Mitral annulus calcification: current management and future challenges.

Mitral annulus calcification is a chronic degenerative process in the fibrous base of the mitral valve. Assessment and treatment of mitral valve disease in patients with severe mitral annulus calcification is challenging, and a multimodal approach is helpful to delineate its severity and anatomic features, and to guide the therapeutic strategy. This article reviews the current literature to provide a clinically relevant description of mitral annulus calcification, analyze the diagnostic pathway of a patient with mitral annulus calcification, and summarize the therapeutic options

Minimally invasive tricuspid valve surgery in patients at high risk

Objective: Reports of minimally invasive tricuspid valve operations are rare, and results are often contradictory. This study analyzes our 5-year experience with minimally invasive tricuspid valve operations in high-risk patients. Methods: Between November 2005 and December 2011, tricuspid valve surgery using a nonsternotomy minimally invasive technique was performed in 64 patients (19 male, 45 female; mean age, 63.2 \ub1 12.8 years). Mean preoperative European System for Cardiac Operative Risk Evaluation was 7.3 \ub1 2.9, and predicted mortality was 11.6% \ub1 11.7%. Tricuspid valve regurgitation cause was functional in 36 patients (56.2%), endocarditis in 2 patients (3.1%), and rheumatic in 24 patients (37.5%). Two patients (3.1%) showed prosthesis dysfunction. Forty patients (62.5%) had undergone previous cardiac surgery. Results: Tricuspid valve repair was performed in 35 patients (54.7%). Tricuspid valve replacement with bioprosthesis was performed in 27 patients (42.2%), and the remaining 2 patients (3.1%) underwent bioprosthetic replacement. Concomitant procedures (48) included mitral valve surgery (42 patients), atrial septal defect closure (5 patients), and myxoma exeresis (1 patient). Conversion to sternotomy occurred in 1 patient (1.6%). Overall hospital mortality was 7.9%. Stroke occurred in 1 patient (1.6%), and 5 patients underwent reoperation for bleeding (7.8%). Mean follow-up time was 21 \ub1 16 months (range, 1-59 months) and 100% completed. Cumulative Kaplan-Meier estimated 5-year survival was 81.3%, and 5-year freedom from reoperation was 100%. Conclusions: The heart-port-based minimally invasive approach seems to be safe, feasible, and reproducible in case of tricuspid valve operations. It ensures low perioperative morbidity, moderate to low rates of tricuspid regurgitation recurrence, and low late mortality. It also seems to have an added value in case of reoperative procedures. Copyright \ua9 2014 by The American Association for Thoracic Surgery

Right Minithoracotomy for Mitral Valve Surgery: Impact of Tailored Strategies on Early Outcome

Background Interest in right minithoracotomy mitral valve surgery (MVS) is rapidly growing and, to date, different perfusion strategies and aortic clamping techniques are available. However each approach carries specific advantages and drawbacks. This retrospective study analyses our experience in right minithoracotomy MVS with different arterial perfusion and aortic clamping strategies, highlighting the results of a patient tailored approach. Methods Between March 2009 and March 2014, 460 patients with a full preoperative work-up that included also aortoiliac-femoral axis\u2019 screening underwent right minithoracotomy MVS. One hundred and eight were redo cases (23.5%), 63 had aortoiliac atheromatous disease or significant tortuosity (13.7%), and 38 had chronic obstructive pulmonary disease (8.3%). Based on anatomy and comorbidities, each patient was allocated to the most appropriate of 3 approaches: femoral arterial cannulation with endoaortic balloon (P+EB) (247, 53.7%) or with transthoracic clamp (P+XC) (150, 32.6%), and direct aortic cannulation with endoaortic balloon occlusion (C+EB) (63, 13.7%). Results No cases of aortic dissection were reported. Early outcome were similar between the 3 groups; no differences were reported in terms of stroke rate (1.7% in the P+EB, 2% in the P+XC, and no cases in the C+EB group; p = NS) and 30-day mortality (2.1% in the P+EB, 2.7% in the P+XC, and 1.6% in the C+EB group; p = NS). Logistic regression showed no influences of arterial perfusion and aortic clamping techniques on 30-day mortality and stroke. Conclusions Right minithoracotomy MVS can routinely be performed with favorable outcomes in all comers when perfusion strategies and clamping techniques are carefully selected after proper evaluation of the patient's preoperative characteristics

