On-pump fibrillating heart mitral valve replacement with the SAPIEN™ XT transcatheter heart valve

In some high-risk patients, standard mitral valve replacement can represent a challenging procedure, requiring a risky extensive decalcification of the annulus. In particular, high-risk redo patients and patients with a previously implanted transcatheter aortic valve, who develop calcific mitral disease, would benefit from the development of new, minimally invasive, transcatheter or hybrid techniques for mitral valve replacement. In particular, mixing transcatheter valve therapies and well-established minimally invasive techniques for mitral replacement or repair can help in decreasing the surgical risk and the technical complexity. Thus, placing transcatheter, balloon-expandable Sapien™ XT stent-valves in calcified, degenerated mitral valves through a right thoracotomy, a left atriotomy and on an on-pump fibrillating heart, represents an attractive alternative to standard surgery in redo patients, in patients with concomitant transcatheter aortic stent-valves in place and in patients with a high-risk profile. We describe this hybrid technique in detai

Imaging for trans-catheter pulmonary stent-valve implantation without angiography: role of intravascular ultrasound

Patients with stenosed biologic pulmonary conduits require redo cardiac surgery to prevent severe right ventricular dysfunction. Following the latest trends, the trans-catheter pulmonary stent-valve implantation represents a new fascinating alternative carrying a lower operative risk, compared with the standard open-heart re-intervention. Traditionally, the pulmonary stent valve is positioned off pump, under fluoroscopic control, and requires angiographies. However, alternative tools not requiring contrast injections for the intra-operative cardiac imaging have to be also considered strongly. The usefulness of intravascular ultrasound for the positioning of aortic endoprosthesis has already been proven in previous reports and, following the same principle, we have started to routinely implant balloon-expandable stent valves (Edwards Sapien™ THV) in stenosed pulmonary valve conduits using intravascular ultrasound for the stent-valve positioning without angiography. We describe the intra-operative intravascular imaging technique with technical detail

Modified ‘dumbbell' technique: a simple and intuitive method to position balloon-expandable stent valves

Intraoperative cardiac imaging plays a key role during transcatheter aortic valve replacement. In recent years, new techniques and new tools for improved image quality and virtual navigation have been proposed, in order to simplify and standardize stent valve positioning and implantation. But routine performance of the new techniques may require major economic investments or specific knowledge and skills and, for this reason, they may not be accessible to the majority of cardiac centres involved in transcatheter valve replacement projects. Additionally, they still require injections of contrast medium to obtain computed images. Therefore, we have developed and describe here a very simple and intuitive method of positioning balloon-expandable stent valves, which represents the evolution of the ‘dumbbell' technique for echocardiography-guided transcatheter valve replacement without angiography. This method, based on the partial inflation of the balloon catheter during positioning, traps the crimped valve in the aortic valve orifice and, consequently, very near to the ideal landing zone. It does not require specific echocardiographic knowledge; it does not require angiographies that increase the risk of postoperative kidney failure in elderly patients, and it can be also performed in centres not equipped with a hybrid operating roo

Transapical aortic valve replacement in extreme-risk patients: outcome, risk factors and mid-term results

OBJECTIVES Transcatheter aortic valve replacement (TAVR) provides good results in selected high-risk patients. However, it is unclear whether this procedure carries advantages in extreme-risk profile patients with logistic EuroSCORE above 35%. METHODS From January 2009 to July 2011, of a total number of 92 transcatheter aortic valve procedures performed, 40 ‘extreme-risk' patients underwent transapical TAVR (TA-TAVR) (EuroSCORE above 35%). Variables were analysed as risk factors for hospital and mid-term mortality, and a 2-year follow-up (FU) was obtained. RESULTS The mean age was: 81 ± 10 years. Twelve patients (30%) had chronic pulmonary disease, 32 (80%) severe peripheral vascular disease, 14 (35%) previous cardiac surgery, 19 (48%) chronic renal failure (2 in dialysis), 7 (17%) previous stroke (1 with disabilities), 3 (7%) a porcelain aorta and 12 (30%) were urgent cases. Mean left ventricle ejection fraction (LVEF) was 49 ± 13%, and mean logistic EuroSCORE was 48 ± 11%. Forty stent-valves were successfully implanted with six Grade-1 and one Grade-2 paravalvular leakages (success rate: 100%). Hospital mortality was 20% (8 patients). Causes of death following the valve academic research consortium (VARC) definitions were: life-threatening haemorrhage (1), myocardial infarction (1), sudden death (1), multiorgan failure (2), stroke (1) and severe respiratory dysfunction (2). Major complications (VARC definitions) were: myocardial infarction for left coronary ostium occlusion (1), life-threatening bleeding (2), stroke (2) and acute kidney injury with dialysis (2). Predictors for hospital mortality were: conversion to sternotomy, life-threatening haemorrhage, postoperative dialysis and long intensive care unit (ICU) stay. Variables associated with hospital mortality were: conversion to sternotomy (P = 0.03), life-threatening bleeding (P = 0.02), acute kidney injury with dialysis (P = 0.03) and prolonged ICU stay (P = 0.02). Mean FU time was 24 months: actuarial survival estimates for all-cause mortality at 6 months, 1 year, 18 months and 2 years were 68, 57, 54 and 54%, respectively. Patients still alive at FU were in good clinical condition, New York Heart Association (NYHA) class 1-2 and were never rehospitalized for cardiac decompensation. CONCLUSIONS TA-TAVR in extreme-risk patients carries a moderate risk of hospital mortality. Severe comorbidities and presence of residual paravalvular leakages affect the mid-term survival, whereas surviving patients have an acceptable quality of life without rehospitalizations for cardiac decompensatio

