Valvular cardiac surgery

Demonstration of infective endocarditis by cardiac CT and transoesophageal echocardiography: comparison with intra-operative findings.

Eur Heart J Cardiovasc Imaging. 2017 Feb 23;:

Authors: Koo HJ, Yang DH, Kang JW, Lee JY, Kim DH, Song JM, Kang DH, Song JK, Kim JB, Jung SH, Choo SJ, Chung CH, Lee JW, Lim TH

Abstract
Aims: We aimed to compare imaging findings of infective endocarditis between computed tomography (CT) and transoesophageal echocardiography (TEE) using surgical inspection as a reference standard.
Methods and results: Forty-nine patients (aged 54 ± 17 years, 69% men) who underwent pre-operative CT and TEE for infective endocarditis were included. Twelve of these patients had prosthetic valve endocarditis. Imaging findings of infective endocarditis were classified as vegetation, leaflet perforation, abscess/pseudoaneurysm, and paravalvular leakage. Diagnostic performances of CT and TEE were evaluated using surgical inspection as a reference standard. Interobserver agreements for CT findings were obtained using Cohen's κ test. The detection rates of infective endocarditis per patient with CT and TEE were 93.9% (46/49) and 95.9% (47/49), respectively. In per-imaging analysis, the sensitivities of CT and TEE were not significantly different for both native and prosthetic valve infective endocarditis (sensitivity: vegetation, 100% in TEE and 90.9% in CT; leaflet perforation, 87.5% in TEE and 50.0% in CT; abscess/pseudoaneurysm, 40.0% in TEE and 60.0% in CT; paravalvular leakage, 100% in TEE and 50.0% in CT). Interobserver agreements for CT findings were substantial or excellent (0.79-0.88).
Conclusion: Cardiac CT can accurately demonstrate infective endocarditis in pre-operative patients with a similar diagnostic accuracy to TEE. The interobserver agreements for the CT findings of infective endocarditis were excellent.

PMID: 28329276 [PubMed - as supplied by publisher]

A novel approach in the management of right-sided endocarditis: percutaneous vegectomy using the AngioVac cannula.

Future Cardiol. 2017 Mar 22;:

Authors: Thiagaraj AK, Malviya M, Htun WW, Telila T, Lerner SA, Elder MD, Schreiber TL

Abstract
The AngioVac is a vacuum-based device introduced in 2012 to percutaneously remove undesirable material from the intravascular system. In scattered reports, the AngioVac has been used for removal of device lead vegetations and right-sided thrombi. In this article, we describe three cases of right-sided endocarditis treated with AngioVac: a mobile mass extending from the vena cava into the right atrium, large native tricuspid vegetations, and bioprosthetic tricuspid vegetations. This device shows benefit in reducing vegetation load, decreasing septic lung embolization, and reducing reinfection in active intravenous drug users. These cases exhibit the AngioVac's arrival as a new and exciting tool in endocarditis treatment, providing an alternative to open surgery and accessorizing antimicrobial treatment.

PMID: 28326804 [PubMed - as supplied by publisher]

Successful percutaneous implantation of symetis ACURATE neo transcatheter aortic bioprosthesis for the treatment of pure aortic regurgitation.

Catheter Cardiovasc Interv. 2016 Aug;88(2):319-23

Authors: Cerillo AG, Griese D, Berti S

Abstract
Transcatheter aortic valve implantation (TAVI) was initially developed for the treatment of calcific aortic stenosis. In the recent years, however, TAVI has been used to treat selected patients with pure, severe AR. We report successful transfemoral implantation of a Symetis ACURATE neo bioprosthesis in a severely symptomatic, 87-year-old woman with pure AR and major comorbidities. We decided to use the ACURATE neo bioprosthesis for some of its features appeared to us as potentially useful in the setting of pure AR: the stabilization arches ensure perfect coaxial alignment and extreme stability of the device during deployment, and the "waist" and the skirt were considered useful to obtain a good seal in the absence of significant valvular and annular calcifications. Finally, we decided to use a self-expanding valve to minimize the trauma to the aortic annulus. The procedure was successful and the patient was discharged home on postoperative day 3. At the 3-month control echocardiography, there was no residual AR, and the mean transprosthetic gradient was 3 mm Hg. The current case demonstrates that percutaneous TAVI with the ACURATE neo bioprosthesis may be used to treat pure, isolated AR in selected patients. The device has several interesting features that could make it advantageous in this setting. © 2016 Wiley Periodicals, Inc.

PMID: 26762474 [PubMed - indexed for MEDLINE]

Balloon aortic valvuloplasty in the transcatheter aortic valve implantation era: A single-center registry.

