Simplifying Mitral Valve Repair: A Guide to Neochordae Reconstruction.

Mitral valve reconstruction techniques using polytetrafluoroethylene sutures are associated with high repair rates and excellent durability but are dependent on accurate neochordae length estimates. Current strategies to determine the appropriate length of artificial neochordae commonly rely on nonphysiologic saline testing on the arrested heart, with erroneous lengths resulting in residual mitral regurgitation. We present a guide for reproducible and accurate neochordae reconstruction based upon transesophageal echocardiographic measurements, which simplifies mitral repair for most patients with degenerative mitral regurgitation and can be used in conventional or minimally invasive approaches.

Impact of a tailored surgical approach on autograft root dimensions in patients undergoing the Ross procedure for aortic regurgitation†.

OBJECTIVES: The Ross procedure in patients with aortic regurgitation (AR) has been associated with increased autograft dilatation and late reintervention. The aim of this study was to evaluate the impact of a tailored approach aimed at mitigating that risk on early changes in autograft root dimensions following the Ross procedure in patients with AR. METHODS: From 2011 to 2018, 241 consecutive patients underwent a Ross procedure with >1 year of follow-up [46 (7) years]. Aortic root dimensions were prospectively measured on serial echocardiograms. Patients with aortic stenosis group (n = 171; 71%) were compared to those with AR or mixed aortic disease (AR group) (n = 70; 29%). Mean length of follow-up was 29 ± 11 months (100% complete). Changes in aortic dimensions were analysed using mixed-effect models. RESULTS: At 4 years, mean indexed diameters of the annulus, sinuses of Valsalva and the sinotubular junction in the AR group were 12.3 (0.2) mm/m2, 20.0 (0.4) mm/m2 and 16.3 (0.9) mm/m2, respectively, vs 11.9 (0.2), 18.4 (0.3) and 15.5 (0.5) in the aortic stenosis group. Overall, there were no significant differences in the rates of autograft annulus, sinuses of Valsalva and sinotubular junction dimension changes between the aortic stenosis and AR groups up to 4 years after surgery (P = 0.55, P = 0.12, P = 0.59 and P = 0.48, respectively). CONCLUSIONS: Use of a tailored surgical approach, combined with a strict blood pressure control, appears to mitigate clinically significant early dilatation of the autograft root following a Ross procedure in patients with AR. Further follow-up is needed to determine if this will translate into a lower incidence of long-term reintervention.

Developing skills for thoracic aortic surgery with hypothermic circulatory arrest.

OBJECTIVES: To examine the performance curves of 8 early-career aortic surgeons with the use of hypothermic circulatory arrest (HCA) and to analyze the impact of the learning curve on perioperative outcomes. METHODS: A total of 1025 consecutive patients who underwent aortic reconstruction with HCA between 2002 and 2017 were analyzed for mortality and 5 other complications (stroke, reoperation for bleeding, dialysis, prolonged ventilation, and sternal wound complications), subdivided into 3 consecutive time periods. This cohort represents the complete inaugural experience of 8 Canadian academic aortic surgeons. A risk-adjusted cumulative sum analysis was used to evaluate the performance curve with respect to predetermined 80% alert and 95% alarm boundary lines. RESULTS: Mean age was 62 ± 13 years, 71% of patients were male, and 24% presented nonelectively. Hemiarch repair was performed in 80% and total arch replacement in 20%. There was a reduction in the incidence of the primary composite outcome over time (P1: 26%, P2: 23%, and P3: 16%; P = .010). Overall in-hospital mortality was 5% and remained stable throughout the 3 periods. Rates of stroke were lower in the late period (P1: 4%, P2: 6%, and P3: 2%; P = .035). Risk-adjusted cumulative sum analysis demonstrated that all surgeons remained within the 95% reassurance boundary throughout their experience, with 6 surgeons performing as expected and 2 performing better than expected. CONCLUSIONS: Early-career surgeons can safely perform operations with HCA from the initiation of their practice. The cumulative sum analysis method is valuable for monitoring competence in aortic surgery and could prove useful in structuring training programs.

Expanding Eligibility for the Ross Procedure: A Reasonable Proposition?

