A composed graft for subclavian artery reconstruction in case of redo surgery for aortic coarctation.

We report the case of a 66-year-old woman admitted to the intensive care unit (ICU) for ongoing dyspnea and hemoptoe. She was operated upon in 1979 for aortic coarctation by the interposition of a 14 mm Dacron prosthesis from the left subclavian artery to descending aorta. Clinical evaluation performed over the years was normal with no signs of cardiac failure or prosthesis malfunctioning. The computed tomography scans (CT) showed a progressive increase of the descending aorta diameters and the onset of a pseudo-aneurysm of 50 mm in diameter. Patient was re-operated through a median sternotomy enlarged by a left thoracotomy and intra-operative findings revealed the pseudo-aneurysm originating from a dehiscence of the proximal suture. In order to allow a safe reconstruction of the dilated subclavian artery, a T-shaped composed graft was confectioned and then sutured to the descending aorta and the subclavian artery, respectively. Post-operative course was uneventful and three months CT scan showed a normal position of the composed graft.

Bilateral pulmonary endarterectomy and Bentall procedure completed in one surgical session.

We describe the performance, in one surgical session, of bilateral pulmonary endarterectomy and a button-technique Bentall operation in a 68-year-old man. The patient had chronic thromboembolic pulmonary hypertension and an ascending aortic aneurysm with moderate aortic regurgitation. The procedures were concurrently completed during short periods of systemic circulatory arrest, with antegrade cerebral perfusion maintained through the brachiocephalic artery at a flow rate of 10 mL/min/kg. The patient's cerebral perfusion was monitored with use of near-infrared spectroscopy, to prevent symmetric bilateral values from falling below 20% of the base value. The patient experienced no multiorgan failure or neurologic sequelae and, by the 6th postoperative day, improved from New York Heart Association functional class IV to class I.The reliable maintenance of continuous antegrade cerebral perfusion made the lengthy combined operation feasible, with low risk. The use of near-infrared spectroscopy enabled real-time monitoring of the patient's cerebral blood flow. Our experience shows the possibility of safely performing lengthy or multiple procedures in one surgical session.

Left main compression by an aortic root abscess.

A 79-year-old man with severe aortic stenosis, history of coronary artery disease and a recent hospitalization for sepsis presented at our institution following a syncope and angina at rest. Coronary angiography and aortography showed an aortic root abscess, causing left main coronary artery compression. This life-threatening complication of aortic valve endocarditis is rare and requires immediate surgical correction.

Left ventricular reverse remodeling in percutaneous and surgical aortic bioprostheses: an echocardiographic study.

BACKGROUND: Surgical aortic valve replacement (SAVR) is the definitive proven therapy for patients with severe aortic stenosis who have symptoms or decreased left ventricular (LV) function. The development of transcatheter aortic valve implantation (TAVI) offers a viable and "less invasive" option for the treatment of patients with critical aortic stenosis at high risk with conventional approaches. The main objective of this study was the comparison of LV hemodynamic and structural modifications (reverse remodeling) between percutaneous and surgical approaches in the treatment of severe aortic stenosis. METHODS: Fifty-eight patients who underwent TAVI with the CoreValve bioprosthetic valve were compared with 58 patients with similar characteristics who underwent SAVR. Doppler echocardiographic data were obtained before the intervention, at discharge, and after 6-month to 12-month follow-up. RESULTS: Mean transprosthetic gradient at discharge was lower (P<.003) in the TAVI group (10±5 mm Hg) compared with the SAVR group (14±5 mm Hg) and was confirmed at follow-up (10±4 vs 13±4 mm Hg, respectively, P<.001). Paravalvular leaks were more frequent in the TAVI group (trivial to mild, 69%; moderate, 14%) than in the SAVR group (trivial to mild, 30%; moderate, 0%) (P<.0001). The incidence of severe prosthesis-patient mismatch (PPM) was significantly lower (P<.004) in the TAVI group (12%) compared with the SAVR group (36%). At follow-up, LV mass and LV mass indexed to height and to body surface area improved in both groups, with no significant difference. In patients with severe PPM, only the TAVI subgroup showed significant reductions in LV mass. LV ejection fraction improved at follow-up significantly only in TAVI patients compared with baseline values (from 50.2±9.6% to 54.8±7.3%, P<.0001). CONCLUSIONS: Hemodynamic performance after TAVI was shown to be superior to that after SAVR in terms of transprosthetic gradient, LV ejection fraction, and the prevention of severe PPM, but with a higher incidence of aortic regurgitation. Furthermore, LV reverse remodeling was observed in all patients in the absence of PPM, while the same remodeling occurred only in the TAVI subgroup when severe PPM was present.

