A novel surgical technique of left atrial appendage closure.

BACKGROUND AND AIMS: Surgical left atrial appendage occlusion or exclusion has been performed with various techniques, however, during the following years the left atrial appendage elimination often fails. We propose a novel, rapid surgery process of safely closing and obliterating the left atrial appendage by an intra-atrial sutureless closure. METHODS: The left atrial appendage elimination is performed by invaginating the appendage into the left atrium and tying it on the interluminal base to permanently prevent its evagination back into the normal position. RESULTS: In the current study we present two cases where this technique was performed with a satisfactory result. In both cases the postoperative course was uneventful, and at follow-up echocardiography the left atrial appendage was not visualized. CONCLUSIONS: While we have shown that this technique is feasible, a longer follow-up and a larger series of patients is necessary before this method can be accepted in routine clinical practice.

Clinical and Echocardiographic Outcomes After Aortic Valve Repair Surgery.

OBJECTIVE: To assess early and late clinical outcomes in patients who underwent aortic valve repair surgery for aortic valve insufficiency, and to investigate predictors for recurrence. METHODS: Of 151 consecutive patients who underwent aortic valve repair surgery for varying degrees of aortic insufficiency (AI) in our department between 2004 and 2018, 60 (40%) underwent aortic root replacement, 71 (47%) aortic cusp plication, 31 (20%) subcommissural annuloplasty, 29 (19%) circular annuloplasty, and 28 (18%) autologous pericardial patch augmentation. RESULTS: One patient died in the hospital (0.7%). Mean clinical and echocardiographic follow-up was 62±43 months (range 1 to 159) and 50 ± 40 months (range 1 to 158), respectively. The overall survival rate was 99.3% at 1 year and 98% at 5 years of follow-up. Seventeen patients (11.3%) had recurrent severe AI, and all of them underwent reoperation with a mean duration to reoperation of 35 ± 39 months. Risk factors for the development of recurrent significant AI (≥3) or reoperation, by univariable analysis, were unicuspid or bicuspid aortic valve (AV) (P = 0.018), the use of subcommissural annuloplasty (P = 0.010), the need for cusp repair (P = 0.001), and the use of pericardial patch augmentation (P < 0.001). By multivariable analysis only the use of pericardial patch augmentation emerged as a significant independent predictor for the development of recurrent significant AI (≥3) or reoperation (P = 0.020). CONCLUSION: AV repair can be performed with low morbidity and mortality, with good early and late clinical outcomes. However, in our experience there was a significant rate of recurrent AI especially in patients who underwent cusp augmentation using glutaraldehyde-treated autologous pericardial patch.

Preoperative Extracorporeal Membrane Oxygenation for Postinfarction Ventricular Septal Defect.

The mortality rate after the development of ventricular septal defect (VSD) remains high despite progress in pharmaceutical therapy, invasive cardiology, and surgical techniques. Although early surgical repair of postinfarction VSD is associated with a high mortality rate, in hemodynamic unstable patients surgery cannot always be postponed and surgical repair may be required urgently. We present two cases of patients diagnosed with postinfarction VSD who were in cardiogenic shock with multiorgan failure despite optimal treatment. They were therefore connected to venoarterial extracorporeal membrane oxygenation as a bridge to reparative surgery.

Short- and long-term results after prosthetic mitral valve implantation in patients with severe mitral annulus calcification†.

OBJECTIVES: To investigate short- and long-term outcomes of a conservative decalcification approach in mitral valve replacement (MVR) surgery in the presence of mitral annulus calcification (MAC). METHODS: Of the 1038 patients who underwent MVR, 133 (13%) had significant MAC with at least 30% of the annular circumference heavily calcified. In most patients, the surgical approach to MAC included conservative decalcification, supra-annular prosthesis implantation and insertion of a pericardial patch between the MV annulus and the prosthesis. These patients were matched by a propensity score to a group of patients who underwent MVR without MAC ( n = 118 in each group) and served as a control group. RESULTS: There were 6 early deaths in each group with an overall mortality of 5% ( P = 0.90). Early complications included one major stroke in the non-MAC group and acute renal failure needing dialysis in 2 and 3 patients in the MAC and non-MAC groups, respectively. Mean follow-up was 55 ± 37 months and 99.1% complete. There were 38 (33%) and 33 (29%) late deaths with an estimated survival of 61% and 69% at 6 years in the MAC and non-MAC groups, respectively ( P = 0.55). At follow-up, functional class did not differ between groups ( P = 0.096). Mean echo follow-up time was 40 ± 35 months and was 83% complete. Freedom from moderate or severe mitral regurgitation was 95% and 98%, with an estimated freedom of 95% and 96% at 6 years ( P = 0.20), and mean gradient was 4.9 ± 2.3 mmHg and 5.2 ± 2.0 mmHg for MAC and non-MAC groups, respectively ( P = 0.58). CONCLUSIONS: A conservative approach for dealing with MAC is suitable for the majority of patients. Early and late clinical and echocardiographic outcomes did not differ between the MAC and non-MAC patients, including freedom from early and late occurrence of MV prosthesis paravalvular leak.

