Eur J Cardiothorac Surg. 2018 Apr 16. doi: 10.1093/ejcts/ezy148. [Epub ahead of print]
Systematic bilateral internal mammary artery grafting: lessons learned from the CATHolic University EXtensive BIMA Grafting Study.
Gaudino M1, Glieca F1, Luciani N1, Pragliola C1, Tsiopoulos V1, Bruno P1, Farina P1, Bonalumi G1, Pavone N1, Nesta M1, Cammertoni F1, Munjal M2, Di Franco A1, Massetti M1.
1
Department of Cardiovascular Sciences, Catholic University, Rome, Italy.
2
Department of Cardiothoracic Surgery, Cornell Medicine, New York, NY, USA.
Abstract
OBJECTIVES:
Despite claims of feasibility, to date no study has examined the effect of systematic bilateral internal mammary artery (BIMA) use in a large cohort of real-world unselected patients. The CATHolic University EXtensive BIMA Grafting Study (CATHEXIS) registry was designed to assess the feasibility and safety of systematic BIMA grafting.
METHODS:
The CATHEXIS was a single-centre, prospective, observational, propensity-matched study. The study was supposed to include 2 arms of 500 patients each: a prospective arm and a retrospective arm. The prospective arm included almost all patients referred for coronary artery bypass grafting (CABG) at our institution after the start of the CATHEXIS with very few exceptions. BIMA would have been used in all these patients. The retrospective arm included patients submitted to CABG before the start of the CATHEXIS and propensity matched to the prospective group (average BIMA use 50%; the radial artery was extensively used). Safety analyses were scheduled after enrolment of 200, 300 and 400 BIMA patients.
RESULTS:
After the first 226 patients, the BIMA use percentage was 88.5% (200 of 226). In 178 (89%) patients, mammary arteries were used as Y graft. Postoperative mortality was 2%, and incidence of perioperative myocardial infarction, graft failure and sternal complications were 3.5%, 3% and 5.5%, respectively. No perioperative stroke occurred. The incidence of major adverse cardiac events (particularly graft failure and sternal complications) in the BIMA arm were significantly higher than those in the propensity-matched cohort; the study was stopped for safety.
CONCLUSIONS:
In a real world setting the systematic use of BIMA was associated with a higher incidence of perioperative adverse events (particularly sternal complications). Individualization of the revascularization strategy and use of alternative arterial conduits are probably preferable to systematic use of BIMA.
Eur J Cardiothorac Surg. 2013 Sep;44(3):415-8. doi: 10.1093/ejcts/ezt085. Epub 2013 Feb 22.
The use of internal thoracic artery grafts in patients with aortic coarctation.
Gaudino M1, Farina P, Toesca A, Bonalumi G, Tsiopoulos V, Bruno P, Massetti M.
1
Division of Cardiac Surgery, Department of Cardiovascular Medicine, Catholic University, Rome, Italy.
Abstract
The choice of conduits for surgical revascularization in patients with aortic coarctation can be puzzling, as the internal thoracic arteries can be dilated, atherosclerotic and unsuitable for grafting. Reports in the literature are controversial: in some cases, the internal thoracic artery was not suitable for revascularization, while in others, it could be used with discordant outcomes. Here, we review the literature on the subject
Aortic Arch Reconstruction: Are Hybrid Debranching Procedures a Good Choice?
Papakonstantinou NA1, Antonopoulos CN2, Baikoussis NG3, Kakisis I4, Geroulakos G4.
Abstract
INTRODUCTION:
Conventional open total arch replacement is the treatment of choice for surgical aortic arch pathologies. However, it is an invasive procedure, requiring cardiopulmonary bypass and deep hypothermic circulatory arrest leading to significant morbidity and mortality rates. Hybrid aortic arch debranching procedures without (type I) or with (type II) ascending aorta replacement seek to limit operative, bypass, and circulatory arrest times by making the arch repair procedure simpler and shorter.
MATERIAL AND METHODS:
A meta-analysis and detailed review of the literature published from January 2013 until December 2016, concerning hybrid aortic arch debranching procedures was conducted and data for morbidity and mortality rates were extracted.
RESULTS:
As far as type I hybrid aortic arch reconstruction is concerned, among the 122 patients included, the pooled endoleak rate was 10.78% (95%CI=1.94-23.40), 30-day or in-hospital mortality was 3.89% (95%CI=0.324-9.78), stroke rate was 3.79% (95%CI=0.25-9.77) and weighted permanent paraplegia rate was 2.4%. In terms of type II hybrid approach, among 40 patients, endoleak rate was 12.5%, 30-day or in-hospital mortality rate was 5.3%, stroke rate was 2.5%, no permanent paraplegia was noticed and late mortality rate was 12.5%.
CONCLUSIONS:
Hybrid aortic arch debranching procedures are a safe alternative to open repair with acceptable short- and mid-term results. They extend the envelope of intervention in aortic arch pathologies, particularly in high-risk patients who are suboptimal candidates for open surgery.
Copyright © 2018 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved
.
J Card Surg. 2014 Jul;29(4):487-9. doi: 10.1111/jocs.12315. Epub 2014 Mar 10.