Impact of treatment choice on the outcome of patients proposed for transcatheter aortic valve implantation.

AIMS: Transcatheter aortic valve implantation (TAVI) is a new option for patients with severe aortic stenosis at high surgical risk. We compared the clinical outcome of patients referred for TAVI and subsequently treated with TAVI, surgical aortic valve replacement (SAVR), balloon aortic valvuloplasty (BAV), or medical management (MM). METHODS AND RESULTS: All consecutive patients (n=166, EuroSCORE 24.9 ± 13.9%) referred for TAVI to our two centres were enrolled in a prospective registry and were assigned to SAVR (n=21), TAVI with the CoreValve prosthesis (n=75), BAV (n=20), or MM (n=50) by a multi-specialty team. The primary endpoint was 6-month cardiac mortality. Patients undergoing BAV had a significantly higher EuroSCORE (33.6 ± 15.9%; p=0.01). Median follow-up time was nine months (interquartile range 4.5-12.4 months). Six-month freedom from cardiac death was 81.0 ± 8.6%, 92.0 ± 3.1%, 72.9 ± 10.5%, and 72.7 ± 6.5% for SAVR, TAVI, BAV, and MM groups, respectively. Freedom from major cardiac and cerebrovascular events was 76.2 ± 9.3%, 83.9 ± 4.3%, 72.9 ± 10.5%, and 65.6 ± 6.8% for SAVR, TAVI, BAV, and MM groups, respectively. CONCLUSIONS: With respect to medical management and BAV, TAVI was associated with lower cardiac mortality at six months. Clinical outcome after TAVI was similar to that of less sick patients undergoing SAVR.

Minimally invasive aortic valve replacement in a transplanted heart.

Heart transplantation is subject to a number of chronic complications that may limit graft survival and be detrimental to the patient's quality of life. Aortic valve stenosis is a rare complication found after cardiac transplantation, which we believe has never been described on a tricuspid normal aortic valve. In the present study, we report a case of successful aortic valve replacement performed 16 years after cardiac transplantation on an extensively calcified tricuspid valve. Surgery was performed by using a minimally invasive approach with a reverse T upper mini-sternotomy, and the aortic valve was replaced by a biological prosthesis. The postoperative course was uneventful and the patient was discharged 7 days after the operation.

A hanging mass in the ascending aorta diagnosed by transthoracic echocardiography in a totally asymptomatic subject.

Aortic mural thrombosis is generally associated with several diseases, including coagulopathies, aortic dissection or trauma, tumors, and complicated atherosclerotic plaques. The development of a friable mobile thrombus, especially in the ascending aorta or proximal aortic arch, is a rare event with potentially ominous consequences because of a life-threatening risk of stroke and peripheral embolization. The treatment of choice of this condition is still controversial. We report a case of an absolutely asymptomatic 57-year-old patient with a mobile, pedunculated mass attached to the posterior wall of an otherwise normal ascending aorta. The aortic mass, identified by transthoracic echocardiography, was surgically removed and demonstrated to be a thrombus, and the aortic wall specimen was microscopically normal.

Adjustable sinotubular junction for aortic valve reimplantation procedures.

Sinotubular junction size in aortic valve reimplantation procedures is usually predetermined on the basis of mathematical calculations and intraoperative measurements. We propose a new method for aortic valve reimplantation by which intraoperative measurements can be eliminated and sinotubular junction size adjusted after cross clamp removal to fit the patient's need. Aortic valve commissures are reimplanted in the expandable skirt of a Valsalva (Vascutek, Renfrewshire, Scotland) graft to realize an oversized sinotubular junction that is subsequently reduced to the proper size by wrapping, with Dacron rings of decreasing size, the neo-sinotubular ridge under transesophageal echocardiographic guidance.