Steps Forward in Minimally Invasive Cardiac Surgery: 10-Year Experience

Background: Minimally invasive cardiac surgery (MICS) has constantly evolved over the past years, and new technologies have been introduced. The aims of this study were to analyze the evolution of our 10-year experience in MICS and to highlight outcomes in different spans of time. Methods: Patients undergoing MICS for mitral valve, tricuspid valve, and/or atrial septal defect or atrial masses from November 2005 to November 2015 were retrospectively analyzed. A comparative analysis was performed by identifying 2 groups: the control group (in the first time span of our experience) and the tailored group (patients who underwent surgery after a full preoperative anatomic evaluation with allocation to the proper setting). Results: During the study period 971 patients underwent MICS. MICS procedures increased from 44% in 2006 to 96% in 2015. Subgroup analysis revealed a significant decrease in the rate of procedures performed with retrograde arterial perfusion (99.1% vs 91.7%, P < .0001), a significant increase in the rate of complex mitral valve procedures (22.4% vs 7.9%, P < .0001), and a significant decrease in the rate of stroke (from 5.2% to 1%, P < .001) in the tailored group. The logistic regression analysis showed that the tailored approach was a protective factor against neurologic complications. Conclusions: The present study shows the considerable and attractive results of our decision-making process based on the tailored approach. The 10-year outcome analysis demonstrated a trend toward a progressive decrease in the overall rate of postoperative complications and a significant protective effect of the tailored approach on the occurrence of stroke

The HeartLander: A novel epicardial crawling robot for myocardial injections

Abstract. Myocardial infarction is the leading cause of congestive heart failure and death in the industrialized world. Stem cell transplantation to failing myocardium appears to improve heart function following myocardial infarction, but further refinement of the delivery methodology is required. The HeartLander miniature mobile robot has the ability to adhere to the epicardium, travel to the operative site, and perform intramyocardial injections under direct control of the surgeon. This paradigm obviates sternotomy, cardiopulmonary bypass, mechanical stabilization and lung deflation, while granting improved access. To facilitate movement under the pericardium, a small prototype with a tapered front has been constructed that is 11 mm tall and fits through a 15-mm cannula. This prototype was tested in beating-heart porcine trials via median sternotomy, but with the pericardium intact (N =2). The HeartLander was able to maintain prehension and travel without being displaced by the overhead motion of the pericardium. Myocardial injections of tissue dye were performed successfully at several locations. These experiments show the feasibility of navigating under the pericardium and performing needle injections into the myocardium using video feedback. Future research will move toward minimally invasive testing without sternotomy, including bot

The Use of CO2 Removal Devices in Patients Awaiting Lung Transplantation: An Initial Experience

Background: Lung transplantation is the treatment of choice for patients with end-stage lung failure. Limitations are presented by the shortage of donors and the long waiting list periods. New techniques, such as extracorporeal membrane ventilator devices with or without pump support, have been developed as bridges to transplantation for patients with severe, unresponsive respiratory insufficiency. Methods: Between November 2005 and September 2009, 12 patients (7 males and 5 females), of overall mean age of 43.3 \ub1 15.5 years underwent decapneization with extracorporeal devices. In 6 cases, a NovaLung system was used; in the remaining 6 patients, it was a Decap device. Causes of respiratory failure that led to implantation of such devices were cystic fibrosis (n = 6), pulmonary emphysema (n = 5), and chronic rejection of a previous double lung transplant (n = 1). Results: Mean time on extracorporeal decapneization was 13.5 \ub1 14.2 days. Eight patients died on the device. Three patients were bridged to lung transplantation; 1 recovered and was weaned from the device after 11 days. Mean PaCO2 on the extracorporeal gas exchanger was significantly lower for both the devices at 24, 48, and 72 hours after implantation (P < .05). No significant difference was observed for the 2 systems. Conclusion: In our initial experience, decapneization devices have been simple, efficient methods to support patients with mild hypoxia and severe hypercapnia that is refractory to mechanical ventilation. This could represent a valid bridge to lung transplantation in these patients. \ua9 2010 Elsevier Inc. All rights reserved