Survival After Surgical Drainage of Malignant Pericardial Effusion

Objectives: Management of malignant pericardial effusion (PE) is complex. Cardiac surgeons are not necessarily familiar with or are challenged by the many underlying etiologies. Analyzing risk factors for mortality may help to estimate the benefit of surgery in high-risk patients. Methods: Patients undergoing a surgical pericardiotomy for malignant PE, between 2001 and 2011, were included. The influence of tumor type, disease extension, intra-pericardial tumor infiltration on early mortality and long-term survival as well as freedom from symptoms after drainage, and the use of sclerosing agents on PE recurrence rates was analyzed. Results: PE drainage was performed on 46 patients 12±30months after tumor diagnosis. Malignant diseases were lung cancers (50%), breast cancers (15%), lymphoma and leukemia (13%), cancers of the digestive tract (13%), and others (9%). 80% of patients were symptomatic and symptom relief was achieved in 65%. Nobody died during surgery. Recurrence rate was 4%. Early in-hospital mortality was 22%. After 1year, 29% of patients were alive. Eleven patients (24%) had a complete tumor regression. Metastatic spread (p<0.001), pericardial infiltration (p=0.02), and intra-pericardial Bleomycin (p=0.01) injection were associated with increased mortality. Hematological malignancies had a better prognosis for survival. Conclusion: Surgical pericardiotomy is safe, associated with a low recurrence rate and symptom relief in the majority of dyspneic patients. Intra-pericardial Bleomycin may reduce recurrent effusion but does not ameliorate survival. Long-term survival rate was low with an increased mortality in cases of metastatic spreading, pericardial infiltration, and as the tumor of origin: breast cancers. Leukemic and lymphatic tumors have better prognosis

Sarcoma of the heart: survival after surgery

Abstract OBJECTIVES Malignant intracardiac tumours are rare, and consensus concerning the optimal therapeutic approach is lacking. We performed a retrospective medical analysis, identifying 9 patients having been operated for cardiac sarcomas. All of them had a complete postoperative long-term follow-up. To enhance understanding of the best therapeutic approach for future patients, it is crucial to reveal special medical problems and to analyse the potential impact they may have on disease course and survival rate in this specific patient group. METHODS Cardiac tumours operated on 2000 to the end of 2015 were reviewed. Late mortality during the follow-up period was determined. The impact of tumour extension, tumour localization, resection status (complete versus partial) and histopathological diagnosis on survival was analysed retrospectively. RESULTS Of all cardiac malignant tumours resected, sarcomas were, with an incidence of 0.14% (9 patients), the most frequent histological group admitted to cardiac surgery. All of the patients presented with cardiac symptoms. All of the patients survived the operation and all had relief or improvement of cardiac symptoms. The mean follow-up period was 17 ± 13 months. Five patients died after 6, 8, 12, 12 and 15 months, respectively. Four survivors (3 with a pulmonary artery tumour sarcoma and 1 with a left atrial sarcoma) had a mean follow-up of 26 ± 17 months. Macroscopically complete tumour resection, absence of metastatic spread and histological sarcoma type had an impact on follow-up survival. CONCLUSIONS Although cardiac sarcomas are rare, surgeons occasionally encounter them. A 1-year mortality rate of 44% reflects an unfavourable prognosis, but surgery seems to be a secure, reliable option in selected patients for treating cardiac symptoms and avoiding early cardiac-related deaths