Electrosurgical Detachment of MitraClips From the Anterior Mitral Leaflet Prior to Transcatheter Mitral Valve Implantation.

OBJECTIVES: The aim of this study was to test the hypothesis that transcatheter electrosurgery might allow intentional detachment of previously placed MitraClip(s) from the anterior leaflet to recreate a single mitral orifice for transcatheter mitral valve implantation (TMVI), leaving the retained MitraClip(s) securely fastened to the posterior leaflet and without interfering with the mitral bioprosthesis. BACKGROUND: Patients with severe mitral regurgitation or stenosis despite edge-to-edge mitral repair with the MitraClip typically have few therapeutic options because the resultant double orifice precludes TMVI. Transcatheter electrosurgery may allow detachment of failed MitraClip(s) from the anterior leaflet to recreate a single orifice for TMVI. METHODS: This was a single-center, 5-patient, consecutive, retrospective observational cohort. Patients underwent transcatheter electrosurgical laceration and stabilization of failed MitraClip(s) to recreate a single orifice, leaving the MitraClip(s) securely fastened to the posterior leaflet. Subsequently, patients underwent TMVI with an investigational device, the Tendyne mitral bioprosthesis, on a compassionate basis. Patients were followed up to 30 days. RESULTS: MitraClip detachment from the anterior leaflet and Tendyne implantation were successful in all patients. All patients survived to discharge. All patients were discharged with grade 0 central mitral regurgitation. Two patients had moderate perivalvular mitral regurgitation that did not require reintervention. During the follow-up period of 30 days, there were no deaths, cases of valve dysfunction, or reintervention. There was no evidence of erosion or bioprosthetic valve dysfunction attributable to the retained MitraClip(s) still attached to the posterior leaflet. CONCLUSIONS: Transcatheter electrosurgical detachment of failed MitraClips from the anterior leaflet followed by TMVI is technically feasible and safe at 30 days. Longer term study is needed to determine the clinical benefit of this approach and new algorithms for TMVI sizing following electrosurgical laceration and stabilization of a failed MitraClip to avoid perivalvular leak.

Antegrade Intentional Laceration of the Anterior Mitral Leaflet to Prevent Left Ventricular Outflow Tract Obstruction: A Simplified Technique From Bench to Bedside.

BACKGROUND: Intentional laceration of the anterior mitral leaflet (LAMPOON) is an effective adjunct to transcatheter mitral valve replacement that prevents left ventricular outflow tract (LVOT) obstruction. To date, LAMPOON has been performed in over 150 patients using a retrograde approach that can be technically challenging. A modified antegrade transseptal technique may simplify the procedure. METHODS: Antegrade LAMPOON was developed and tested in nonsurvival pig experiments. Thereafter, antegrade LAMPOON was performed in patients at prohibitive risk of LVOT obstruction. Clinical, procedural, and angiographic details were abstracted from medical records of their index procedure, and were compared with findings in comparable patients at risk of fixed-LVOT obstruction in the LAMPOON investigational device exemption trial. RESULTS: Eight patients at risk of fixed LVOT obstruction underwent antegrade LAMPOON. Leaflet traversal and laceration were technically successful in all. There were no cases of clinically significant LVOT obstruction (mean LVOT gradient at discharge: 5.4±1.4 mm Hg). One patient suffered a ventricular wire perforation, unrelated to the antegrade LAMPOON technique, and did not survive to discharge. At the time of discharge, no patients had an increase of >10 mm Hg in LVOT gradient compared with baseline. Procedure times (from traversal to transcatheter mitral valve replacement) were shorter, compared with the retrograde technique in the LAMPOON investigational device exemption trial (39±09 versus 65±35 minutes). All patients survived (8/8, 100%) the procedure, and 7/8 (88%) survived to 30 days, similar to subjects in the LAMPOON investigational device exemption trial. CONCLUSIONS: Antegrade LAMPOON is an effective, reproducible, and simplified strategy to lacerate the anterior leaflet before transcatheter mitral valve replacement. The authors recommend the technique as the new standard for LAMPOON.

Basic suture techniques for medicine students: comparative results according to training by surgeons versus peers.

OBJETIVO: Comparar la adquisición de habilidades básicas de sutura en estudiantes de medicina según la enseñanza práctica por cirujanos o por pares. MÉTODO: Estudio preexperimental antes y después. Se realizó un taller práctico de suturas para 46 estudiantes de medicina de octavo semestre de la Universidad de Concepción, entre noviembre y diciembre de 2017. Se distribuyó aleatoriamente a los participantes. La mitad de ellos fueron entrenados por cirujanos subespecialistas y la otra mitad por estudiantes de medicina (monitores de sutura). Se evaluaron la sutura continua y discontinua sobre un modelo biológico mediante la escala "The Objective Structured Assessment Of Technical Skills" (OSATS). Se aplicó una encuesta de satisfacción al finalizar el taller. Se comparan los resultados de la escala OSATS antes y después del taller. Se utilizó SPSS24â para el análisis estadístico mediante la prueba t de Student para muestras independientes, y se consideró significativo un valor de p < 0.05. RESULTADOS: Ambos grupos progresaron significativamente en la escala OSATS al comparar los resultados antes y después del taller: 13.0 vs. 26.0 (p < 0.001) para cirujanos y 16.8 vs. 28.0 (p < 0.001) para monitores de sutura. Los resultados después del taller no presentan diferencias significativas. CONCLUSIÓN: Los participantes adquieren habilidades básicas de sutura evidenciando una progresión significativa y similar grado de satisfacción independientemente de si son entrenados por cirujanos subespecialistas o por pares entrenados.

