stitches passed from the inside to join the anterior wall to the septum by starting as high as possible where the scar began and continuing in an oblique direction toward the new apex. An oval polyethylene terephthalate fiber (Dacron) patch was then sutured from the septum (at the end of the direct suture through the border with the inferior septum) to the anterior wall (between the healthy wall and the scarred wall) and up to the new apex. RESULTS: The 30-day mortality rate was 2.2% (1 patient, due to the failure of a previously implanted defibrillator). Three patients experienced acute renal failure. No patient had restrictive syndrome. After a mean follow-up period of 8.5 +/- 4.9 months (range, 4-22 months), the mean NYHA class improved from 2.7 +/- 0.9 to 1.6 +/- 0.5 (P < .001). The 18- month survival rate and the probability of being alive in NYHA class I or II were 93.2% +/- 2.0% and 90.9% +/- 4.3%, respectively. Echocardiographic results showed reductions in the left ventricle volume with a normalization of the stroke volume. The diastolic longitudinal length remained unchanged, and the diastolic sphericity index was reduced but not significantly. CONCLUSIONS: At 1 year after surgery, the good clinical and morphologic results demonstrate the safety and effectiveness of septal reshaping for anteroseptal scars.

Myocardial revascularization with and without cardiopulmonary bypass in multivessel disease patients.

BACKGROUND: Off-pump coronary artery bypass surgery is widely performed because of its proved safety, but its effectiveness remains controversial. The aim of this retrospective study was to compare early and late results in patients with multivessel disease, operated on off-pump and on-pump. METHODS: From November 1994 to December 2001, 2957 patients with multivessel disease underwent isolated coronary revascularization, on-pump (n = 1924) and off-pump (n = 1033). Sixty-five patients (2.2%) who were converted from off-pump to on-pump were considered as part of the off-pump group. RESULTS: Stepwise logistic regression analysis showed that the use of cardiopulmonary bypass was an independent predictor for early death, early negative primary endpoints, and early major events. Conversion to on-pump was an independent risk factor for a higher incidence of death due to any cause and cardiac death, early negative primary endpoints, and early major events. Conversion, however, did not affect late clinical outcome. The 6-year freedom from death (any cause, cardiac cause), myocardial infarction, redo/coronary angioplasty and any events was similar in the two groups. CONCLUSIONS: These results suggest that off-pump surgery reduces early mortality and morbidity. These benefits are not at the expense of the long-term clinical outcome which seems to be similar in the two groups. Patients who require conversion from off-pump to on-pump have a much higher mortality and morbidity although this does not seem to influence their long-term clinical outcome.