Aortic valve stenosis and cancer: a common and complex association.

Introduction. The prevalence of aortic valve stenosis (AS) and malignancy are both high, especially in elderly people and in developed countries. These two conditions frequently coexist and share the same risk factors as atherosclerotic disease.Area covered. The progression of calcified AS may be accelerated by both cardiovascular risk factors and cancer treatments, such as radiotherapy. The standard treatment for symptomatic severe AS is surgical aortic valve replacement; however, in cancer patients, transcatheter implantation may be preferred as they are often at high-risk for cardiac surgery. In patients with AS and cancer, physicians may face difficult treatment decisions.To date, there is limited information on the impact of malignancy on outcomes in patients with severe AS; hence, there is no established treatment policy.Expert Opinion. Treating clinicians must integrate complex information about the severity of valve disease and expected cardiac outcomes with information regarding the cancer prognosis and the need for specific treatment, including surgery. Other comorbidities, age and frailty also contribute to decision-making about whether, when, and how to perform aortic valve replacement.

Triple-orifice valve repair in severe Barlow disease with multiple-jet mitral regurgitation: report of mid-term experience.

OBJECTIVES: Barlow disease represents a surgical challenge for mitral valve repair (MR) in the presence of mitral insufficiency (MI) with multiple regurgitant jets. We hereby present our mid-term experience using a modified edge-to-edge technique to address this peculiar MI. METHODS: From March 2003 till December 2010, 25 consecutive patients (mean age 54 ± 7 years, 14 males) affected by severe Barlow disease with multiple regurgitant jets were submitted to MR. Preoperative transesophageal echo (TEE) in all the cases showed at least 2 regurgitant jets, involving one or both leaflets in more than one segment. In all the patients, a triple orifice valve (TOV) repair with annuloplasty was performed. Intra-operative TEE and postoperative transthoracic echocardiography (TTE) were carried out to evaluate results of the TOV repair. RESULTS: There was no in-hospital death and one late death (non-cardiac related). At intra-operative TEE, the three orifices showed a mean total valve area of 2.9 ± 0.1cm(2) (range 2.5-3.3 cm(2)) with no residual regurgitation (2 cases of trivial MI) and no sign of valve stenosis (mean transvalvular gradient 4.6 ± 1.5 mmHg). At follow up (mean 38 ± 22 months), TTE showed favourable MR and no recurrence of significant MI (6 cases of trivial and 1 of mild MI). Stress TTE was performed in 5 cases showing persistent effective valve function (2 cases of trivial MI at peak exercise). All the patients showed significant NYHA functional class improvement. CONCLUSIONS: This report indicates that the TOV technique is effective in correcting complex Barlow mitral valves with multiple jets. Further studies are required to confirm long-term applicability and durability in more numerous clinical cases.

Giant asymptomatic left atrial myxoma.

The classic triad of myxoma clinical presentation is characterized by intracardiac obstruction, embolisms, and constitutional symptoms with fever, weight loss, or symptoms resembling connective tissue disease. Giant myxoma without symptoms are very rare. We present a case of a 30-year-old female with a giant asymptomatic myxoma in the left atrium, discovered by echocardiography. The patient was asymptomatic.

Two easy ways to ensure safe sternotomy and sternal closure.

Appropriate sternotomy and sternal closure are the most important factors in mechanical stability of the sternum and prevention of several postoperative complications. Easy techniques for identifying the sternal midline to facilitate opening and for obtaining reinforced closure are described. These techniques require minimal additional time. They are particularly indicated in patients at risk of sternotomy-related complications, and helpful to young surgeons in training.

Emergency surgery after saphenous vein graft perforation complicated by catheter balloon entrapment and hemorrhagic shock.

Emergency surgery for acute vein graft perforation and balloon entrapment during percutaneous angioplasty is reported here. Prompt extracorporeal circulation through peripheral cannulation enabled the control of systemic perfusion despite cardiac arrest. Vein graft repair was achieved by an autologous pericardial patch. Appropriate and tailored mechanical circulatory support allowed successful extracorporeal circulation withdrawal, limited intraoperative cardiac damage, and postoperative controlled recovery of ventricular function with ultimate favorable outcome.

Edge-to-edge mitral valve repair for isolated prolapse of the anterior leaflet caused by degenerative disease.