On pump evaluation of the anastomotic patency of in situ arterial grafts.
Tsiopoulos V1, Pragliola C, Gaudino M, Massetti M.
1
Dipartimento di Scienze Cardiovascolari, Unità di Chirurgia del Cuore e dello Scompenso Cardiaco, Università Cattolica del Sacro Cuore, Policlinico Agostino Gemelli, Roma, Italy.
Abstract
We describe a variation of the standard intraoperative transit time flow evaluation that allows the assessment of the anastomotic patency of in situ arterial grafts before the release of the aortic cross clamp. The advantages of this technique are the immediate correction of technical imperfections and the evaluation of native competitive flow situations that may compromise long-term patency.
Ann Ital Chir. 2011 Nov-Dec;82(6):429-35.
Infections of the aorta and iliac arteries. Report of 20 years experience in a single centre.
Ferrante A1, Cina A, Tsiopoulos VD, Snider F.
1
Vascular Surgery Unit, Department of Cardiovascular Medicine, Catholic University of Sacred Heart School of Medicine, "A. Gemelli" University Hospital, Rome, Italy. aferrante@rm.unicatt.it
Abstract
AIM:
Retrospective review of aorto-iliac infections in a single vascular surgery center.
METHODS:
From a retrospective review of their experience in the last 20 years, the Authors analyze a series of 12 cases of aorto-iliac infection. Prognostic factors, surgical options and results are discussed and compared with the literature.
RESULTS:
Infections of the aorta eventually associated with aneurysmal degeneration are uncommon (less than 3% of all aortic aneurysms) but still a life-threatening condition with high hospital mortality (25%). No statistical evaluation can be drawn from small series; however, early results are apparently influenced by emergency surgery and comorbidities affecting the immune response; in-situ reconstruction is associated with better long-term results (patency 100%, recurrent infection 0%).
CONCLUSIONS:
In our experience, in situ aortic grafting reconstruction associated with proper antibiotic therapy obtained satisfactory results in terms of mortality and long-term survival Endovascular treatment can be adopted in critical patients with prohibitive surgical risk.
J Am Coll Cardiol. 2011 Aug 2;58(6):581-4. doi: 10.1016/j.jacc.2011.03.040.
Aortic expansion rate in patients with dilated post-stenotic ascending aorta submitted only to aortic valve replacement long-term follow-up.
Gaudino M1, Anselmi A, Morelli M, Pragliola C, Tsiopoulos V, Glieca F, Possati G.
1
Department of Cardiac Surgery, Catholic University, Rome. mgaudino@tiscali.it
Abstract
OBJECTIVES:
This study was conceived to describe the evolution of aortic dimensions in patients with moderate post-stenotic ascending aorta dilation (50 to 59 mm) submitted to aortic valve replacement (AVR) alone.
BACKGROUND:
The appropriate treatment of post-stenotic ascending aorta dilation has been poorly investigated.
METHODS:
Ninety-three patients affected by severe isolated calcific aortic valve stenosis in the tricuspid aortic valve accompanied by moderate dilation of the ascending aorta (50 to 59 mm) were submitted to AVR only. All patients were followed for a mean of 14.7 ± 4.8 years by means of periodic clinical evaluations and echocardiography and tomography scans of the thorax.
RESULTS:
Operative mortality was 1.0% (1 patient). During the follow-up, 16 patients died and 2 had to be reoperated for valve dysfunction. No patients experienced acute aortic events (rupture, dissection, pseudoaneurysm), and no patient had to be reoperated on the aorta. There was not a substantial increase in aortic dimensions: mean aortic diameter was 57 ± 11 mm at the end of the follow-up versus 56 ± 02 mm pre-operatively (p = NS). The mean ascending aorta expansion rate was 0.3 ± 0.2 mm/year.
CONCLUSION:
In the absence of connective tissue disorders, AVR alone is sufficient to prevent further aortic expansion in patients with moderate post-stenotic dilation of the ascending aorta. Aortic replacement can probably be reserved for patients with a long life expectancy.
Copyright © 2011 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.
Human epicardium-derived cells fuse with high efficiency with skeletal myotubes and differentiate toward the skeletal muscle phenotype: a comparison study with stromal and endothelial cells.
Gentile A1, Toietta G, Pazzano V, Tsiopoulos VD, Giglio AF, Crea F, Pompilio G, Capogrossi MC, Di Rocco G.
1
Laboratorio di Patologia Vascolare, Istituto Dermopatico dell'Immacolata-IRCCS, 00167 Rome, Italy.