BACKGROUND: Although the Ross procedure offers potential benefits in young adults, technical complexity represents a significant limitation. Therefore, the safety of expanding its use in more complex settings is uncertain. The aim of this study was to compare early outcomes of standard isolated Ross procedures vs expanding elgibility to higher-risk clinical settings. METHODS: From 2011 to 2016, 261 patients (46 ± 12 years) underwent Ross procedures in 2 centres. Patients were divided into 2 groups: standard Ross (n = 166) and expanded eligibility Ross (n = 95). Inclusion criteria for the expanded eligibility group were previous cardiac surgery, acute aortic valve endocarditis, severely impaired left ventricular (LV) function and patients undergoing concomitant procedures. All data were prospectively collected and are 100% complete. RESULTS: Hospital mortality was 0% in the standard group (0/166) vs 2% in the expanded eligibility group (2/95) (P = 0.13). Sixteen patients (10%) developed acute renal injury in the standard group vs 13 (14%) patients in the expanded eligibility group (P = 0.31). There were no postoperative myocardial infarctions, no neurological events, and no infectious complications. Median intensive care unit (ICU) stay in the standard group was 2 vs 3 days in the expanded eligibility group (P = 0.004), whereas median hospital stay was 6 vs 7 days, respectively (range: 3-19 days) (P < 0.001). CONCLUSION: Aside from longer ICU and hospital lengths of stay after the Ross procedure in higher-risk clinical scenarios, perioperative mortality and morbidity is similar to standard Ross procedures. Expanding the use of the Ross operation in young adults is a safe alternative in centres of expertise.

Mitral repair and the robot: a revolutionary tool or marketing ploy?

PURPOSE OF REVIEW: In this review, we discuss the current evidence supporting each minimally invasive mitral repair approach and their associated controversies. RECENT FINDINGS: Current evidence demonstrates that minimally invasive mitral repair techniques yield similar mitral repair results to conventional sternotomy with the benefits of shorter hospital stay, quicker recovery, better cosmesis and improved patient satisfaction. Despite this, broad adoption of minimally invasive mitral repair is still not achieved. Two main approaches of minimally invasive mitral repair exist: endoscopic mini-thoracotomy and robotic-assisted approaches. SUMMARY: Both minimally invasive approaches share many commonalities; however, most centres are strongly polarized to one approach over another creating controversy and debate about the most effective minimally invasive approach.

Reexamining the Role of Surgical Aortic Valve Replacement After Mediastinal Radiation Therapy.

BACKGROUND: The risk of aortic valve replacement (AVR) for patients after mediastinal radiation therapy (MRT) remains unaccounted for in traditional risk scores. The aim of this study was to examine perioperative and midterm outcomes in patients undergoing AVR after MRT in the current era. METHODS: From 2000 to 2016, 49 consecutive patients previously exposed to MRT underwent AVR with or without concomitant procedures at a single center. Patients were divided into two groups: isolated AVR (n = 18) and AVR with concomitant procedures (n = 31). The logistic European System for Cardiac Operative Risk Evaluation II mean score was 2.8% ± 3.4% and The Society of Thoracic Surgeons mean score was 1.7% ± 1.5%. Median follow-up was 6.6 years and was 90% complete within 12 months of study closure. RESULTS: Overall inhospital mortality was 10% (0% in the isolated group versus 16% in the concomitant group; p = 0.14). A total of 21 patients (47%) died at follow-up. Mean interval to death was 2.0 ± 1.1 years from surgery in the isolated group versus 1.4 ± 1.6 years in the concomitant group (p = 0.18). Actuarial survival was 93% ± 6%, 73% ± 11%, and 65% ± 13%, at 1, 3, and 5 years, respectively, in the isolated group versus 74% ± 8%, 44% ± 11%, and 37% ± 11% in the concomitant group (p = 0.03). CONCLUSIONS: Isolated AVR can be performed safely in patients with MRT-induced disease. In contrast, AVR with concomitant procedures is associated with high mortality, which is vastly underestimated using traditional risk scores. In both groups, survival at 5 years is markedly impaired.

Impact of the Learning Curve on Early Outcomes Following the Ross Procedure.

