Cardiac valve papillary fibro-elastoma: a report on three different clinical cases.

Cardiac papillary fibro-elastoma is a rare benign endocardial tumour predominantly affecting the aortic and mitral valves. We report three cases with different clinical presentations, and discuss the diagnostic and therapeutic strategies.

Should minimally invasive aortic valve replacement be restricted to primary interventions?

BACKGROUND: The role of minimally invasive aortic valve replacement in cardiac reoperations has not yet been defined. The purpose of this study is to report our experience with this technique. METHODS: Nineteen consecutive patients underwent aortic valve replacement via J-sternotomy as a reoperative cardiac procedure between 1999 and 2005. The mean age was 73.6 +/- 11.4 years. Previous cardiac operations included 12 (63.2 %) coronary artery bypass graftings, 6 (31.5 %) aortic valve replacements and 1 (5.2 %) mitral valve replacement. Mean follow-up was 23.6 +/- 19.7 months. The medical records were retrospectively analyzed. RESULTS: All procedures were successful. Mean aortic cross-clamping time and cardiopulmonary bypass time were 87.4 +/- 32.7 and 133.1 +/- 54.4 minutes, respectively. Cannulation sites were: ascending aorta (52.6 %), femoral artery (47.4 %), femoral vein (94.8 %) and right atrium (5.2 %). Myocardial protection was obtained by selective coronary osteal cold crystalloid cardioplegia and systemic cooling (mean 26.2 +/- 4 degrees C). Average intubation time was 1.5 +/- 1.4 days. Mean intensive care unit stay and postoperative hospital stay was 2.9 +/- 2.6 and 12.9 +/- 5.7 days, respectively. Median chest tube output was 550 ml. There were 4 revisions for bleeding. There were 2 late deaths and one non-incision related hospital death (5 %). This patient, who was already being treated for chronic dialysis, died on day 22 due to a cerebrovascular accident. CONCLUSIONS: Minimally invasive aortic valve replacement is feasible as a reoperative procedure. Its major advantage is avoidance of cardiac reexposure with potential damage to coronary grafts. We think this technique deserves more widespread application.

Laser-assisted lead extraction: the European experience.

AIMS: The aim of this study is to investigate the safety and effectiveness of Excimer laser-assisted lead extraction in Europe. The final European multi-centre study experience is presented. METHOD AND RESULTS: The Excimer is a cool cutting laser (50 degrees C) with a wavelength of 308 nm. The energy is emitted from the tip of a flexible sheath and is absorbed by proteins and lipids, 64% of the energy is absorbed at a tissue depth of 0.06 mm. The sheath is positioned over the lead, and the fibrosis surrounding the lead is vaporized while advancing the sheath without damaging other leads. From August 1996 to March 2001, 383 leads (170 atrial, 213 ventricular) in 292 patients (mean age 61.6 years, range 13-96) were extracted at 14 European centres. Mean implantation time was 74 months (3-358). Most frequent indications were pocket infection (26%), non-functional leads (21%), patient morbidity (21%), septicaemia or endocarditis (14%), erosion (5%), and lead interference (8%). Median extraction time was 15 min (1-300). Complete extraction was achieved in 90.9% of the leads and partial extraction in 3.4%. Extraction failed in 5.7% of the leads. Major complications = perforations caused 10/22 (3.4/5.7%) of the failures. Most partially extracted patients were considered clinically successful, as only minor lead parts without clinical significance were left. Femoral non-laser technique was used to remove 8/12 of the non-complication failures. The total complication rate, including five minor complications (1.7%), was 5.1%. No in-hospital mortality occurred. CONCLUSION: Pacing and implantable cardioverter-defibrillator leads can safely, effectively, and predictably be extracted. Open-heart extractions can be limited to special cases. The results indicate that the traditional policy of abandoning redundant leads, instead of removing them, may be obsolete in many patients.

Robotically enhanced minimally invasive direct coronary artery bypass surgery: a winning strategy?