Abstract
Recent studies have underscored a role for the epicardium as a source of multipotent cells. Here, we investigate the myogenic potential of adult human epicardium-derived cells (EPDCs) and analyze their ability to undergo skeletal myogenesis when cultured with differentiating primary myoblasts. Results are compared to those obtained with mesenchymal stromal cells (MSCs) and with endothelial cells, another mesodermal derivative. We demonstrate that EPDCs spontaneously fuse with pre-existing myotubes with an efficiency that is significantly higher than that of other cells. Although at a low frequency, endothelial cells may also contribute to myotube formation. In all cases analyzed, after entering the myotube, nonmuscle nuclei are reprogrammed to express muscle-specific genes. The fusion competence of nonmyogenic cells in vitro parallels their ability to reconstitute dystrophin expression in mdx mice. We additionally show that vascular cell adhesion molecule 1 (VCAM1) expression levels of nonmuscle cells are modulated by soluble factors secreted by skeletal myoblasts and that VCAM1 function is required for fusion to occur. Finally, treatment with interleukin (IL)-4 or IL-13, two cytokines released by differentiating myotubes, increases VCAM1 expression and enhances the rate of fusion of EPDCs and MSCs, but not that of endothelial cells
J Cardiovasc Surg (Torino). 2018 Apr 24. doi: 10.23736/S0021-9509.18.10516-7. [Epub ahead of print]
Hybrid arch surgery challenges other forms of arch treatment.
Wallen TJ1,2, Bavaria JE2, Vallabhajosyula P3.
Abstract
INTRODUCTION:
The gold standard for aortic arch replacement remains total arch replacement (TAR) procedure. Hybrid techniques, utilizing a combination of open and endovascular approaches, have been developed with goal of lowering postoperative mortality and morbidity, as well as providing an alternative therapy for patients who are elderly, have significant comorbid burden, or patients in whom circulatory arrest may pose significant risk.
EVIDENCE ACQUISITION:
To date, there are no prospective randomized trials comparing hybrid aortic ach procedures to TAR. Further, many case series describing the outcomes of hybrid procedures involve cohorts with significant comorbidities and, thus, comparison with historical, total arch replacement controls is difficult. However, retrospective studies comparing hybrid arch procedures to TAR are accruing including a Society of Thoracic Surgery Database review conducted by our institution.
EVIDENCE SYNTHESIS:
Review of the literature demonstrates that the optimal surgical management of aortic arch pathology remains a clinical challenge. Several institutions, including our own, have demonstrated that hybrid arch procedures can be safely performed with acceptable post-operative outcomes and improvements in aortic remodelling. However, many other groups have advocated for the use of hybrid procedures only in the setting of high risk patients due to concerns for increased risk as compared to total arch replacement. At present, the majority of the available data suggests that hybrid arch procedures are most frequently reserved for patients who are of significant operative risk.
CONCLUSIONS:
Hybrid arch procedures are frequently employed for high risk patients. The available data demonstrates that in this population these procedures produce satisfactory outcomes
Thorac Cardiovasc Surg. 2011 Jun;59(4):229-32. doi: 10.1055/s-0030-1250640. Epub 2011 Mar 15.
Contemporary results for isolated aortic valve surgery.
Gaudino M1, Anselmi A, Glieca F, Tsiopoulos V, Pragliola C, Morelli M, Possati G.
1
Division of Cardiac Surgery, Catholic University, Rome, Italy. mgaudino@tiscali.it
Abstract
BACKGROUND:
We aimed to give an overview of the contemporary status of aortic valve replacement.
MATERIALS AND METHODS:
This single-center prospective study was initiated in January 2003. From this date on, every patient with aortic valve disease admitted to our hospital was reviewed by a cardiologist and a surgeon to determine eligibility for replacement. In no instance was the operation denied in the absence of surgical consultation. All operations were performed using a median sternotomy, with cardiopulmonary bypass and cardioplegic arrest.
RESULTS:
A total of 873 cases were screened until the end of the study. We identified three groups of patients: Group 1 (inoperable cases) consisted of 15 patients (1 %); Group 2 (high-risk cases) included 99 patients with an additive EuroSCORE ≥ 10 or an expected mortality > 20 % (logistic model); Group 3 (moderate- to low-risk cases) consisted of 759 patients with an additive EuroSCORE < 10 or an expected mortality < 20 %. In-hospital mortality was 6.0 % (6/99) for Group 2 and 0.3 % (3/759) for Group 3. Major complications occurred in 5 patients of Group 2 (5 %) and in 9 patients of Group 3 (1.1 %). At predischarge echocardiography, 99.3 % of the implanted valves were perfect. At a follow-up of 28.9 ± 12.3 months 798/849 patients were alive; 89 % of them (711) were in NYHA 1-2.
CONCLUSIONS:
Surgical aortic valve replacement provides excellent results and has a low operative mortality even in high-risk patients. Surgical consultation for every aortic patient resulted in an extremely low rate of surgery refusals. Our data should be regarded as a benchmark for transcatheter techniques.
J Am Coll Cardiol. 2013 Mar 5;61(9):903-7. doi: 10.1016/j.jacc.2012.08.1034.
The heart team of cardiovascular care.
Holmes DR Jr1, Rich JB, Zoghbi WA, Mack MJ.
Abstract
The management of complex cardiovascular disease has changed markedly with the development of new strategies of care, an increasing amount of scientific evidence-based data and appropriate use criteria. Applying this plethora of information and synthesizing it for presentation and recommendations to the patient and family have assumed central importance. To facilitate this process of patient centric evidence-based care multidisciplinary Heart Teams have become identified as cornerstones. While specific strategies for implementation of these teams will vary, this broad approach will become the standard of cardiovascular care.
Thorac Cardiovasc Surg. 2017 Oct;65(7):519-523. doi: 10.1055/s-0037-1606356. Epub 2017 Sep 18.
