The 'beating-heart butterfly technique' for repair of basal post-infarction ventricle septum defect

Ischaemic ventricular septal defect is a serious complication of acute myocardial infarction with poor outcome. We present the 'beating-heart butterfly' technique to close the ventricular septal defect with a double-layered pericardial patch sewn to the intact septum under beating-heart cardiopulmonary bypass in 4 highest-risk patients. This technique combined with a liberal postoperative mechanical circulatory support and open-chest treatment allowed excellent results with 12 months of survival in all patients. Keywords: Beating heart; Butterfly technique; Infarction; Surgical repair; Ventricular septal defec

Recombinant hirudin for extended aortic surgery in patients with heparin-induced thrombocytopenia

AbstractJ Thorac Cardiovasc Surg 1999;118:191-

Resolution of severe secondary mitral valve regurgitation following aortic valve replacement in infective endocarditis.

We present the case of a patient with infective endocarditis anesthetized for replacement of severely regurgitant aortic valve. Intraoperative transesophageal echocardiography revealed a new diagnosis of severe secondary mitral regurgitation. After aortic valve replacement and tricuspid valve repair, severe mitral regurgitation resolved rapidly without any intervention. In multivalvular disease, instant spontaneous resolution of secondary mitral regurgitation is possible after surgical correction of an aortic regurgitation causing left ventricular volume overload

Transapical aortic valve implantation in patients with severely depressed left ventricular function

ObjectivesTransapical aortic valve implantation significantly reduces operative risk in elderly patients with aortic valve stenosis and comorbidities. However, it is unknown whether this procedure is feasible in patients with advanced heart failure.MethodsBetween April 2008 and July 2010, 258 patients underwent transapical aortic valve implantation. Twenty-one patients had advanced heart failure with decompensation and a left ventricular ejection fraction of 10% to 25%. The mean age of these patients was 74 ± 11 years (range, 36-88 years). The mean left ventricular ejection fraction was 20% ± 5% (range, 10%-25%). Mean logistic EuroSCORE was 66% ± 21% (range, 27%-97%) and mean Society of Thoracic Surgeons score 33% ± 25% (range, 4%-90%). Nine patients were operated on using femorofemoral cardiopulmonary bypass and 12 without.ResultsTechnical success of the procedure was 100% with no conversion to conventional surgery. The mean time of cardiopulmonary bypass was 27 ± 25 minutes (range, 6-81 minutes). Postoperatively, the left ventricular ejection fraction increased to 38% ± 12% (range, 20%-60%). There were no postoperative neurologic complications. A new pacemaker implantation was needed in 2 (10%) patients. The 30-day mortality was 4.8%. Survival at 1, 3, 12, and 24 months was 95%, 81%, 76%, and 62%, respectively.ConclusionsTransapical aortic valve implantation can be performed safely in patients with decompensated heart failure or even in the presence of cardiogenic shock

die Wirkung eines strukturierten Ausbildungsprogramms auf das klinische Ergebnis

Introduction: The purpose of the study was to test whether the cumulative knowledge from the field of transapical transcatheter aortic valve implantation, when incorporated into a structured training and then gradually dispersed by internal proctoring, might eliminate the negative effect of the learning curve on the clinical outcomes. Methodology: The present study was a retrospective, single-center, observational cohort study of prospectively collected data from all 500 consecutive high-risk patients undergoing transapical transcatheter aortic valve implantation at our institution from April 2008 to December 2011. Of the 500 patients, 28 were in cardiogenic shock. Differences during the study period in baseline characteristics, procedural and postprocedural variables, and survival were analyzed using different statistical methods, including cumulative sum charts. Results: The overall 30-day mortality was 4.6% (95% confidence interval, 3.1% - 6.8%) and was 4.0% (95% confidence interval, 2.6% - 6.2%) for patients without cardiogenic shock. Throughout the study period, no significant change was seen in the 30-day mortality (Mann-Whitney U test, p = 0.23; logistic regression analysis, odds ratio, 0.83 per 100 patients; 95% confidence interval, 0.62 - 1.12; p = 0.23). Also, no difference was seen in survival when stratified by surgeon (30-day mortality, p = 0.92). An insignificant change was seen toward improved overall survival (hazard ratio, 0.90 per 100 patients; 95% confidence interval, 0.77 - 1.04; p = 0.15). Conclusions: The structured training program can be used to introduce transapical transcatheter aortic valve implantation and then gradually dispersed by internal proctoring to other members of the team with no concomitant detriment to patients.Einführung: Das Ziel der vorliegenden Studie war es zu analysieren, ob das kumulative Wissen auf dem Gebiet der transapikalen kathetergestützten Aortenklappenimplantation - eingebettet in ein strukturiertes Ausbildungsprogramm - die negativen Einflüsse einer Lernkurve auf das klinische Ergebnis bei der Einführung der Methodik eliminieren kann. Methodik: Bei der vorliegenden Studie handelt es sich um eine retrospektive Einzelzentrums-, Beobachtungs- und Kohortenstudie, basierend auf prospektiv gesammelten Daten aller konsekutiven 500 Hochrisikopatienten, die beginnend im April 2008 bis Dezember 2011 in unserer Einrichtung eine kathetergestützte Aortenklappenimplantation über einen transapikalen Zugang erhalten haben. Unter den 500 Patienten befanden sich 28 Patienten im manifesten kardiogenen Schock. Veränderungen von Ausgangscharakteristika, der prozeduralen und postprozeduralen Variablen sowie im Überleben über den Studienzentraum hinweg wurden mit verschiedenen statistischen Methoden, einschließlich Darstellung der kumulativen Summe, analysiert. Ergebnisse: Die Gesamtletalität im 30-Tage- Zeitraum betrug 4,6% (95%-Konfidenzintervall, 3,1% - 6,8%) sowie 4,0% (95%-Konfidenzintervall, 2,6% - 6,2%) für Patienten, die sich nicht im kardiogenen Schock befanden. Über den Studienzeitraum hinweg waren keine signifikanten Änderung in der 30-Tage-Letalität erkennbar (U-Test nach Mann- Whitney, p = 0,23; logistische Regressionsanalyse, Odds Ratio 0,83 pro 100 Patienten; 95%-Konfidenzintervall, 0,62 - 1,12; p = 0,23). Ebenso fanden sich keine Unterschiede im Überleben, wenn dies hinsichtlich des ausführenden Chirurgen analysiert wurde (30-Tage-Letalität, p = 0,92). Es war ein nichtsignifikanter Trend hin zu einem besseren Gesamtüberleben sichtbar (Hazard Ratio, 0,83 pro 100 Patienten; 95%-Konfidenzintervall, 0,77 – 1,04; p = 0,15). Schlussfolgerungen: Das strukturierte Ausbildungsprogramm kann angewandt werden, um die Methodik der transapikalen kathetergestützten Aortenklappenimplantation einzuführen und dann unter schrittweiser interner Anleitung auf weitere Mitglieder des implantierenden Teams zu übertragen, ohne dass dabei für den Patienten nachteilige Begleitfolgen zu beobachten sind