AIM: Minimally invasive direct coronary artery bypass (MIDCAB) through a small anterolateral thoracotomy on the beating heart can be considered as the better approach for treating isolated lesions on the left anterior descending (LAD) artery. This original MIDCAB procedure, however, involves a larger and often painful thoracotomy due to rib spreading. We describe our experience with robotically enhanced harvesting of one or both internal mammary arteries (IMAs), and with anastomosis performed under direct vision on a beating heart through a very small thoracotomy without rib retraction. METHODS: Between February 2001 and January 2006, 146 consecutive patients underwent robotically enhanced MIDCAB surgery. Perioperative and early follow-up data were analyzed. RESULTS: In all, 144 left and 13 right IMAs were harvested. The mean extubation time was 11.3 h, the mean intensive care (ICU) stay was 30.3 h, the mean hospital stay 8 days. There were no in-hospital deaths, postoperative myocardial infarctions or renal failures. Systematic control angiograms performed in the first 64 patients showed a 96.3% patency rate of the investigated anastomoses. CONCLUSION: Robotically assisted takedown of the IMA and direct off-pump anastomosis through a small anterolateral thoracotomy with no rib retraction appears to be safe, with minimal morbidity, little blood loss, and a reasonable ventilation time, ICU and hospital stay. It is recommended as the preferred method of revascularization for a growing number of indications and certainly an acceptable alternative to percutaneous transluminal coronary angioplasty.

Surgical treatment of atrial fibrillation.

Atrial fibrillation is a very common arrhythmia that carries a considerable risk of thromboembolic complications. Surgical treatment is an effective way to convert atrial fibrillation into sinus rhythm and significantly prevents thromboembolism postoperatively. In this review we describe recent advancements in the surgical options and detail our strategy for the surgical treatment of atrial fibrillation.

Minimally invasive aortic root replacement: a bridge too far?

AIM: Minimally invasive aortic valve surgery has been studied widely with outcomes comparable or better than standard sternotomy. We recently reported on decreased blood loss, cross clamp time and length of hospital stay when compared to conventional full sternotomy. We expanded the indication to aortic root surgery and report here our 8 years experience. METHODS: From December 1997 to November 2005, 35 patients (mean age 51.3+/-15 years) underwent aortic root replacement, through a partial upper J-sternotomy. A homograft was implanted in 26 (74.3%) patients; the remainder received a valved (4 bioprosthesis, 5 mechanical) conduit. Mean preoperative euroscore was 7+/-2.7 and mean predicted mortality was 11.5+/-13.8%. Mean and median follow-up time was 51+/-31 and 66 months, respectively. RESULTS: Mean aortic cross clamp and cardiopulmonary bypass time were 126+/-25 and 182+/-61 min respectively. Revision for bleeding was necessary in 1 (2.9%) patient. Mean extubation time was 10.4+/-4.8 hours. No postoperative strokes occurred. Intensive care unit stay ranged from 1 to 42 days (2.7+/-7.4 days, median 1). There were 3 (8.5%) early deaths (sepsis, multi-organ failure and low cardiac output) and 2 late non-cardiac deaths. Hospital morbidity included acute renal failure (n=3), pacemaker implantation (n=3), and prolonged ventilation (n=3). Eleven (31.4%) patients experienced atrial fibrillation. No other reoperations were performed. Actuarial survival at 99 months was 74.4% (n=30). CONCLUSIONS: Our results indicate that minimally invasive aortic root replacement is a challenging but feasible procedure with a lower observed mortality than predicted mortality. We continue to perform this procedure in good risk patients.

Preservation of renal function after heart transplantation: initial single-center experience with sirolimus.