Cardiovasc Revasc Med. 2010 Oct-Dec;11(4):263.e5-9. doi: 10.1016/j.carrev.2009.07.003.
A case of myocardial infarction effectively treated by emergency coronary stenting soon after a Bentall-De Bono aortic surgery.
Marino M1, Cellini C, Tsiopoulos V, Pavone N, Zamparelli R, Corrado M, Cosentino N, Lombardo A, Belloni F, Niccoli G.
1
Department of Cardiovascular Medicine, Institute of Cardiology, Catholic University, Rome, Italy.
Erratum in
Cardiovasc Revasc Med. 2011 Jan-Feb;12(1):71. Pavoni, Natalia [corrected to Pavone, Natalia].
Abstract
Postoperative ischemia may complicate cardiac surgery, despite myocardial protection and recent technical developments. Its medical management in the intensive cardiac care unit is usually efficient, although sometimes it requires the revision of the surgical site. In other cases, urgent coronary angiography and subsequent coronary stenting may resolve the situation. Ostial stenosis of coronary anastomoses is a well-known uncommon but dramatic complication after aortic surgery causing myocardial ischemia. Cases of effort angina have been described several months after surgery, but in some cases, acute myocardial infarction may occur days or weeks after intervention. We here describe an anteroseptal ST-elevation myocardial infarction soon after a Bentall aortic root replacement due to compression of the left main ostium by surgical glue, which has been effectively treated by emergency coronary stenting. This case highlights the importance of a joint management of acute myocardial ischemia after cardiac surgery by the cardiac surgeon and the interventional cardiologist.
J Cardiovasc Med (Hagerstown). 2010 Nov;11(11):815-9. doi: 10.2459/JCM.0b013e32833cdb96.
Different clinical pictures of penetrating ulcer of the aorta, an underrated aortic disease.
Anselmi A1, Luciani N, Perri G, Palladino M, Tsiopoulos V.
1
Department of Cardiovascular Medicine, Division of Cardiac Surgery, Catholic University, Rome, Italy. amedeo.anselmi@alice.it
Abstract
Penetrating ulcer of the aorta has been recognized as a distinct aortic disorder, defined by the ulceration of an atherosclerotic plaque. The lesion has the potential to evolve acutely into aortic rupture, but chronic pictures are possible. Late evolution into rupture, frank aortic dissection and progressive aortic enlargement have been documented. We discuss different modalities of presentation on the basis of recent clinical cases. As the optimal treatment, either surgical (open or endovascular) or medical, is based on a correct diagnosis, we highlight the importance of including aortic ulcers in the differential diagnosis of chest pain. Although endovascular treatment can be advisable in cases with favorable anatomic condition and in patients with multiple comorbidities, the open surgical option should be available given the heterogeneous location and clinical scenarios of these lesions.
Curr Treat Options Cardiovasc Med. 2018 Mar 8;20(3):25. doi: 10.1007/s11936-018-0613-3.
Hybrid Epicardial-Endocardial Approach to Atrial Fibrillation Ablation.
Tahir K1, Kiser A2, Caranasos T3, Mounsey JP4, Gehi A5.
Abstract
WHO SHOULD UNDERGO HYBRID AF ABLATION?: Patients with symptomatic persistent or long-standing persistent atrial fibrillation refractory to pharmacological or routine catheter ablation can be considered for hybrid epicardial-endocardial AF ablation. Although it seems clear that patient selection should be important when considering hybrid AF ablation for optimal results, unfortunately, available data on the outcomes of hybrid epicardial-endocardial ablation is limited. Hybrid ablation is rarely compared to stand-alone catheter ablation, the surgical approach (access site, lesion set, ablation tool) is inconsistent, and the patient population studied is often suitable for a catheter ablation approach (paroxysmal AF, minimal structural heart disease). We believe that the hybrid approach should be considered in patients who either have had unsuccessful catheter ablations or have significant structural heart disease evident by enlarged left atrial size or atrial fibrosis. These are the patients who warrant the added risk of a hybrid approach and who stand to benefit from a more extensive ablation including isolation of the posterior wall of the left atrium. Multi-center studies with a uniform hybrid ablation approach and comparison with a stand-alone catheter ablation approach are needed to help clarify the role of hybrid AF ablation
PLoS One. 2018 Jan 3;13(1):e0190170. doi: 10.1371/journal.pone.0190170. eCollection 2018
Heart Team: Joint Position of the Swiss Society of Cardiology and the Swiss Society of Cardiac Surgery.
Pedrazzini GB1, Ferrari E2, Zellweger M1, Genoni M2.
