Mid-term results of leaflet augmentation in severe tricuspid functional tethering.

OBJECTIVES: Functional tricuspid regurgitation (FTR) is usually managed surgically using various types of annuloplasty. FTR has been reported to recur in up to 45% of patients, with severe leaflet tethering being an important risk factor for recurrence. The aim of this study is to report the clinical and echocardiographic mid-term results after leaflet augmentation in patients with FTR due to severe leaflet tethering. METHODS: From May 2008 to July 2014, 22 patients were found to have a severe FTR with a tethering height of at least 8 mm; all of them underwent leaflet augmentation: the anterior and part of the posterior leaflet were detached from the anterior annulus; a patch of fresh autologous pericardium was used to generously fill the gap between the anterior annulus and the detached leaflet. A 5/0 Pronova suture locked at every step was used to avoid any purse string effect. In 2 patients, the septal leaflet also needed to be augmented using a comparable technique. In all but one (annular calcification) patient, a semi-rigid ring annuloplasty was added. The mean age was 67.1 ± 13.7 years; it was a redo procedure in 12 cases (54.5%), 11 patients (50%) had right ventricle failure and 3 (23.1%) had renal failure. RESULTS: The median follow-up was 2.1 ± 1.9 years. Thirty-day and 4-year survival averaged at 81.1 ± 8.5 and 71.6 ± 9.8%, respectively. At 4 years, 84 ± 10.6% of the survivors were in NYHA class I or II and only 2 patients had a TR of ≥2 with a global freedom from TR ≥2 of 85.7 ± 13.2%. There was no reintervention. CONCLUSIONS: Tricuspid leaflet augmentation combined with annuloplasty is feasible and leads to excellent clinical and echocardiographical mid-term results even in the presence of severe leaflet tethering and right ventricular failure.

Anomalous Origin of the Circumflex Artery: An Underestimated Threat During Mitral Valve Operation.

Ischemic iatrogenic lesions can complicate surgical procedures on the mitral valve. One of the causative mechanisms is direct injury to or distortion of the circumflex coronary artery. The risk of damaging the circumflex coronary artery depends mainly on the proximity of that vessel to the posterior segment of the mitral annulus, and this varies from patient to patient. Herein, we report the case of an iatrogenic circumflex coronary artery lesion after mitral annuloplasty in a patient with an anomalous origin of the circumflex artery.

Myectomy and mitral repair through the left atrium in hypertrophic obstructive cardiomyopathy: the preferred approach for contemporary surgical candidates?

OBJECTIVE: Patients with hypertrophic obstructive cardiomyopathy due to diffuse hypertrophy extending to or below the papillary muscles are poor candidates for alcohol septal ablation and suboptimal candidates for transaortic septal myectomy. In addition, the outflow obstruction is often aggravated by an abnormal mitral valve and subvalvular apparatus. METHODS: We performed transatrial myectomy in 12 patients with diffuse hypertrophy, who were highly symptomatic despite maximal medical therapy. All had at least moderate mitral regurgitation and systolic anterior motion. The anterior mitral leaflet (AML) was detached from commissure to commissure, allowing an easy myectomy through this AML toward the base of the anterior papillary muscle, with mobility fully restored. The abnormal chordae from the septum to the anterior papillary muscle and AML were divided. The continuity of this AML was restored with augmentation using an autologous pericardial patch. The height of the posterior mitral leaflet was reduced and the repair completed using an oversized annuloplasty ring. RESULTS: The peak intraventricular gradients decreased spectacularly from 98.8 ± 6.29 to 19.2 ± 13.4 mm Hg (P < .001), and the systolic anterior motion and mitral regurgitation disappeared. One patient died of left ventricular diastolic dysfunction. All other patients left the hospital in New York Heart Association class I or II. CONCLUSIONS: We believe that this technique is preferable for patients with hypertrophic obstructive cardiomyopathy and diffuse hypertrophy extending to the midportion of the left ventricle or beyond. It results in disappearance of outflow tract gradients and allows correction of the mitral valve abnormality.

Functional impact of transmitral gradients at rest and during exercise after restrictive annuloplasty for ischemic mitral regurgitation.

OBJECTIVES: Restrictive mitral valve annuloplasty combined with coronary artery bypass grafting is the treatment of choice for ischemic mitral regurgitation. Postoperative functional mitral stenosis and its potential impact on functional capacity remain the object of debate. The aim of this study was to assess functional and hemodynamic outcome at rest and during exercise in a population with ischemic mitral regurgitation after a standardized restrictive mitral valve annuloplasty. METHODS: A total of 23 patients with ischemic mitral regurgitation who were previously treated with coronary artery bypass grafting and restrictive mitral valve annuloplasty underwent a semi-supine (bicycle) exercise test with Doppler echocardiography and ergospirometry. The surgical technique was identical in all patients, using a complete semi-rigid ring downsized by 2 sizes after measuring the height of the anterior mitral leaflet, to achieve a coaptation length of at least 8 mm. RESULTS: At a mean follow-up of 28 ± 15 months, mean transmitral gradients at rest and maximal exercise were 4.4 ± 1.8 mm Hg and 8.2 ± 4.2 mm Hg, respectively (P < .001). Transmitral gradients did not correlate with exercise capacity (maximal oxygen uptake) or pulmonary artery pressures. Patients with a resting mean gradient of 5 mm Hg or greater (n = 9) reached a significantly higher maximal oxygen uptake; however, they had a better ejection fraction and cardiac output at rest and reached a higher cardiac output at peak exercise. CONCLUSIONS: Transmitral gradients after restrictive mitral valve annuloplasty for ischemic mitral regurgitation did not correlate with functional capacity as measured by maximal oxygen uptake during semi-supine bicycle testing. Functional capacity and transmitral gradients are determined not only by the severity of mitral stenosis but also by hemodynamic factors, such as ejection fraction and cardiac output. Transmitral gradients should be interpreted with respect to patient hemodynamics and not necessarily be considered as detrimental for functional capacity.