BACKGROUND: Long-term survivors of heart transplantation are often confronted with chronic kidney disease, by definition related to the intake of calcineurin-inhibitors. Sirolimus is increasingly proposed as an alternative immunosuppressive agent due to its absence of nephrotoxicity. METHODS: Between November 2002 and November 2003, 9 adult heart transplant candidates with moderate to severe chronic renal disease were switched from cyclosporine to sirolimus. The conversion scheme consisted of an immediate stop of cyclosporine and an 8-mg loading dose of sirolimus, followed by 3 mg/d; after 1 week, the sirolimus dose was adjusted to maintain trough levels between 5 and 15 microg/L. The majority of patients were on corticosteroids, and on either azathioprine or mycophenolate mofetil. At conversion, the mean serum creatinine level was 2.11 (+/-0.4) mg/dL and the mean glomerular filtration rate (GFR) was 32 (+/-7) mL/min/1.73 m(2). Prior to conversion, the renal dysfunction was predominantly stable. RESULTS: After conversion, there were 7 dropouts (75%) due to several side effects related to sirolimus: edema (n = 2), general discomfort (n = 2), delayed wound healing (n = 1), cardiac thrombus (n = 1), and diarrhea (n = 1). The median treatment time with Sirolimus, therefore, was only 4.0 months. While on sirolimus, the renal function of all patients remained unchanged or showed even some improvement. Retrospective nephrological review revealed severe renal artery stenoses in 2 patients and serious generalized abdominal and renal atheromatosis in 7 patients. No cardiac dysfunction was seen. CONCLUSION: Conversion from cyclosporine to sirolimus was problematic due to sirolimus side effects, occurring at any time after the switch. One should also question whether chronic kidney disease after heart transplantation is routinely caused by the administration of calcineurin-inhibitors, in view of the generalized renal and abdominal atheromatosis.

Superior vena cava syndrome caused by a pseudoaneurysm of the ascending aorta.

Pseudoaneurysm of the ascending aorta is a well known complication after aortic root surgery. A case of a large pseudoaneurysm is reported, seen as a superior vena cava syndrome, a very rare clinical presentation. Perioperative transoesophageal echocardiography showed the presence of a large pseudoaneurysm starting from the left coronary ostium implantation.

Initial experience with an endoscopic radial artery harvesting technique.

OBJECTIVE: The purpose of the study was to investigate the feasibility of an endoscopic radial artery harvesting technique to improve esthetic results and possibly reduce the incidence of neurologic complications observed with the open method. METHODS: Between July 1, 2002, and October 1, 2003, a total of 54 patients underwent endoscopic radial artery harvesting at our institution. Standard endoscopic equipment and a Harmonic Scalpel (Ethicon Endo-Surgery, Inc, Cincinnati, Ohio) were used. Mean age of the patients was 63 +/- 8.1 years, and 16% were female. All patients underwent a preoperative Allen test and duplex ultrasonography to demonstrate adequate ulnar collateral flow. The nondominant arm was used for radial artery harvesting. Mean clinical follow-up was 13 +/- 4.6 months. RESULTS: The artery was harvested through a 3-cm incision at the wrist and was divided at the elbow either through a small counterincision (n = 16) or endoscopically with the use of clips, Endoloop, and endoscopic scissors (n = 38). Mean harvest time was 42.2 +/- 16.9 minutes but decreased from 85 minutes for the first cases to 25 minutes for the last 5 cases. Mean harvested length was 19.6 +/- 1.7 cm. Harvesting complications included 1 conversion, 2 postoperative hematomas, 1 injury, 8 endoscopically controlled bleedings, and 15 cases of at least some superficial radial nerve paresthesia at 6 weeks (clinically relevant in 4 cases). Selective postoperative angiography revealed 1 occluded graft and 1 stenotic graft requiring percutaneous transluminal coronary angioplasty of the native vessel. Eighty-seven percent of the patients were enthusiastic about this new procedure. CONCLUSIONS: Endoscopic radial artery harvesting is a feasible procedure that requires a definite learning curve. Although nerve paresthesias were not completely eliminated in our experience, the technique provided ample patient satisfaction. Further clinical follow-up is required to determine long-term patency rates.