Abstract
The Swiss Society of Cardiology (SSC) and the Swiss Society of Cardiac and ThoracicVascular Surgery (SSCTVS) have formulated their mutual intent of a close, patient-oriented, and expertise-based collaboration in the Heart Team Paper. The interdisciplinary dialogue between the SSC and SSCTVS reflects an attitude in decision making, which guarantees the best possible therapy for the individual patient. At the same time, it is a cornerstone of optimized process quality, placing individual interests into the background. Evaluation of the correct indication for a treatment is indeed very challenging and almost impossible to verify retrospectively. Quality in this very important health policy process can therefore only be assured by the use of mutually recognized indications, agreed upon by all involved physicians and medical specialties, whereby the capacity of those involved in the process is not important but rather their competence. These two medical societies recognize their responsibility and have incorporated international guidelines as well as specified regulations for Switzerland. Former competitors now form an integrative consulting team able to deliver a comprehensive evaluation for patients. Naturally, implementation rests with the individual caregiver. The Heart Team Paperof the SGK and SGHC, has defined guide boards within which the involved specialists maintain sufficient room to maneuver, and patients have certainty of receiving the best possible therapy they require.
J Cardiovasc Med (Hagerstown). 2010 Aug;11(8):583-6. doi: 10.2459/JCM.0b013e328337d856.
Case series of resection of pelvic leiomyoma extending into the right heart: surgical safeguards and clinical follow-up.
Anselmi A1, Tsiopoulos V, Perri G, Palladino M, Ferrante A, Glieca F.
1
Division of Cardiac Surgery, Catholic University, Rome, Italy. amedeo.anselmi@alice.it
Abstract
OBJECTIVE:
To analyze the clinical features, surgical management and oncologic results of a series of six patients undergoing seven operations for resection of uterine leiomyoma extending into the right cardiac chambers.
METHODS:
A retrospective review of patients operated on for surgical resection of a pelvic leiomyomatous mass originating from the uterus and extending into the right cardiac chambers was performed. The most common symptoms at presentation were syncope and dyspnea; two patients were asymptomatic. Four patients had been misdiagnosed as having intracardiac thrombus or primary cardiac tumor. The intracardiac and upper intracaval portion was removed under circulatory arrest in moderate hypothermia; the remaining portion was removed by caval incision. In one patient with cardiogenic shock, the sole intracardiac portion of the mass was removed at primary surgery. A mean of 2.8 +/- 1.5 years of follow-up was available, consisting of clinical and radiological tests (computed tomography scan, echocardiography).
RESULTS:
There were no cases of operative mortality in the present series. No recurrence was observed at the end of the follow-up in all cases of complete resection of the mass from its intracardiac to its pelvic end. Conversely, in the only case in which partial resection was performed due to the patient's clinical condition, recurrence of the intracardiac involvement was observed 6 months after primary surgery.
CONCLUSION:
Radical resection is curative for uterine leiomyomatosis extending into the right cardiac chambers. Surgery can be afforded with acceptable risks. A high level of suspicion for intracardiac extension of pelvic leiomyomatosis should be retained in the presence of a floating mass within the right cardiac chambers. Such a finding should prompt radiographic evaluation of the abdomen and the pelvis.
Curr Opin Cardiol. 2017 Sep;32(5):627-632. doi: 10.1097/HCO.0000000000000432.
The coronary heart team.
Yanagawa B1, Puskas JD, Bhatt DL, Verma S.
Abstract
PURPOSE OF REVIEW:
The concept of a Coronary Heart Team has generated increased interest, including support from major practice guidelines. Here, we review the rationale and the published experience of Coronary Heart Teams.
RECENT FINDINGS:
A Coronary Heart Team should be led by both cardiology and cardiac surgery with a shared decision-making approach. The team should incorporate data from anatomic and clinical risk prediction models to offer individualized care. Most teams focus on management of complex patients and those with indications for both coronary artery bypass graft and percutaneous coronary intervention. The potential benefits of a Coronary Heart Team include balanced decision-making, greater adherence to evidence-based practice guidelines, as well as promoting greater collegiality and exchange of knowledge between specialties. Single-center series have demonstrated consistency in decision-making by Coronary Heart Teams but prospective data demonstrating improved patient outcomes and/or cost effectiveness are necessary.
SUMMARY:
The concept of a Coronary Heart Team is gaining traction for patients with complex coronary artery disease. There is a growing literature in support of Coronary Heart Teams but comparative and prospective data demonstrating improved patient outcomes are needed.
Thorac Cardiovasc Surg. 2018 Feb 28. doi: 10.1055/s-0038-1627478. [Epub ahead of print]
Minimally Invasive Mitral Valve Surgery in Re-Do Cases-The New Standard Procedure?
Salman J1, Fleißner F1, Naqizadah J1, Avsar M1, Shrestha M1, Warnecke G1, Ismail I1, Rümke S1, Cebotari S1, Haverich A1, Tudorache I1.
Abstract
BACKGROUND:
Minimally invasive mitral valve surgery (MIMVS) is superior to "classical" mitral valve surgery via a sternotomy regarding wound healing and postoperative pain. It is however a more challenging procedure. Patients' preference is leading clearly toward minimally invasive approaches, and surgeons are driven by upcoming new technologies in interventional procedures such as the MitraClip. Especially in re-do cases, the access via right mini-thoracotomy, as previously non-operated situs, is a possible advantage over a re-sternotomy. We therefore retrospectively analyzed our result regarding MIMVS in re-do cases at our institute.
METHODS:
From January 2011 and June 2016, 33 operations were MIMVS re-do procedures. Mean age was 60 years (±16 years), and 51% were male.