BACKGROUND: Use of the Ross procedure has decreased in recent years, in part because of concerns about operative risks. The aim of this study was to assess the impact of the learning curve on early outcomes when starting a Ross program in the current era. METHODS: From 2011-2016, 200 consecutive Ross procedures were performed in young and middle-aged adults (< 65 years), representing our entire inaugural experience. The cohort was chronologically divided into 2 consecutive periods of 100 patients. Efficiency end points (cross-clamp and bypass times), safety (including mortality and major morbidity) and efficacy end points (aortic or pulmonary regurgitation > 1/4) were compared. A cumulative sum analysis (CUSUM) was performed to evaluate the primary safety end points. RESULTS: Overall, there were 2 operative mortalities (1%). There was a temporal trend towards reduction in the incidence of major complications after the first period (11 [11%]) vs the second period (4 [4%]; P = 0.06). Similarly, there was a statistically significant improvement in efficiency after the first period regarding cross-clamp times (first period, 194 ± 29 minutes vs second period, 170 ± 28 minutes; P = 0.001) and bypass times (first period, 225 ± 42 minutes vs second period, 205 ± 37 minutes; P = 0.001). CUSUM analysis shows that improvements in safety and efficiency occur after approximately 75-100 cases. CONCLUSIONS: The learning curve associated with the Ross procedure for an early-career surgeon is approximately 75-100 cases, with improvements in safety and efficiency outcomes in a dedicated program. Despite a definite learning curve effect, overall operative mortality remained low.

Is the Ross procedure a riskier operation? Perioperative outcome comparison with mechanical aortic valve replacement in a propensity-matched cohort.

OBJECTIVES: The aim of this study was to compare perioperative outcomes in young adults following isolated Ross procedure versus mechanical aortic valve replacement (AVR) in a high-volume centre. METHODS: From 2007 to 2015, 337 elective isolated mechanical AVRs and 137 Ross procedures were performed in young adults (<65 years) at our centre. Using a 1:1 propensity score match analysis, 140 patients were included in the study (n = 70 in each group). Perioperative outcomes were defined using STS guidelines. The primary outcome was operative mortality. RESULTS: Median age was 52 [14] years and EuroSCORE II was 1.0 [0.4]%. There were no mortalities in the two groups. There were no differences in the incidence of myocardial injury (0% overall) and neurological complications (0.7% overall). Three (4%) reinterventions for bleeding were required in the Ross cohort versus six (9%) in the mechanical AVR cohort (P = 0.49). A significant increase in serum creatinine (>2-fold increase) was more commonly observed after the Ross procedure (11 vs 1%; P = 0.03), but there was no significant difference in the rate of temporary dialysis. Twenty-seven patients (39%) required ≥1 blood product transfusion in the Ross group, whereas 21 patients (31%) did so in the mechanical AVR group (P = 0.47). Median hospital length of stay was similar in both the groups (6 days). CONCLUSIONS: There are no differences in mortality or major perioperative outcomes in adults undergoing an isolated Ross procedure or mechanical AVR.

Conduction Disorders After Sutureless Aortic Valve Replacement.

BACKGROUND: Sutureless self-expandable aortic bioprostheses rely on radial forces for stabilization, raising concern that these devices may increase the risk of postoperative conduction disease. The purpose of this study was to determine the incidence of conduction disorders after sutureless aortic valve replacement (AVR) with the Perceval S (Sorin Group, Saluggia, Italy) bioprosthesis. METHODS: Between June 2011 and March 2013, 108 consecutive patients underwent sutureless AVR with the Perceval S prosthesis. Six patients (6%) had a permanent pacemaker (PPM) preoperatively and were excluded from the present study. Mean electrocardiographic follow-up was 14.6 ± 6.0 months. RESULTS: Mean age was 79.2 ± 4.8 years (52% female). During the postoperative period, 34 patients (34%) had first-degree atrioventricular block, 2 (2%) had Mobitz-II atrioventricular block, and 16 (16%) had complete atrioventricular block. New-onset left bundle branch block and right bundle branch block were observed in 33 patients (33%) and 22 patients (22%), respectively. Inhospital postoperative PPM implantation was required in 23 patients (23%). Preoperative aortic valve area, age more than 85 years, and preoperative right bundle branch block were found to be independently associated with inhospital PPM implantation or new-onset postoperative conduction disorder. At follow-up, 3 more patients (3%) underwent PPM implantation. The cumulative incidences of PPM dependency and ventricular pacing more than 25% of the time were 18% ± 11% and 21% ± 10%, respectively, at 18 months. CONCLUSIONS: In the present study, the postoperative PPM implantation rate (23%) after sutureless AVR with the Perceval S prosthesis was high. Surgical strategies aimed at mitigating this risk should be further investigated.