Minimally invasive video-assisted mitral valve repair: short and mid-term results.

BACKGROUND AND AIM OF THE STUDY: Port-Access video-assisted surgery for mitral valve repair has become an alternative for mid-sternotomy. However, mid-term results are not yet available. METHODS: Between February 1997 and December 1999, 121 patients underwent mitral valve surgery through a 4- to 5-cm right anterolateral thoracotomy using the Heartport endovascular cardiopulmonary bypass system; among these patients, 77 (57 males, 20 females; mean age 59 years; range 31-84 years) underwent mitral valve repair. Severe (4+) mitral regurgitation (MR) was seen in 63 patients (82%). Mean NYHA class was 2.5+/-0.4. Standard Carpentier mitral valve repair procedures were used in all patients; 11 received PTFE chordae for anterior leaflet prolapse. RESULTS: Pathologies were degenerative (n = 69), chronic endocarditis (n = 4), annular dilatation (n = 3) and rheumatic (n = 1). Hospital mortality was 1.3% (n = 1). Two patients (2.6%) had conversion to sternotomy for aortic dissection caused by the Endo-Aortic Clamp. Nine patients (11%) underwent revision for bleeding. Mean cross-clamp and perfusion times were 103 min (range: 24-160 min) and 140 min (range: 75-215 min), respectively. Mean hospital stay was eight days (range: 4-36 days). During follow up (mean 31 months; range: 17-51 months) all patients improved their NYHA class; eight (11%) remained in class II. Left ventricular (LV) end-diastolic and LV end-systolic diameters decreased from 61+/-7.3 mm to 53+/-6.9 mm (p <0.01) and from 37+/-6.8 mm to 34+/-6.9 mm (p <0.05), respectively. Sixty-two patients (88%) had no or trivial MR, and nine (12%) had moderate MR (2+). There were two late valve replacements for endocarditis, and no late deaths. CONCLUSION: Port-Access mitral valve repair constitutes a valid alternative to the standard procedure, and has good mid-term results. Video-assisted mitral valve repair appears to be safe and reproducible.

Aggressive primary treatment for poststernotomy acute mediastinitis: our experience with omental- and muscle flaps surgery.

OBJECTIVE: The surgical treatment of poststernotomy acute mediastinitis remains challenging. After disappointing results with a conservative management of post coronary artery bypass grafting (CABG) mediastinitis, we shifted towards a more aggressive surgical management. METHODS: From March 1993 until December 1999, 32 patients (6 female/26 male), 0.5% of the total sternotomy population, were operated for mediastinitis, defined as wound and sternal dehiscence with medistinal pus and positive culture. Mean age was 66 years (32-79 years). Twenty-two patients (75%) underwent CABG and 16 patients were in New York Heart Association (NYHA) class III/IV. RESULTS: We performed an omentoplasty in 11 patients, a pectoralis muscle flap associated with an omentoplasty in 20 patients. One patient had a bilateral pectoralis myoplasty. The reconstruction surgery occurred at an average of 11 days (6-26) after primary surgery. Twelve patients had a previous surgical drainage (1-3 surgical procedures) of the mediastinum. Hospital mortality was nine patients (28%). Seven of these patients (77%) were in NYHA IV with inotropic support. Five patients had to be reoperated on: four patients had a bilateral myoplasty after omentoplasty, one patient had an omentoplasty after a unilateral myoplasty. Late epigastric hernia was seen in three patients, two patients had wound revision and one had a retroperitoneal drainage for pancreatitis. There were no early or late flap failures. CONCLUSION: In our experience, omental and pectoralis flaps for poststernotomy acute mediastinitis provides good outcome of our stable patients. We would be reluctant to use it as standard therapy in our unstable patients.

Minimally invasive video-assisted mitral valve surgery: our lessons after a 4-year experience.