RESULTS:
Sixty-one percent were elective cases, 29% were urgent cases, and 9% were emergency operations. Operation times, cardiopulmonary bypass (CPB) times, and clamp times were 235 minutes (±51 min), 149 minutes (±42 min), and 62 minutes (±45min), respectively. Mitral valve repair and replacement was performed in 24% (n = 8) and 76% (n = 25), respectively. Overall in-hospital mortality, apoplexy, and re-operation rates (all for bleeding) were 0% (n = 0), 3% (n = 1), and 9% (n = 3). New onset of dialysis was required in two (6%) patients. Two (6%) patients developed superficial wound infection. Overall intensive care unit (ICU) and hospital stay was 3 days (±4 days) and 15 days (±7 days), respectively.
CONCLUSION:
MIMVS for re-do cases can be performed with minimal mortality and morbidity and therefore represents a safe alternative to conventional mitral valve surgery in cardiac re-do operations. However, postoperative morbidity is highly dependent on preoperative patient status.
Gen Thorac Cardiovasc Surg. 2016 Dec;64(12):699-706. Epub 2016 Sep 16.
Minimally invasive mitral valve surgery through a right mini-thoracotomy.
Abstract
Since its introduction in the mid-1990s, minimally invasive mitral valve surgery (MIMVS) has been shown to be a feasible alternative to a conventional full-sternotomy approach, and several studies have reported excellent clinical outcomes with low perioperative morbidity and mortality. As a result, MIMVS is being increasingly employed as a routine procedure worldwide. On the other hand, several issues have been raised, including complications specific to this technique and its steep learning curve, while there are also concerns regarding the durability of a mitral valve repair through a limited access. In this study, the current status and future perspectives of MIMVS were examined.
Early and long-term outcomes of minimally invasive mitral valve surgery through right minithoracotomy: a 10-year experience in 1604 patients.
Glauber M1, Miceli A2, Canarutto D3, Lio A4, Murzi M5, Gilmanov D6, Ferrarini M7, Farneti PA8, Quaini EL9, Solinas M10.
Abstract
BACKGROUND:
To report early and long-term outcomes of patients undergoing minimally invasive mitral valve surgery (MIMVS) through right mini-thoracotomy (RT) over a 10-year period.
METHODS:
From September 2003 to December 2013, a total of 1604 consecutive patients underwent MIMVS through RT.
RESULTS:
The mean age was 63 ± 13 years, 770 (48 %) patients were female and 218 (13.6 %) had previous cardiac operations. The most predominant pathology was degenerative disease (70 %), followed by functional mitral valve regurgitation (12 %), rheumatic disease (9.4 %), endocarditis (5 %) and prosthetic dysfunction (3.2 %). Mitral valve repair was performed in 1137 (71 %) patients and 476 (29 %) had mitral valve replacement. Direct aortic cannulation was achieved in 1325 (83 %) patients. Among patients with degenerative disease candidate for repair (n = 958), rate of mitral valve repair was 95 %. Repair techniques included annuloplasty (95 %), leafleat resection (63 %), neochordae implantation (16 %) and sliding plasty (11 %). Concomitant procedures included tricuspid valve repair (14.6 %), atrial fibrillation ablation (9.5 %) and atrial septal defect closure (3.2 %). Overall in-hospital mortality was 1.1 %. Thirty-four patients (2.1 %) had conversion to sternotomy. Incidence of stroke was 2 %. Overall survival at 10 years was 88 ± 2 %. Freedom from reoperation at 10 years was 94 ± 2 % for repair and 80 ± 6 % for replacement. Freedom from recurrent mitral regurgitation >3+ at 10 years was 90 ± 3 %.
CONCLUSIONS:
Minimally invasive mitral valve surgery is a safe and reproducible approach associated with low mortality and morbidity, high rate of mitral valve repair and excellent late results.
J Thorac Dis. 2018 Mar;10(3):1588-1595. doi: 10.21037/jtd.2018.03.47.
Right anterior mini-thoracotomy vs. conventional sternotomy for aortic valve replacement: a propensity-matched comparison.
Del Giglio M1,2, Mikus E1, Nerla R1, Micari A1, Calvi S1, Tripodi A1, Campo G3, Maietti E4, Castriota F1, Cremonesi A1.
Abstract
Background:
Right anterior mini-thoracotomy (MIAVR) is a promising technique for aortic valve replacement. We aimed at comparing its outcomes with those obtained in a propensity-matched group of patients undergoing sternotomy at our two high-volume centers.
Methods:
Main clinical and operative data of patients undergoing aortic valve replacement between January 2010 and May 2016 were retrospectively collected. A total of 678 patients were treated with a standard full sternotomy approach, while MIAVR was performed in 502. Propensity score matching identified 363 patients per each group.
Results:
In-hospital mortality was not significantly different between the propensity-matched groups (1.7% in MIAVR patients vs. 2.2% in conventional sternotomy patients; P=0.79). No significant difference in the incidence of major post-operative complications was observed. Post-operative ventilation times (median 7, range 5-12 hours in MIAVR patients vs. median 7, range 5-12 in conventional sternotomy patients; P=0.72) were not significantly different between the two groups. Cardiopulmonary bypass time (61.0±21.0 vs. 65.9±24.7 min in conventional sternotomy group; P<0.01) and aortic cross-clamping time (48.3±16.7 vs. 53.2±19.6 min in full sternotomy group; P<0.01) were shorter in MIAVR group. EuroSCORE (OR 1.52, 95% CI, 1.12-2.06; P<0.01) was found to be the only independent predictor of intra-hospital mortality in the whole propensity-matched population.