Rev Port Cardiol. 2017 Mar 16;:

Authors: G Francisco AR, Nobre Menezes M, Carrilho Ferreira P, Jorge C, Silva D, Infante de Oliveira E, Pinto FJ, Canas da Silva P

Abstract
INTRODUCTION: Percutaneous balloon aortic valvuloplasty (BAV) has been limited by the risk of complications and restenosis. However, growing use of transcatheter aortic valve implantation (TAVI) has revived interest in this technique. We analyzed the current indications for BAV and outcomes in a single center.
METHODS: Acute results and long-term outcomes were analyzed in a retrospective single-center registry of patients undergoing BAV between January 2013 and January 2016.
RESULTS: Twenty-three patients underwent BAV, 56.5% male, mean age 78±7 years. Indications were severe aortic stenosis and decompensated heart failure (n=5), urgent non-cardiac surgery (n=8), or bridge to definitive treatment (n=10). Peak invasive gradient decreased from a median of 54.0±19.0 mmHg to 28.5±13.8 mmHg (p=0.002). Complications included one ischemic stroke, one lower limb ischemia and one femoral pseudoaneurysm requiring surgery. During a mean follow-up of 11±10 months, eight patients underwent TAVI and two underwent surgical aortic valve replacement. Thirteen patients died, nine of non-cardiovascular causes. On Kaplan-Meier analysis mortality was significantly lower among patients undergoing definitive treatment (20.0% vs. 84.6% at two-year follow-up; p=0.005).
CONCLUSION: BAV should be considered for selected patients with temporary contraindications to definitive therapy or as palliative therapy.

PMID: 28318856 [PubMed - as supplied by publisher]

Elective Primary or Secondary Delayed Sternal Closure Improves Outcome in Severely Compromised Patients.

Thorac Cardiovasc Surg. 2017 Mar 17;:

Authors: Calafiore AM, Sheikh AA, Alfonso JJ, Tantawi T, Maklouf B, Shawki A, Allam A, Awadi MO, Osman AA, Habib AM, Di Mauro M

Abstract
Background Delayed sternal closure (DSC) in patients with severely compromised preoperative hemodynamics can be helpful as the chest sometimes cannot be able to contain both lungs and heart. We report our experience to evaluate the midterm results of this strategy in an adult population. Materials and Methods From May 2009 till July 2015, 33 patients had DSC as first treatment of severe hemodynamic deterioration after cardiac surgery. Surgical procedures were valvular (9.27%) or coronary artery bypass grafting + others (24.73%). Stepwise logistic regression (SLR) showed that patients with lower ejection fraction, dilated right ventricle, and severe pulmonary hypertension were more likely to need DSC. Patients were divided in two groups: group A (n = 17), when the sternum was reopened before any hemodynamic collapse, or was never closed, and group B (n = 16), when the sternum was reopened after hemodynamic collapse. Results Inhospital mortality was 39% (n = 13), 18% in group A and 62% in group B (p < 0.0001). In 28 patients where the sternum was reopened, cardiac index increased from 1.7 (1.6, 1.9) L/m(2) to 2.8 (2.4, 3) L/m(2), p < 0.0001. The sternum was closed in 28 patients (85%), 94% in group A and 75% in group B (p = 0.13), after a median of 4 (2.5) days. SLR showed that only group B (p < 0.0001) was a risk factor for early death. Two-year survival was 48 ± 9%, higher in group A (71 ± 13) than in group B (25 ± 11), p < 0.0001. Cox's analysis showed that group B (p < 0.0001) and redo (p < 0.0001) were risk factors for lower survival. Conclusion Elective DSC represents a useful strategy in severely compromised patients, entailing an improvement of hemodynamics and a higher survival.

PMID: 28315287 [PubMed - as supplied by publisher]

Completeness of revascularization and its impact on the outcomes of a staged approach of percutaneous coronary intervention followed by minimally invasive valve surgery for patients with concomitant coronary artery and valvular heart disease.