BACKGROUND: Right thoracotomy is a well known alternative to median sternotomy to gain access to the left atrium. To avoid the potential drawbacks associated with sternotomy coupled to the desire for a smaller scar and a more rapid rehabilitation in young and active patients, we investigated the purported advantages in patients undergoing video-assisted Port-Access mitral valve surgery. METHODS: Between February 1997 and November 2000, 175 patients (94 men, 81 women) with a mean age of 60 years (range 25 to 84) underwent either Port-Access mitral valve repair (n = 117) or replacement (n = 57) for degenerative disease (n = 112), rheumatic disease (n = 36), chronic endocarditis (n = 15), annular dilatation (n = 8), sclerotic disease (n = 2), and ingrowing myxoma (n = 1). There was one closure of a preexisting paravalvular leak. Standard Carpentier-Edwards repair procedures were used in all patients; in 14 patients polytetrafluoroethylene chordae were inserted for anterior leaflet prolapse. A total of 74 patients (42%) were in New York Heart Association functional class III/IV. RESULTS: Hospital mortality was 1.1% (n = 2). Four patients had conversion to sternotomy and conventional extra corporeal circulation for repair of a dissected aorta (n = 2) or the inabilty to proceed to a safe femoral cannulation (n = 2). Sixteen patients (9%) underwent a revision for bleeding. Mean cross-clamp time and perfusion time was 95 minutes (range 24 to 160) and 135 minutes (range 75 to 215) respectively. Mean intensive care unit and total hospital stay was 1.8 days (1 to 30) and 8.7 days (4 to 36), respectively. Three patients experienced late acute endocarditis: 2 had late mitral valve replacements and 1 patient had medical therapy for late prosthetic valve endocarditis. There were no myocardial infarctions, cerebrovascular events or peripheral ischemia due to thromboembolic phenomena. No wound complications were observed. The degree of patient satisfaction was very high. CONCLUSIONS: The video-assisted Port-Access mitral valve approach is a valid alternative to sternotomy, with the same standards of results and quality.

Minimally invasive video-assisted mitral valve surgery: from Port-Access towards a totally endoscopic procedure.

UNLABELLED: Right thoracotomy is an alternative to mid-sternotomy for left atrium access. The Port-Access approach is an option that reduces the skin incision and obviates rib spreading. PATIENTS AND METHODS: From February 1997 until November 1999, 121 patients underwent mitral valve surgery through a right antero-lateral thoracotomy using the Heartport cardiopulmonary bypass (CPB) system. Mean age was 60 years (31-84). Most patients had normal ejection fractions and were in NYHA Class II or III. Seventy-five patients had valve repair (62%) and 46 (38%) had valve replacement. Pathologies were myxoid (n = 80), rheumatic (n = 30), chronic endocarditis (n = 5), annular dilatation (n = 3), sclerotic (n = 1), ingrowing myxoma (n = 1), and one closure of a paravalvular leak. RESULTS: Two patients had conversion to sternotomy for aortic dissection (one died) with the Endo-Aortic Clamp, and two others for peripheral vascular problems. One patient died at postoperative day 1 after reoperation for failed repair, another with double valve surgery on postoperative day 4 after two revisions for bleeding. Twelve underwent revision for bleeding (10%). Three had prolonged ICU stay for respiratory insufficiency. Two late valve replacements for endocarditis occurred. Echographic control revealed residual insufficiencies (grade 1-2) in two valvular repairs. There were neither paravalvular leaks nor myocardial infarcts. There were no cerebrovascular accidents due to embolic phenomena. Mean ICU and hospital stay were 2.1 and 8.7 days, with a major difference between the first 30 patients and those who followed. CONCLUSION: Port-Access mitral valve surgery can be a valid alternative to conventional sternotomy and seems to be an important improvement in minimally invasive cardiac surgery.

Coronary artery bypass grafting and defibrillator implantation in patients with ventricular tachyarrhythmias and ischemic heart disease.