Management of small aortic annulus in the era of sutureless valves: A comparative study among different biological options.

OBJECTIVE: Aortic valve replacement (AVR) in patients with a small aortic annulus is a challenging problem. The objective of this study was to compare 4 surgical approaches in terms of hemodynamics and perioperative outcomes. METHODS: A retrospective single-center study included 351 consecutive patients with a small aortic annulus (≤21 mm) who underwent aortic valve surgery between January 2007 and December 2014. Surgical techniques included standard AVR in 259 (74%) patients, aortic root enlargement in 20 (6%), implantation of a stentless bioprosthesis in 23 (6%), and sutureless AVR in 49 (13%). RESULTS: Three hundred and eleven (89%) patients were female. The mean Logistic EuroSCORE II varied significantly among the groups and ranged from 6.5% ± 5.4% in the standard AVR group to 9.2% ± 4.7% in the stentless group. Early mortality occurred in 26 (7%) patients. Patients in the stentless group had the lowest aortic valve mean gradients on predischarge transthoracic echocardiography (10.9 ± 6.2 mm Hg; P < .001). In the stented group, the Trifecta prosthesis displayed the lowest postoperative mean transaortic gradient (10.3 ± 3.6; P < .001) with no severe prosthesis-patient mismatch. Postoperative gradients of the sutureless group were comparable with stented prostheses. CONCLUSIONS: In our study, stentless AVR and Trifecta bioprostheses had the best hemodynamic outcomes. The Perceval sutureless prosthesis provides reasonable hemodynamic performance and is a safe alternative.

A Novel Minimally Invasive Approach for Surgical Septal Myectomy.

BACKGROUND: Transaortic septal myectomy is the gold standard for the treatment of symptomatic hypertrophic obstructive cardiomyopathy that is refractory to medical therapy. The aim of this study was to assess early outcomes of minimally invasive septal myectomy performed through a right anterior minithoracotomy. METHODS: Between 2011 and 2014, 24 consecutive patients underwent isolated septal myectomy through a 4-5-cm right parasternal minithoracotomy. Perioperative clinical and echocardiographic outcomes in these patients were compared with those of a historical cohort of 26 consecutive patients who underwent isolated septal myectomy performed through a median sternotomy between 2002 and 2010. RESULTS: Age and sex distribution were similar between the groups. Median aortic cross-clamp time was 57 minutes in the minithoracotomy group vs 43 minutes in the sternotomy group (P = 0.149). There was no in-hospital mortality in either group. Intraoperative conversion to sternotomy was required in 1 patient. Postoperative permanent pacemaker implantation was required in 5 patients from each group (P = 0.999). Both groups demonstrated similar reductions in left ventricular outflow tract gradient and septal thickness. Residual obstructive systolic anterior motion of the mitral valve was observed in 2 patients (8%) in the minithoracotomy group and 1 patient (4%) in the sternotomy group (P = 0.602). CONCLUSIONS: This study demonstrates the feasibility of transaortic septal myectomy through a right minithoracotomy. Our early results suggest that this technique yields clinical and echocardiographic outcomes similar to those obtained with standard sternotomy.

Beating Heart Minimally Invasive Mitral Valve Surgery in Patients With Patent Coronary Bypass Grafts.

BACKGROUND: Redo mitral valve surgery in patients with patent coronary bypass grafts carries a risk of graft injury and postoperative bleeding. We compare early results of reoperative minimally invasive on-pump beating heart mitral valve surgery (OPBMS) via mini thoracotomy vs the results of standard sternotomy mitral valve surgery (SSMS) in the presence of patent coronary bypass grafts. METHODS: Between 2009 and 2015, 12 patients underwent OPBMS through a right mini thoracotomy and 6 patients underwent SSMS. All patients had at least 1 patent bypass graft. RESULTS: Median age and EuroSCORE II were not statistically different between the 2 groups. There was no early death in the OPBMS group vs 1 death (17%) in the SSMS group. There was a statistically significant lower median perioperative blood loss in the OPBMS group compared with the SSMS group (200 vs 650 mL; P = 0.005). Four patients (33%) in the OPBMS group required blood transfusion compared with 4 in the SSMS group (67%; P = 0.32). There was 1 perioperative stroke (17%) and 1 acute myocardial infarction (17%) in the SSMS group. Four patients developed acute renal failure in the OPBMS group compared with 3 in the SSMS group (50%; P = 0.62). The predischarge transthoracic echocardiogram showed ≤ 1 mitral regurgitation in all patients. CONCLUSIONS: Redo mitral surgery in patients with patent bypass grafts can safely be performed via minimally invasive mini thoracotomy on a beating heart. The main benefits of this approach are to avoid the sternotomy and decrease the amount of postoperative blood loss.