Conclusions:
Our experience shows that mini-access isolated aortic valve surgery is a reproducible, safe and effective procedure with similar outcomes and no longer operative times compared to conventional sternotomy
Curr Opin Cardiol. 2017 Jan;32(1):17-21.
Hybrid ablation for atrial fibrillation: current approaches and future directions.
Abstract
PURPOSE OF REVIEW:
Catheter ablation of atrial fibrillation has rapidly evolved during the past decade: although the treatment of paroxysmal atrial fibrillation via a transcatheter approach has been consistently successful, persistent and long-standing atrial fibrillation still represents a major clinical challenge with less favorable outcomes to date. Because novel, minimally invasive surgical approaches have been developed for atrial fibrillation ablation, the aim of the present review is to analyze the current evidence surrounding the integration of surgical and transcatheter strategies in a hybrid fashion for the treatment of atrial fibrillation.
RECENT FINDINGS:
Long-standing persistent, atrial fibrillation requires further understanding. Wide antral circumferential ablation of the pulmonary veins represents the cornerstone of any ablation therapy. Additional linear lesions and/or targeting complex fractionated atrial electrograms may also be considered. One of the limitations is achieving a transmural lesion. The combined endocardial and epicardial approach may represent a superior approach.
SUMMARY:
Hybrid ablation of atrial fibrillation represents a novel therapeutic strategy for the treatment of complex scenarios, such as long-standing persistent atrial fibrillation. A specialized team including dedicated surgeons and cardiologists appears to be crucial in order to achieve durable and satisfactory outcomes following hybrid ablation of atrial fibrillation.
Heart Lung Circ. 2018 Mar 30. pii: S1443-9506(18)30132-X. doi: 10.1016/j.hlc.2018.03.016. [Epub ahead of print]
Int J Med Robot. 2018 Apr 27. doi: 10.1002/rcs.1913. [Epub ahead of print]
Robot-assisted aortic valve surgery: State of the art and challenges for the future.
Balkhy HH1, Lewis CTP2, Kitahara H1.
Abstract
Robotic cardiac surgery was FDA-approved in 2002 and since then several different procedures have been performed to facilitate a truly minimally invasive approach. The use of robotics in aortic valve surgery, however, is still in its infancy. In this article, we report our clinical experience and chronological development with robot-assisted aortic valve surgery. This includes a description of how robotic assistance was gradually integrated during right mini-thoracotomy aortic valve replacement, a series of cases in which the robot was docked for parts of the procedure, a single case of a totally endoscopic robot-assisted aortic valve replacement with a stentless valve, and three cases of aortic valve papillary fibroelastoma resections. All of these were performed safely with early postoperative recovery and excellent clinical results. Additionally, we review the latest literature describing robot-assisted aortic valve surgery. Finally, we describe current issues, and challenges for robot-assisted aortic valve surgery.
J Thorac Dis. 2018 Jan;10(1):464-467. doi: 10.21037/jtd.2017.12.28.
Eur J Cardiothorac Surg. 2017 Oct 1;52(4):740-745. doi: 10.1093/ejcts/ezx162.
European prospective multicentre study of hybrid thoracoscopic and transcatheter ablation of persistent atrial fibrillation: the HISTORIC-AF trial.
Muneretto C1, Bisleri G2, Rosati F1, Krakor R3, Giroletti L1, Di Bacco L1, Repossini A1, Moltrasio M4, Curnis A1, Tondo C4, Polvani G4.
Abstract
OBJECTIVES:
The HISTORIC-AF trial is a prospective, multicentre, single-arm study designed to evaluate the outcomes of a staged endoscopic and transcatheter ablation in patients with stand-alone, persistent or long-standing persistent atrial fibrillation (AF).
METHODS:
From 2012 to 2015, 100 consecutive patients were enrolled and underwent thoracoscopic left atrial epicardial isolation ('box lesion') followed by transcatheter ablation in case of AF recurrency. The safety end point was the composite outcome of freedom from major adverse events at 30-days, while efficacy end points were: (i) primary: freedom from AF and stable sinus rhythm following isolated thoracospic ablation >60% and (ii) secondary: freedom from AF and stable sinus rhythm >80% following hybrid ablation (as per HRS criteria).
RESULTS:
No death occurred and surgical thoracoscopic procedure was successfully completed in all patients. Survival free from major adverse events at 30 days was 94%: there were 3 permanent pacemaker implants, 2 episodes of stroke and 1 revision for bleeding. At discharge, 87% of patients were in sinus rhythm. A staged transcatheter ablation was carried out in all patients with AF recurrences at the end of 3 months blanking period (17% of patients). At 12-months follow-up, a stable restoration of sinus rhythm was achieved in 75% and 88% of patients following isolated thoracoscopic ablation and hybrid ablation, respectively.