Sutureless Versus Stented Valve in Aortic Valve Replacement in Patients With Small Annulus.

BACKGROUND: Aortic valve replacement, particularly in elderly patients with small aortic annulus, could lead to patient-prosthesis mismatch. Sutureless bioprosthesis could be an ideal solution for these patients. We compared results of aortic valve replacement with sutureless versus stented bioprosthetic valves. METHODS: Of the 63 patients undergoing aortic valve replacement with sutureless bioprosthesis between 2011 and 2014 in our department, 22 (20 women, 77 ± 6 years) had a small annulus less than 21 mm (sutureless group). They were matched for sex, age, body surface area, and left ventricular ejection fraction with 22 patients (20 women, 79 ± 6 years) undergoing stented bioprosthesis valve replacement (stented group). Body mass index and body surface area were 28 ± 5 kg/m(2) and 28 ± 3 kg/m(2) (p = 0.9), 1.6 ± 0.2 m(2) and 1.6 ± 0.1 m(2) (p = 0.9), in the sutureless and stented groups, respectively. Logistic EuroSCOREs were similar between groups. RESULTS: Postoperative peak transvalvular gradient was lower in the sutureless group (15 ± 7 mm Hg versus 20 ± 11 mm Hg; p = 0.02). The indexed effective orifice area was greater in the sutureless group (1.12 ± 0.2 cm(2)/m(2) versus 0.82 ± 0.1 cm(2)/m(2); p < 0.05). Aortic cross-clamp and cardiopulmonary bypass times were 47 ± 21 and 67 ± 15 minutes, respectively (p < 0.05) in the sutureless group versus 70 ± 22 and 85 ± 21 minutes, respectively (p = 0.02) in the stented group. Intensive care unit stay, hospitalization, and major complications were not significantly different between groups. At follow-up, regression of left ventricular hypertrophy was better in the sutureless group (93 ± 21 g/m(2) versus 106 ± 14 g/m(2); p = 0.02). CONCLUSIONS: Sutureless bioprosthetic valves demonstrate improved hemodynamic performance compared with stented valves in elderly patients with small aortic annulus, providing better regression of left ventricular hypertrophy and decreased rates of patient-prosthesis mismatch. Aortic cross-clamp and cardiopulmonary bypass times are also decreased.

Coxiella burnetii Endocarditis and Aortic Vascular Graft Infection: An Underrecognized Disease.

BACKGROUND: Q fever is considered endemic worldwide, and endocarditis, or aortic vascular infection, or both caused by Coxiella burnetii can be a fatal disease. The importance of surgical intervention has not yet been defined. We performed a descriptive retrospective study to assess indications for surgical treatment, timing of treatment, and outcome. METHODS: We studied all patients from the cardiac surgery department of a large tertiary hospital who underwent valve surgical procedure due to endocarditis or aortic surgical procedure due to graft infection. RESULTS: Throughout a 10-year period, we performed a total of 171 procedures due to valve endocarditis and/or vascular infection. In 16 patients (9.36%) Coxiella burnetii infection was diagnosed. Ten patients had previous cardiac surgical procedures, 3 had previous aortic surgical procedures, 2 had preexisting valvular disease, and 1 patient had no previous valve disorder. All patients received prolonged oral-specific antibiotic therapy under serologic guidance. In 9 patients antibiotic treatment (doxycycline and hydroxychloroquine) was started before the surgical procedure (12.4 ± 37.5 days), and in 7 patients after the surgical procedure (5.1 ± 13.5 days). We observed one in-hospital death (6.25%) and no long-term mortality. The mean follow-up period was 50.5 ± 34.7 months (range, 2 to 104 months). CONCLUSIONS: In this series surgical treatment yielded good results for both Q fever endocarditis and vascular graft infection. No association was found between timing of the surgical procedure and patients' outcomes.