Percutaneous mitral annuloplasty: an anatomic study of human coronary sinus and its relation with mitral valve annulus and coronary arteries.

BACKGROUND: To allow performance of "stand-alone" mitral annuloplasty with minimal invasiveness, percutaneous techniques consisting of delivery into the coronary sinus (CS) of devices intended to shrink the mitral valve annulus have recently been tested in animal models. These techniques exploit the anatomic proximity of the CS and mitral valve annulus in ovine or dogs. Knowledge of a detailed anatomic relationship between the CS, coronary arteries, and mitral valve annulus in humans is essential to define the safety and efficacy of percutaneous techniques in clinical practice. We sought to determine the qualitative and quantitative anatomic relationships between CS and surrounding structures in human hearts. METHODS AND RESULTS: The distance from the CS to the mitral valve annulus and the relationship between the CS and surrounding structures were studied in 61 excised cadaveric human hearts. Maximal distance from the CS to the mitral valve annulus was found to be up to 19 mm (mean, 9.7+/-3.2 mm). A diagonal or ramus branch, main circumflex artery, or its branches were located between anterior interventricular vein/CS and the mitral valve annulus in 16.4% and 63.9% of cases, respectively. CONCLUSIONS: Surgical anatomy suggests that in humans the CS is located behind the left atrial wall at a significant distance from the mitral valve annulus. Percutaneous mitral annuloplasty devices probably shrink the mitral valve annulus only by an indirect traction mediated by the left atrial wall; a theoretical risk of compressing coronary artery branches exists. Chronic studies are needed to address this problem and to determine long-term efficacy of such methods.

A technique to reposition sinotubular junction in aortic valve reimplantation procedures with the De Paulis Valsalva graft.

Sinotubular junction reconstruction in reimplantation type of valve-sparing aortic procedure can present some problem when a Valsalva graft is used. Since in the Valsalva graft the sinotubular junction height is predetermined, correct matching with native commissures height can be difficult. We propose a method by which it is possible to create a new sinotubular junction in Valsalva graft without altering its original configuration.

The ideal theoretical graft oversizing in valve-sparing aortic operations with a standard tubular or a Valsalva graft.

OBJECTIVE: We sought to determine, by a mathematical model, the ideal theoretical degree of ascending aortic graft oversizing needed to obtain normal sinuses dimension in the reimplantation type of valve-sparing aortic operations. METHODS: To define a normal-range value, size of sinuses of Valsalva was conventionally expressed as the area surrounding fully opened aortic cusps, the so-called beyond leaflets area (BLA), and measured in 50 healthy subjects. A mathematical relationship between aortic annulus diameter, aortic sinuses diameter and resulting BLA was defined. By simulating intra-operative scenarios, the effect of different degrees of a standard or Valsalva graft oversizing on BLA extension was tested. RESULTS: The same degree of graft oversizing resulted in a bigger beyond leaflets area for the Valsalva graft than for a standard graft. Oversizing degrees exceeding +7mm for a standard graft and +3mm for the Valsalva graft resulted in a beyond leaflets area over normal limits. Results were expressed in a visual form as two different normograms, one for the standard graft and one for the Valsalva graft. CONCLUSIONS: A less pronounced graft oversizing is needed to achieve normal-range sinuses size when using a Valsalva graft, the ideal theoretical graft oversizing was +7mm for a standard graft and +3mm for the Valsalva graft, our normograms can be helpful in selecting a proper graft size when performing a valve-sparing aortic procedure.

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.

Port Access Cardiac Surgery.

The port-access technique for cardiac surgery was recently developed at Stanford University in California as a less invasive method to perform some cardiac operations. The port-access system has been described in detail elsewhere. It is based on femoral arterial and venous access for cardiopulmonary bypass (CPB) and on the adoption of a specially designed triple-lumen catheter described originally by Peters, and subsequently modified and developed in the definitive configuration called the endoaortic clamp.