Right anterior mini-thoracotomy vs. conventional sternotomy for aortic valve replacement: A propensity-matched comparison

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

MitraClip after failed surgical mitral valve repair: an international multicenter study

BackgroundRecurrence of mitral regurgitation (MR) after surgical mitral valve repair (SMVR) varies and may require reoperation. Redo mitral valve surgery can be technically challenging and is associated with increased risk of mortality and morbidity. We aimed to assess the feasibility and safety of MitraClip as a treatment strategy after failed SMVR and identify procedure modifications to overcome technical challenges.Methods and ResultsThis international multicenter observational retrospective study collected information for all patients from 16 high-volume hospitals who were treated with MitraClip after failed SMVR from October 29, 2009, until August 1, 2017. Data were anonymously collected. Technical and device success were recorded per modified Mitral Valve Academic Research Consortium criteria. Overall, 104 consecutive patients were included. Median Society of Thoracic Surgeons score was 4.5% and median age was 73 years. At baseline, the majority of patients (82%) were in New York Heart Association class >= III and MR was moderate or higher in 86% of patients. The cause of MR pre-SMVR was degenerative in 50%, functional in 35%, mixed in 8%, and missing/unknown in 8% of patients. The median time between SMVR and MitraClip was 5.3 (1.9-9.7) years. Technical and device success were 90% and 89%, respectively. Additional/modified imaging was applied in 21% of cases. An MR reduction of >= 1 grade was achieved in 94% of patients and residual MR was moderate or less in 90% of patients. In-hospital all-cause mortality was 2%, and 86% of patients were in New York Heart Association class <= II.ConclusionsMitraClip is a safe and less invasive treatment option for patients with recurrent MR after failed SMVR. Additional/modified imaging may help overcome technical challenges during leaflet grasping.Cardiolog

Shockwave intravascular lithoplasty for the treatment of calcified carotid artery stenosis: A very early single-center experience

Endovascular treatment of calcified carotid disease represents one of the main challenges for the interventionalists. Plaque calcium load is one of the most important factors affecting the risk of procedural complications. A new tool called Shockwave intravascular lithotripsy (S-IVL; Shockwave Medical, Inc.) has been recently approved for the treatment of heavily calcified coronary and lower limb arteries but minimal data exist about the treatment of carotid arteries. We report our early experience of carotid stenting using S-IVL. We report two cases of symptomatic patients with severely calcified carotid artery diseases who were turned down for vascular surgeries. The first case was successfully performed through radial access using a distal cerebral embolic protection device in the context of contralateral carotid occlusion. In the second case, a very tight and calcified left internal carotid artery stenosis was successfully treated through femoral access using a proximal cerebral protection device. In both cases, advanced imaging confirmed effective calcium debulking and good stent expansion after IVL treatment. S-IVL effectiveness basically resides in integrating the effect of balloon angioplasty with the calcium-disrupting power of sonic pressure waves. This could be able to minimize the risk of cerebral embolization due to aggressive conventional balloon predilatation or poststenting dilatation usually needed to obtain an adequate luminal gain in carotid stenting. According to our small case series, the use of S-IVL for the treatment of heavily calcified carotid artery lesions seems to be helpful in this particular setting

Transcatheter aortic valve replacement for aortic regurgitation after septal myectomy in patients with obstructive hypertrophic cardiomyopathy

Transaortic septal myectomy is currently considered to be the most appropriate surgical treatment for patients with obstructive hypertrophic cardiomyopathy (HCM) and heart failure symptoms unresponsive to medical therapy (1). However, a well-described late complication of this approach is the development of a substantial aortic regurgitation (AR), frequently requiring surgical aortic valve replacement (SAVR) (2). Post-myectomy AR may be secondary to the leaflet trauma at the time of surgery since septal myectomy is performed through the aortic valve after aortotomy; secondly, it may be related to the turbulent blood flow in the left ventricle outflow tract after surgery that in turn may cause recurrent trauma to the valve in systole; lastly, septal myectomy involves a piece of myocardium below the right coronary cusp and over time the derangement of septal structure may alter the support of the aortic valve causing gradual distortion of the aortic annulus. A redo SAVR is usually associated with an increased risk profile due to the presence of adherences and comorbidities. Although some studies reported encouraging results (3), TAVR is still an off-label indication for AR

Correlation between frequency-domain optical coherence tomography and fractional flow reserve in angiographically-intermediate coronary lesions

Background: The decision-making process of patients with angiographically-intermediate coronary lesions (ICL) is clinically challenging and may benefit from adjunctive invasive techniques. Fractional-flow-reserve (FFR) represents the gold standard to evaluate ICL but frequency-domain optical-coherence-tomography (OCT) is a novel, promising, high resolution coronary imaging technique, which allows physiopathologic assessment of coronary plaque. We investigated the possible relation between OCT and FFR in selected ICL patients. Methods: Stable or unstable patients with ICL who underwent both FFR and OCT assessment at two large tertiary centers were retrospectively enrolled. FFR was performed according to standard methodology. OCT images were (on blind to clinical and FFR results) analyzed to assess minimal lumen area (MLA), percentage area stenosis (AS), thrombus and plaque ulceration. Results: Forty patients were identified (62 +/- 10 years, 93% symptomatic, 35% acute presentation, 93% left-anterior-descending artery ICL). Percentage diameter stenosis at quantitative coronary angiography was 40 +/- 12% and FFR was 0.85 +/- 0.07. MLA (p = 0.009), AS (p &lt; 0.001) and plaque ulceration (p = 0.02) were significantly associated with FFR values. An integrated assessment of AS (&gt;= or &lt;70%), MLA (&gt;= or &lt;2.5 mm(2)) and presence or absence of thrombus and plaque ulceration was found to have the potential to accurately (sensitivity 91%, specificity 93%) predict FFR results. Conclusion: In patients with ICL, a combination of different OCT parameters may help predict FFR results. These findings suggest that only a comprehensive assessment of lesion features by OCT can allow an accurate prediction of lesion severity assessed by FFR. (c) 2017 Published by Elsevier Ireland Ltd