Evaluation of the impact of a quality improvement program and intensivist-directed ICU team on mortality after cardiac surgery.

OBJECTIVE: Quality improvement is an important pursuit for critical care teams. DESIGN: The authors performed an observational cohort study with historic control. SETTING: Eight-bed cardiac surgery ICU in a tertiary university hospital. PARTICIPANTS: A total of 4,866 patients undergoing cardiac surgery over a 6-year period between January 2005 and December 2010. INTERVENTIONS: In this study, the influence of the introduction of a quality improvement program under the supervision of a newly appointed intensivist on patient outcomes after cardiac surgery was evaluated. Patients were further divided into three 2-year periods: Period I, 2005-2006, before appointment of an intensivist; Period II, 2007-2008, after appointment of an intensivist and initial introduction of a quality improvement program; and Period III, 2009-2010, after implementation of the program and introduction of Critical Care Information Systems. MEASUREMENTS AND MAIN RESULTS: There were 1,633, 1,690, and 1,543 patients in each period, respectively. There was no significant difference in the severity of patient illness between the groups. Unadjusted in-hospital mortality decreased from 6.37% (104 patients) in Period I to 4.32% (73 patients) and 3.3% (51 patients) in Periods II and III, respectively (p< 0.01). CONCLUSIONS: Appointment of an intensivist-directed team model and introduction of quality improvement interventions were associated with decreased mortality after cardiac surgery.

Mitral valve repair: isolated posterior compared to anterior or bileaflet pathology.

OBJECTIVES: The results of mitral valve (MV) repair for anterior leaflet pathology (ALP) are considered less favorable than those for posterior leaflet pathology (PLP). We compared clinical and echocardiography outcomes of PLP repair with ALP and/or bileaflet pathology (BLP) repair. METHODS: Between 2004 and 2011, 407 patients underwent MV repair due to degenerative MV: 276 patients (68%) had PLP and 131 (32%) had ALP/BLP. Mean age was 59 ± 12 and 56 ± 15 years in PLP and ALP/BLP groups, respectively (p = 0.03). Patient characteristics and co-morbidities were similar between groups. Valve repair techniques included leaflet resection (61% and 24%), annuloplasty (99% and 97%), and artificial chordea (46% and 67%), in the PLP and ALP/BLP groups, respectively. RESULTS: There was one (0.4%) in-hospital death in the PLP group, and none in the ALP/BLP group. Early complication rate was similar between groups. Completed clinical and late echocardiography follow-up was 95% (29 ± 22 months, 1 to 87). Freedom from reoperation was 98% (270/276) and 98% (129/131), and there were three (1%) and three (2%) late deaths, in the PLP and ALP/BLP groups, respectively (NS). Late echocardiography revealed that 89% and 94% of patients (PLP and ALP/BLP groups, respectively) were free from moderate or severe mitral regurgitation (MR) (p = 0.13). All other late valve-related complications were similar between groups. CONCLUSIONS: Anterior and bileaflet MV disease can be repaired with early and mid-term results similar to those of posterior MV disease. All patients with severe MR due to anterior or posterior pathology should be considered equally for early valve repair.

Heparin-free management of intra-aortic balloon pump after cardiac surgery.

BACKGROUND: Anticoagulation with heparin is recommended in patients with an intra-aortic balloon pump (IABP) to prevent thrombosis and embolization. However, anticoagulation increases the risk of bleeding, particularly in the early postoperative period after cardiac surgery. We investigated the safety of heparin-free management after IABP insertion in patients who underwent cardiac surgery. METHODS: We studied 203 consecutive patients who received perioperative IABP support between August 2004 and December 2011. All patients were managed without heparin and were followed for thrombotic and/or hemorrhagic complications. RESULTS: Patients were divided into two groups, according to time of IABP treatment following surgery. Group I, 81 patients (39.9%) were treated less than 24 hours following surgery and Group II, 122 patients (60.1%) were treated more than 24 hours following surgery. Vascular complications developed in seven patients (3.4%), two in Group I and five in Group II. Three patients had major and four had minor limb ischemia. There were no major bleeding complications, but minor bleeding complications were observed in eight patients (4.2%). CONCLUSION: In patients undergoing cardiac surgery with IABP support, the rate of thromboembolic complications was relatively low compared to historical controls. Heparin-free management may reduce the risk of hemorrhagic complications, with a low risk of thrombotic complications. Heparin should not be routinely used in patients requiring IABP after cardiac surgery.