OBJECTIVE: To compare the acquisition of basic procedural suture skills in medical students according to practical teaching by surgeons versus peers. METHODS: Pre-experimental study before and after, a practical suture workshop was held for 46 eighth-semester medical students of the University of Concepción between November and December 2017. Participants were randomly distributed in such a way that half of them were trained by sub-specialists surgeons and the other by medical students (suture instructor). The continuous and discontinuous suture was evaluated on the biological model using the "the objective structured assessment of technical skills" (OSATS) scale. A satisfaction survey was applied at the end of the workshop. Results of the OSATS scale are compared before and after the workshop, SPSS24® was used for statistical analysis by Student's t-test for independent samples, considering significant p < 0.05. RESULTS: Both groups progressed significantly on the OSATS scale (13.0 vs. 26.0, p < 0.001 for surgeons and 16.8 vs. 27.9, p < 0.001 for suture instructors) when comparing pre- versus post-workshop results, respectively. The post-workshop results do not show significant differences. CONCLUSION: Participants acquire basic surgical suture skills evidencing significant progression and similar degree of satisfaction regardless of whether they are trained by subspecialist surgeons or trained peers.

Cirugía de la comunicación interventricular post infarto: análisis de los últimos 22 años / Surgery for post infarction ventricular septal defect: a 22-year experience

Introducción: El desarrollo de una comunicación interventricular en la evolución de un infarto miocárdico es una complicación muy grave, aunque infrecuente. Objetivo: Comunicar nuestros resultados con el tratamiento quirúrgico de pacientes con comunicación interventricular post infarto (CIVPI) intervenidos en los últimos 22 años. Método: Analizamos en forma retrospectiva los antecedentes de los pacientes intervenidos entre Enero de 1991 y Diciembre de 2012. Revisamos fichas clínicas, protocolos operatorios y certificamos la mortalidad con el Registro Civil e Identificación de Chile. Resultados: Operamos 43 pacientes, edad promedio de 66,6 +/- 10,2 años. El 58 por ciento eran hombres, de menor edad que las mujeres (63,1 +/- 10,8 vs 71,5 +/- 6,9 años, p=0,006). El tiempo promedio entre el diagnóstico de infarto y de CIVPI fue 10 +/- 15 días. El 74 por ciento fueron intervenidos de urgencia. La CIVPI fue anterior en 58 por ciento. Se realizó revascularización miocárdica concomitante en el 58 por ciento. Trece pacientes fallecieron (30 por ciento) en el posoperatorio. Factores de riesgo de mortalidad operatoria fueron: cirugía de urgencia ( p = 0,019]) y uso de balón intra aórtico (p = 0,006). La cirugía realizada después de las 24 horas del diagnóstico tuvo una mortalidad significativamente menor (7,7 por ciento, p=0,033). El seguimiento promedio fue de 8,36 +/- 5,3 años. La supervivencia alejada, excluida la mortalidad operatoria, a 5 y 10 años, fue 93 por ciento y 71 por ciento, respectivamente. Conclusión: La CIVPI tiene elevada mortalidad operatoria, especialmente en pacientes intervenidos de urgencia y en los que requirieron balón de contra pulsación, pero la supervivencia alejada de los sobrevivientes es muy satisfactoria.

Background: The development of a ventricular septal defect (VSD) after myocardial infarction is a rare but very serious complication for which the treatment of choice is surgical repair. Aim: To report our results with patients operated on for post-infarction VSD in the last 22 years. Methods: This is a retrospective review of all patients operated for post infarction VSD between january 1991 and december 2012. We reviewed all clinical charts and operative notes. Longterm mortality was certified by the "Registro Civil e Identificación de Chile". Results: Fourty three patients with a mean age of 66.6 +/- 10.2 years underwent surgical repair. Fifty eight percent were males. The average time between myocardial infarction and the diagnosis of vsd was 10 +/- 15.2 days. Seventy four percent of patients were operated on as an emergency. In 58 percent of cases the VSD was located in the anterior septum. Myocardial revascularization was performed in 58 percent. Thirteen patients died for an operative mortality of 30 percent. Risk factors for operative mortality were emergency surgery (p = 0,04) and the use of intraaortic balloon pump (p = 0,004). Non emergency surgery had a much lower mortality rate ( 7,7 percent, p = 0,033). Survival excluding operative mortality at 5 and 10 years was 90 percent and 71 percent, respectively. Conclusions: Operative mortality for repair of post infarction VSD remains high, mainly in patients undergoing an emergency operation. Surgical survivors have a very good life expectancy.