In patients with sustained ventricular tachyarrhythmias and myocardial ischemia due to multivessel coronary artery disease, it remains unclear whether revascularization is enough to control the arrhythmias or whether additional implantation of a defibrillator is indicated. We therefore reviewed our clinical strategy of performing both bypass surgery and implantation of a defibrillator in patients with syncopal ventricular tachycardia or fibrillation and significant multivessel coronary artery disease. We retrospectively reviewed the outcome of 18 patients with malignant ventricular tachyarrhythmias, significant multivessel coronary artery disease, and signs of myocardial ischemia who underwent both bypass surgery and defibrillator implantation. Data on these patients were compared to data from 232 other defibrillator patients with respect to baseline clinical variables, cardiac events, and mortality during follow-up. Except for underlying pathology, no other important differences in baseline characteristics were noted between the study patients and the other defibrillator patients. The cumulative occurrence of shocks during follow-up was comparable in both groups (66% vs 67%). The cumulative survival from all-cause mortality was 94% in the study patients and 78% in the others (P = NS). Pre- and postoperative electrophysiological testing was not useful to predict arrhythmia recurrences. In this population of patients with ventricular tachyarrhythmias and ischemia due to multivessel coronary artery disease, bypass surgery alone would not have prevented recurrences of arrhythmias. An excellent survival and a high incidence of shocks after both bypass surgery and defibrillator implantation were observed.

Video-assisted Port-Access mitral valve surgery: from debut to routine surgery. Will Trocar-Port-Access cardiac surgery ultimately lead to robotic cardiac surgery?

A right thoracotomy is a well-known alternative for midsternotomy to have access to the left atrium. The Port-Access (Heartport, Inc, Redwood City, CA) approach is an invaluable option to avoid cracking of ribs and cartilage. EndoCPB (Heartport, Inc) and Endo-Aortic Clamp (Heartport, Inc) allows installation of the extracorporeal circulation and cardiac arrest from the groin. Videoassistance and shafted instruments help the surgeon to perform the surgery through a 5 x 2-cm port and fulfill the main goals of minimally invasive cardiac surgery, comfort, cosmesis, and fast rehabilitation. From February 1997 to November 1998, 75 patients (40 men/35 women) had either Port-Access mitral valve repair (n = 41) or replacement (n = 33) for a variety of reasons: myxoid degeneration (n = 45), rheumatic disease (n = 21), chronic endocarditis (n = 4), annular dilatation (n = 2), and sclerotic disease (n = 2). One valve was replaced because of an ingrowing myxoma. There was one closure of a paravalvular leak. The mean age was 59.3 years of age (range, 32 to 83 years). Most patients had normal ejection fractions but different grades of mitral valve insufficiency and were in NYHA class II. One 71-year-old patient died after reoperation on postoperative day 1 for failed repair. Two patients had conversion to sternotomy and conventional ECC for repair of a dissected aorta. One patient died, one patient suffered a minor cerebrovascular deficit. Three patients had prolonged intensive care unit (ICU) stays for respiratory insufficiency, 5 patients underwent revision for bleeding. Mean ICU stay was 2.5 days; and mean hospital stay, 9 days (range, 4 to 36). A significant difference between the first 30 and last 38 patients in terms of length of stay in the ICU and the hospital was noticed. Two late mitral valve replacements for chronic endocarditis after repair occurred. One patient had medical therapy for endocarditis after mitral valve replacement. The debut of Port-Access mitral valve surgery may be nerve-racking; the routine is a smooth and sure surgery with maximum comfort, a very discrete scar, and a fast rehabilitation. There were no paravalvular leakages nor myocardial infarctions. Cerebrovascular accidents owing to thromboembolic phenomena, vascular lower limb or wound complications were not seen. Port-Access mitral valve surgery is a very important investment in the future of cardiac surgery. Some learning curve pitfalls were associated with the process of starting this revolutionary technique.