CONCLUSIONS:
The HISTORIC-AF trial showed that thoracoscopic isolated surgical ablation reached both the safety and the efficacy end points. Hybrid ablation steadily improved rhythm outcomes and may be considered in the future as the treatment of choice for patients with persistent and long-standing persistent AF.
A technique of minimally invasive aortic valve replacement: an alternative to transcatheter aortic valve replacement (TAVR).
Henderson LB1, Song Z2, Sun X2,3, Pirris JP2.
1
Department of General Surgery, University of Florida College of Medicine, Jacksonville, USA.
2
Division of Cardiothoracic Surgery, Department of Cardiology, University of Florida College of Medicine, Jacksonville, USA.
3
Department of Cardiothoracic Surgery, Huashan Hospital of Fudan University, Shanghai 200040, China.
Abstract
Minimally invasive aortic valve replacement (AVR) is increasingly being adopted worldwide, in which a right mini-thoracotomy (RT) approach plays an important role. Here we reported a novel technique of AVR via RT using sutureless prosthesis, without rib division or groin incision. Surgical access was performed through an anterior right thoracotomy with 5-cm skin incision placed in the third intercostal space. Percutaneous femoral-femoral cardio-pulmonary bypass (CPB) was applied under fluoroscopy guidance to avoid groin incision. A 5-mm stab incision was made in the right chest wall for aortic cross-clamping. A sutureless bioprosthetic valve was utilized in the limited operative field, which reduced the cross-clamp and CPB time. The patient was discharged on post-operative day 2, without obvious cross-valvar gradient, and with no pain or other complication. This report offers a more minimally invasive approach to AVR with proven durable valves, which can benefit high-risk patients.
Transcatheter aortic valve implantation: the transaortic approach.
Chow SC1, Cheung GS2, Lee AP2, Wu EB2, Ho JY1, Kwok MW1, Yu PS1, Wan IY1, Underwood MJ1, Wong RH1.
Abstract
Background Transcatheter aortic valve implantation has been established as a safe and effective treatment option for patients at high or prohibitive surgical risk. However, some patients may not be suitable for the transfemoral approach due to severe iliofemoral disease or aneurysmal disease of the thoracoabdominal aorta. The aim of this case series was to evaluate the feasibility and clinical outcomes of the transaortic approach. Methods From May 2015 to June 2016, 5 patients (mean age 78.4 ± 3.9 years) with severe symptomatic aortic stenosis underwent transaortic transcatheter aortic valve implantation after a heart team discussion. They were considered to be at high surgical risk and ineligible for the transfemoral approach due to iliofemoral or thoracoabdominal aortic disease. Results A CoreValve Evolut R was successfully deployed in all 5 patients. We performed 4 right mini-parasternal incisions and one J-incision partial sternotomy. None of the patients required permanent pacemaker implantation, one required reopening of the mini-parasternal incision for postoperative bleeding. Follow-up echocardiography one month after the procedure showed improvement in the mean aortic gradient (from 63.2 to 8.3 mm Hg) and aortic valve area (from 0.62 to 2.2 cm2). None of the patients had more than mild paravalvular leakage. There was no intraoperative or 30-day mortality. Conclusion Transaortic transcatheter aortic valve implantation is a safe and feasible option for patients with severe aortic stenosis who are considered unsuitable for transfemoral aortic valve implantation
The safety and efficacy of hybrid ablation for the treatment of atrial fibrillation: A meta-analysis.
Jiang YQ1, Tian Y1, Zeng LJ1, He SN2, Zheng ZT2, Shi L1, Wang YJ1, Wang YX1, Yin XD1, Liu XQ1, Yang XC1, Liu XP1.
Abstract
INTRODUCTION:
Hybrid ablation, an emerging therapy that combines surgical intervention and catheter ablation, has become a viable option for the treatment of persistent atrial fibrillation. In this analysis, we aimed to evaluate the safety and efficacy of hybrid ablation, as well as compare the outcomes of one-step and staged approaches.
METHODS:
We conducted a search in major online databases and selected the studies that met the inclusion criteria. The primary endpoint was defined as no episode of atrial fibrillation or atrial tachycardia lasting longer than 30 seconds without administration of antiarrhythmic drugs.
RESULTS:
Sixteen studies including 785 patients (paroxysmal atrial fibrillation, n = 83; persistent atrial fibrillation, n = 214; long-standing persistent atrial fibrillation, n = 488) were selected. Average history of atrial fibrillation was (5.0±1.6) years. The pooled proportion of patients who were arrhythmia-free at the primary endpoint was 73% (95% CI, 64%-81%, Cochran's Q, P<0.001; I2 = 81%). The pooled rate of severe short-term complications was 4% (95% CI, 2%-7%, Cochran's Q, P = 0.01; I2 = 51%). The success rate after one-step procedures (69%) was lower than that after staged procedures (78%). The staged approach could ultimately prove to be safer, although complication rates were relatively low for both approaches (2% and 5%, respectively).
CONCLUSIONS:
Hybrid ablation is an effective and generally safe procedure. The current data suggest that staged hybrid ablation could be the optimal approach, as it is associated with a higher success rate and a seemingly lower complication rate. Additional randomized controlled trials are necessary to confirm these results.