Catheter Cardiovasc Interv. 2016 Sep;88(3):329-37

Authors: Pineda AM, Chandra R, Gowani SA, Santana O, Mihos CG, Kirtane AJ, Stone GW, Kurlansky P, Smith CR, Beohar N

Abstract
BACKGROUND: A staged approach of percutaneous coronary intervention (PCI) followed by minimally invasive valve surgery (MIVS) is an alternative to the conventional combined coronary artery bypass and valve surgery for patients with concomitant coronary artery and valve disease. Limited data exist on degree of the completeness of revascularization achieved with this approach and its impact on outcomes.
METHODS: A total of 138 patients, who underwent a staged approach between January 2009 and June 2013, were retrospectively evaluated. Coronary angiograms were reviewed by two cardiologists blinded to outcomes and were then categorized into two groups: complete or incomplete revascularization, which was defined as ≥1 major epicardial coronary arteries of at least 2.0 mm diameter with ≥70% untreated obstruction after the index PCI and before MIVS.
RESULTS: Complete and incomplete revascularization was achieved in 105 (76%) and 33 (24%) patients, respectively. The patients with incomplete revascularization had a lower ejection fraction, a higher STS score, and more prior myocardial infarctions and multi-vessel coronary artery disease. There were no differences in the post-operative complications, 30-day mortality, or 3-year survival (84 vs. 83%, P = 0.68). After a median follow-up of 29 months, incompletely revascularized patients had a higher incidence of acute coronary syndrome (2.9 vs. 12.9%, P = 0.05).
CONCLUSIONS: In patients undergoing a staged approach of PCI followed by MIVS, incomplete revascularization did not significantly impact the short or mid-term survival, but was associated with an increased incidence of acute coronary syndrome at follow-up. © 2015 Wiley Periodicals, Inc.

PMID: 26526421 [PubMed - indexed for MEDLINE]

Current Interventional and Surgical Management of Congenital Heart Disease: Specific Focus on Valvular Disease and Cardiac Arrhythmias.

Circ Res. 2017 Mar 17;120(6):1027-1044

Authors: Holst KA, Said SM, Nelson TJ, Cannon BC, Dearani JA

Abstract
Successful outcome in the care of patients with congenital heart disease depends on a comprehensive multidisciplinary team. Surgery is offered for almost every heart defect, despite complexity. Early mortality for cardiac surgery in the neonatal period is ≈10% and beyond infancy is <5%, with 90% to 95% of patients surviving with a good quality of life into the adult years. Advances in imaging have facilitated accurate diagnosis and planning of interventions and surgical procedures. Similarly, advances in the perioperative medical management of patients, particularly with intensive care, has also contributed to improving outcomes. Arrhythmias and heart failure are the most common late complications for the majority of defects, and reoperation for valvar problems is common. Lifelong surveillance for monitoring of recurrent or residual structural heart defects, as well as periodic assessment of cardiac function and arrhythmia monitoring, is essential for all patients. The field of congenital heart surgery is poised to incorporate new innovations such as bioengineered cells and scaffolds that will iteratively move toward bioengineered patches, conduits, valves, and even whole organs.

PMID: 28302746 [PubMed - in process]

Left Ventricular Outflow Tract Obstruction in Aortic Arch Anomalies With Ventricular Septal Defect.

Ann Thorac Surg. 2016 Jun;101(6):2302-8

Authors: Sugiura J, Nakano T, Kado H

Abstract
BACKGROUND: The predictors of left ventricular outflow tract obstruction (LVOTO) after the repair of coarctation of the aorta or interruption of the aortic arch (CoA/IAA) with ventricular septal defect have been investigated. However, the predictors remain controversial.
METHODS: We performed primary repair of CoA/IAA with ventricular septal defect for 75 patients from 1996 to 2005. Four of the 75 patients died within 5 years after primary repair without relation to LVOTO. The morphology of the aortic valve of 71 survivors was bicuspid in 23 patients and tricuspid in 48 patients. The mean follow-up was 9.2 ± 2.6 years after primary repair.
RESULTS: There were 12 patients who showed LVOTO of 3.0 m/s or greater after primary repair. All of the 6 bicuspid patients demonstrated valvular aortic stenosis, and all of the 6 tricuspid patients showed discrete subvalvular LVOTO. In 5 of the 6 tricuspid patients, the aortic annular z-score before primary repair was -3.0 or less. A bicuspid aortic valve (p = 0.016) and the aortic annular z-score of -3.0 or less (p = 0.019) were significant risk factors for LVOTO after primary repair. At 10 years after primary repair, 82.6% and 95.6% of the bicuspid and tricuspid patients, respectively, were free from reoperation (p = 0.015).
CONCLUSIONS: The presence of a bicuspid aortic valve and an aortic valve annular z-score of -3.0 or less before primary repair are risk factors for LVOTO, and stenotic bicuspid valves and discrete subvalvular LVOTO are the main causes of LVOTO after primary repair of CoA/IAA with ventricular septal defect. The bicuspid patients more frequently required reoperation than the tricuspid patients.

PMID: 26952292 [PubMed - indexed for MEDLINE]

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Valvular cardiac surgery

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