Cardiac resynchronization therapy with or without defibrillator: experience from a high-volume Belgian implantation centre.

OBJECTIVE: Cardiac resynchronization therapy (CRT) is an important treatment modality for heart failure with reduced ejection fraction and ventricular conduction delay. Considering limited health care budgets in an aging population, adding a defibrillator function to CRT remains a matter of debate. Our aim was to describe the experience of a high-volume Belgian implantation centre with CRT with/without defibrillator (CRT-D/P). METHODS AND RESULTS: Consecutive CRT patients (n = 221), implanted between October 2008 and April 2011 in Ziekenhuis Oost-Limburg (Genk), were reviewed. From 209 primo-implantations, 74 CRT-D and 98 CRT-P patients with complete follow-up inside the centre, were analysed. Despite differences in baseline characteristics, both groups demonstrated similar reverse left ventricular remodelling, improvement in New York Heart Association functional class and maximal aerobic capacity. During mean follow-up of 18 +/- 9 months, 21 patients died and 83 spent a total of 1200 days in hospital. Annual mortality was 8% and equal among the groups. The mode of death differed between CRT-D (predominantly pump failure) and CRT-P patients (pump failure, comorbidity and sudden death). The yearly population attributable risk of malignant ventricular arrhythmia was 8.16% in CRT-D and 1.38% in CRT-P patients. CONCLUSIONS: With current guidelines applied to the Belgian reimbursement criteria and at physicians'discretion, patient selection for CRT-D/ CRT-P was appropriate, with similar reverse remodelling, functional capacity improvement and good clinical outcome in both groups. High-risk patients for malignant ventricular arrhythmia were more likely to receive CRT-D, although the yearly attributable risk remained 1.38% in CRT-P patients.

Salvage extensive coronary thromboendarterectomy for a ruptured left anterior descending artery.

We describe a lifesaving emergent thromboendarterectomy of the entire left anterior descending artery in a 63-year old man. Four days earlier, he had undergone a coronary artery bypass grafting. The left anterior descending artery was not bypassed then due to severe diffuse disease and calcifications. After an uneventful recovery, syncope occurred during exercise. Emergency catheterization revealed patent grafts, but no flow over the left anterior descending artery. At rescue percutaneous coronary intervention, a perforation of the left anterior descending artery occurred, leading to cardiogenic shock. A successful thromboendarterectomy of the left anterior descending artery salvaged the patient's life.

Augmentation of the posterior leaflet of the mitral valve.

The augmentation of mitral valve leaflets is mostly needed in rheumatic valve disease patients. The technical aspects of augmentation of the posterior leaflet by means of an autologous pericardial patch are described: the thickened and semi-rigid posterior leaflet is detached from the posterior annulus from commissure to commissure and augmented by an onlay patch of autologous pericardium which is incorporated using a continuous stitch-locked at each step-of Prolene or Pronova 5/0. The pitfall 'aortic cusp effect in diastole' is described as well as tips to prevent it.

Surgical angioplasty and unroofing technique for intramural coronary anomaly.

A malign intramural course of the left main coronary artery is a rare anatomical anomaly. Surgical repair is mandatory since the condition is associated with myocardial ischemic syndromes and sudden death. Unroofing the intramural part and reconstructing a neo-ostium is challenging if the neo-ostium is immediately adjacent to the intercoronary commissure as there is a risk of narrowing the newly created ostium. We report a case in which we performed a surgical angioplasty of the left main coronary artery in combination with unroofing of the intramural section and resuspension of the intercoronary commissure.

In vivo cellularization of a cross-linked matrix by intraperitoneal implantation: a new tool in heart valve tissue engineering.

AIM: To use in vivo instead of in vitro cell seeding in heart valve tissue engineering. METHODS AND RESULTS: Intraperitoneally preseeded, photo-oxidized bovine pericardial pulmonary valve constructs (group 1) were compared with non-preseeded constructs (group 2) implanted in sheep. All valves functioned normally and were macroscopically intact at explantation [1 week (n = 6) and 1 month (n = 6) in each group], except for one thrombosed leaflet in a group-2 valve at 1 month. Almost 10-fold higher neomatrix deposition and doubling of the leaflet thickness were found in group 1 vs. 2 (P < 0.05). A concomitant significant decrease in leaflet length (15%) was found at 1 month in group 1. The total cross-sectional surface and total amount of collagen of the original matrix remained unchanged in both groups at all times. Immunohistochemistry showed a low immune response, stem/progenitor cell infiltration, appropriated differentiation, and spontaneous endothelialization of the valves. Significantly, increased re-cellularization was found after IP preseeding compared with spontaneous seeding: cell coverage of the leaflet was 71-100 vs. 8-26% (P < 0.05), respectively. CONCLUSION: Complete re-cellularization can be obtained by IP preseeding of an acellularized cross-linked matrix. Well-functioning valve constructs show cellularization and differentiation into myofibroblast phenotype and concomitant neomatrix deposition.