Long-term results after surgical treatment of paravalvular leak in the aortic and mitral position.

OBJECTIVES: The aim of this study was to determine immediate results and long-term outcomes after surgical management of paravalvular leak (PVL). METHODS: Between 1995 and 2012, a total of 190 patients underwent primary surgical repair (n = 142) or valve replacement (n = 48) for a PVL at our institution. The PVL was mild in 6 (3%) patients, moderate in 85 (45%), moderate to severe in 84 (44%), and severe in 15 (8%). Among these, 120 (63%) had PVL in the mitral position, 63 (33%) had PVL in the aortic position, and 7 (4%) had PVL in both valves. Mean follow-up was 5.3 ± 4.6 years. RESULTS: Mean age at surgery was 63 ± 12 years (64% men). Operative mortality occurred in 13 (7%) patients (10 [8%] in mitral; 2 [3%] in aortic; and 1 [14%] in double valve procedures). Survival at 1, 5, and 10 years was 85% ± 3%, 73% ± 4%, and 56% ± 5%, respectively. The cumulative incidence of PVL recurrence was 3% ± 1%, 14% ± 3%, and 32% ± 6%, at 1, 5, and 10 years, respectively. The number of previous surgeries was a predictor of survival and PVL recurrence. Freedom from New York Heart Association class ≥III was 96% ± 2%, 82% ± 4%, and 58% ± 6%, at 1, 5, and 10 years, respectively. The freedom from rehospitalization for heart failure was 92% ± 2%, 83% ± 4%, and 67% ± 6%, at 1, 5, and 10 years. CONCLUSIONS: Surgical treatment of PVL resulted in acceptable outcomes. Nevertheless, the continued risk of PVL recurrence is higher in patients who have had multiple previous surgeries. More studies are needed to compare these results with the transcatheter PVL reduction technique.

Very high repair rate using minimally invasive surgery for the treatment of degenerative mitral insufficiency.

BACKGROUND: Minimally invasive mitral valve surgery (MIMVS) is an established alternative to median sternotomy for mitral valve repair. However, this technique has yet to gain widespread adoption, partly because of concerns that this approach might yield lower repair rates or repairs that are less durable than those performed through a sternotomy. The purpose of this study was to report our inaugural experience with MIMVS, with a focus on mitral valve repair rate and midterm outcomes. METHODS: Between May 2006 and April 2012, minimally invasive mitral valve repair was attempted in 200 consecutive patients with degenerative mitral disease. The approach used was a 4- to 5-cm right anterolateral minithoracotomy with femorofemoral cannulation for cardiopulmonary bypass. Mean follow-up was 2.9 ± 1.8 years, and follow-up was 99% complete. RESULTS: The mitral valve was successfully repaired in all but 2 patients, yielding a repair rate of 99%. Hospital mortality occurred in 2 patients (1%). Intraoperative conversion to sternotomy was necessary in 12 patients (6%), including 1 of the 2 unsuccessful repairs. Mean cardiopulmonary bypass and aortic cross-clamp times were 130.8 ± 41.3 minutes and 104.8 ± 35.6 minutes, respectively. Median hospital stay was 5 days. The 5-year survival and freedom from reoperation were 97.9% ± 1.5% and 98.1% ± 1.3%, respectively. CONCLUSIONS: A very high repair rate can be achieved using MIMVS for the treatment of degenerative mitral regurgitation, including during the learning phase. Midterm survival and freedom from valve-related reoperation are excellent. MIMVS is a safe and effective alternative to mitral valve repair through a sternotomy.