OBJECTIVE: The use of new techniques to correct mitral regurgitation due to prolapse of the anterior leaflet has been shown to expand the original surgical armamentarium and to improve postoperative outcome. We retrospectively analysed our experience with isolated prolapse of the anterior mitral leaflet repaired using the edge-to-edge technique. METHODS: From October 1986 to June 2004, 790 patients underwent mitral valve repair for mitral regurgitation at our institution. Isolated pathology of the anterior mitral leaflet, due to degenerative disease, was the cause of mitral regurgitation in 84 patients and, from 1991, 68 underwent edge-to-edge repair. RESULTS: There was no intraoperative death and one in-hospital death. Three patients died in the late follow-up period for a cumulative 13-year survival rate of 90 +/- 1.4%. No patient underwent early reoperation. Four patients underwent reoperation during the follow-up for a cumulative 13-year freedom from reoperation of 92.3 +/- 3.2%. At echocardiographic evaluation, mitral valve repair failure was associated with severe mitral regurgitation in four patients. Of the remaining 60 patients, 40 had no residual regurgitation, 18 had trivial residual regurgitation, and two had mild regurgitation. At follow-up, 49 patients are still in New York Heart Association (NYHA) class I, 14 in NYHA class II and only one in NYHA class III. CONCLUSIONS: Our study demonstrates that the 'edge-to-edge' technique is a reliable procedure to correct prolapsing leaflets. The addition of this technique to the surgical armamentarium has neutralized prolapse of the anterior leaflet as an incremental risk factor for reoperation.

Mitral insufficiency and its different aetiologies: old and new insights for appropriate surgical indications and treatment.

Mitral insufficiency, as many other fields in medicine, has witnessed profound changes in terms of knowledge, diagnostic process and therapeutic options. Mitral valve reconstruction has become the treatment of choice in the presence of a regurgitant valve, although numerous preoperative and operative clues have been shown to predict less satisfactory results of valve repair in the long term, calling for a careful revision of postoperative data and search for novel techniques of valve repair or reconsider valve replacement as an acceptable therapy in peculiar cases. Old scenarios, like rheumatic valve disease or acute endocarditis, are continuously under reassessment in an attempt to distinguish patient subsets amenable to tailored therapies, whereas new fields of intervention, like dilated cardiomyopathy, or better appraisal of pathophysiological mechanisms, like ischaemic mitral insufficiency, are emerging and represent new indications for surgical solutions. The most recent advances in the understanding of how some aetiologies and related mechanisms of mitral insufficiency exert substantial influence on the postoperative results represent new tools in the guidance of a more appropriate surgical decision-making.

Mitral valve periprosthetic leakage: Anatomical observations in 135 patients from a multicentre study.

OBJECTIVE: Prosthetic valve dysfunction after mitral valve replacement (MVR) may be caused by several factors, which often lead to repeated surgery. One of the most frequent determinants of reoperation is periprosthetic leakage (PPL). A few published reports have analysed PPL incidence and postoperative results after MVR, but no specific attention has been paid towards the potential relation between anatomical factors and PPL occurrence, particularly not bacterial-related. The aim of this study was to evaluate the location of PPL after MVR through a multicentre retrospective study. METHODS: Between January 1985 and November 2005, 135 patients underwent reoperation at four institutions because of PPL after MVR and met the study inclusion criteria. The mitral valve annulus (MVA) was analysed in a clockwise format, indicating 12 o'clock as the mid-point of anterior annulus as viewed from the atrium. RESULTS: Overall hospital mortality was 3.7% (five patients). Repair of PPL was carried out in 83 cases whereas prosthetic valve replacement was necessary in 52 cases. The total number of sectors involved in PPL was 244. PPL occurred more frequently between hour 5 and hour 6, and hour 10 and hour 11, with the risk of leakage being, 2.8 and 2.0 times higher, respectively, than in any other portion of the MVA. CONCLUSIONS: Our study suggests that PPL occurs more frequently at antero-lateral and postero-medial segments of MVA. This finding might be linked to unusual anatomical and functional factors of the MVA and may call for adjunctive care to these sectors of MVA when performing suture placement during MVR.

The triple-orifice repair: a new technique for the treatment of mitral regurgitation in severe Barlow's disease.

We report a case of severe Barlow's disease with a very complex pathology, in which we applied the "edge-to-edge" technique, creating a triple-orifice mitral valve. Different techniques should be used to correct a similar valve defect; the combination of different surgical procedures and the valve pathology may influence the post-repair recurrence of regurgitation. We believe that it is better to perform a simple and reproducible repair than to carry on with combined complex procedures that could increase the risk of a suboptimal outcome.

Mitral regurgitation of degenerative etiology: should the timing of surgery be changed in the mitral valve repair era?

The timing of surgery in patients with chronic mitral regurgitation is a controversial issue. Left ventricular dysfunction progresses silently and is partly predictable; depressed left ventricular contractility sometimes accompanies a normal ejection fraction. Severe symptoms remain a clear recommendation for surgery. However several factors suggest that surgery should not be delayed until severe symptoms appear: impact on survival of ejection fraction < 60%, preoperative symptoms, and atrial fibrillation. Early surgery is justified in patients with degenerative mitral regurgitation independently of the type of lesion (prolapse of posterior, anterior or both the leaflets), because the addition of new techniques to the surgical armamentarium has neutralized prolapse of the anterior leaflet as an incremental risk factor for reoperation. In conclusion, early surgery is a reasonable treatment for low-risk patients with repairable valves and should be considered in asymptomatic patients with ejection fraction approaching the lower limit of normal, history of paroxysmal atrial fibrillation or pulmonary hypertension during exercise.