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Mid-Term Outcome of Mitral Valve Repair and Coronary Artery Bypass Grafting for Ischemic or Degenerative Mitral Regurgitation
Aim of the study. To verify the impact of the etiology of mitral valve regurgitation on a 5-year outcome after repair and concomitant coronary artery bypass grafting (CABG).
Methods. One hundred and eleven consecutive patients (mean age of 69±8 years) who underwent mitral valve repair, 65 for ischemic and 46 for degenerative mitral regurgitation, and concomitant CABG, were retrospectively analyzed. The mean follow-up was 40±28 (9-104) months. Five-year survival (including operative mortality), and survival free from events (postoperative low output syndrome, progression of mitral regurgitation, onset or worsening of congestive heart failure, recurrence of myocardial infarction, and the need for mitral valve replacement) were analyzed.
Results. Compared with degenerative, ischemic mitral regurgitation was associated with a higher incidence of previous myocardial infarction (P<0.0001), left ventricular ejection fraction (LVEF) <0.45 (P<0.0001), and more diseased coronary vessels per patient (P<0.0001). Five-year all-cause mortality was 18% (20/111). Independent predictors of mortality were older age at operation (P=0.0008), LVEF<0.45 (P=0.04), and the ischemic etiology of mitral regurgitation (P=0.03). At five years, survival was 69%±7.6% for ischemic versus 87%±6.5% for degenerative etiology (P=0.03); event-free survival was 58%±8.4% versus 75%±8% (P=0.02), and freedom from late cardiac death was 85%±6.6% versus 100% (P=0.02). Freedom from mitral valve reoperation was 97±2.4%.
Conclusions. Ischemic mitral regurgitation “per se” predicted limited survival and event-free survival. Left ventricular dysfunction is frequently associated with the ischemic etiology. An early surgical indication to prevent left ventricular dysfunction could be important to improve the mid-term outcom
Mini-extracorporeal circulation minimizes coagulation abnormalities and ameliorates pulmonary outcome in coronary artery bypass grafting surgery
Hemostasis is impaired during CABG and coagulation abnormalities often result in clinically relevant organ dysfunctions, eventually increasing morbidity and mortality rates. Fifteen consecutive patients with coronary artery disease submitted to conventional extracorporeal circulation (cECC) have been compared with 15 matched patients, using mini-ECC (MECC). Postoperative lung function was evaluated according to gas exchange, intubation time and lung injury score. In the MECC group, thrombin-antithrombin complex levels (TaTc), prothrombin fragments (PF1+2) formation and thromboelastography (TEG) clotting times were lower compared to the cECC group (p=0.002 and p<0.001, respectively) whereas postoperative blood loss was higher in the cECC group (p=0.030) and more patients required blood transfusion (p=0.020). In the MECC group, postoperative gas exchange values were better, intubation time shorter and lung injury score lower (p<0.001 for all comparisons). Our study suggests that MECC induces less coagulation disorders, leading to lower postoperative blood loss and better postoperative lung function. This approach may be advantageous in high-risk patients. © The Author(s) 2013
Thrombosis of the left anterior descending artery due to compression from giant pseudoaneurysm late after a bentall operation.
BACKGROUND: A postoperative pseudoaneurysm may develop and gradually expand in the mediastinal space even late following Bentall operation for aortic root replacement, particularly in patients with dissection of the aorta.
METHODS: A very large (148 mm) pseudoaneurysm originating of the right coronary ostium suture line was observed in a patient admitted with unstable angina 6 years after Bentall procedure for type A aortic dissection. Angiograms showed reduced flow in the right coronary and thrombotic subocclusion of the left anterior descending (LAD) coronary artery due to extrinsic compression from the expanding mediastinal mass.
RESULTS: Reoperation was performed during femoro-femoral cardiopulmonary bypass and brief period of circulatory arrest to clamp the tubular graft. After closure of the detected right coronary ostium in the tubular graft double bypass, grafting to the right coronary and LAD arteries was required. Postoperative course was uneventful.
CONCLUSIONS: Close long-term follow-up after a Bentall procedure is required to minimize the risk of developing a large pseudoaneurysmal mass, in particular, after dissection of the aorta
Early and long-term results of pectoralis muscle flap reconstruction versus sternal rewiring following failed sternal closure
Objectives: The aim of the study was to compare early and long-term results of pectoralis muscle flap reconstruction with those of sternal rewiring following failed sternal closure. Primary outcomes of the study were survival and failure rate. Respiratory function, chronic pain and quality of life were also evaluated. Methods: In a propensity-score matching analysis, of 94 patients who underwent sternal reconstruction, 40 were selected; 20 underwent sternal reconstruction with bilateral pectoralis muscle flaps (Group 1) and 20 underwent sternal rewiring (Group 2). Survival and failure rates were evaluated by in-hospital records and at follow-up. Respiratory function measures, including vital capacity (VC), were evaluated both by spirometry and computed tomography (CT) volumetry. Chronic pain was evaluated by the visual analogue pain scale. Results: At 85 ± 24 months of follow-up, survival and procedure failure were 95 and 90% in Group 1 and 60 and 55% in Group 2, respectively (P < 0.01, for both comparisons). Based on CT-scan volumetry, in Group 1, severe non-union and hemisternal paradoxical movement occurred less frequently (2 vs 7, P = 0.01). At spirometry assessment, postoperative VC was greater in Group 1 (3220 ± 290 vs 3070 ± 290 ml, P = 0.04). The same trend was detected by CT-scan in-expiratory measures (4034 ± 1800 vs 3182 ± 862 mm3, P < 0.05). Correspondingly, in Group 1, less patients presented in NYHA Class III (P < 0.05), and both chronic persistent pain score and physical health quality-of-life score were significantly better in the same group. Conclusions: In our study, muscle flap reconstruction guaranteed better early and late-term results as shown by lower rates of mortality, procedure failure and hemisternum stability. Moreover, Group 1 patients had greater postoperative VC, lower NYHA class and better quality of life. These results suggest that, in patients with multiple bone fracture, the rewiring approach does not promote physiological bone consolidation, whereas the muscle flap reconstruction can assure more physiological ventilatory dynamics.© The Author 2013. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved
Early and long-term results of pectoralis muscle flap reconstruction vs sternal rewiring following failed sternal closure.
OBJECTIVES:
The aim of the study was to compare early and long-term results of pectoralis muscle flap reconstruction with those of sternal rewiring following failed sternal closure. Primary outcomes of the study were survival and failure rate. Respiratory function, chronic pain and quality of life were also evaluated.
METHODS:
In a propensity-score matching analysis, of 94 patients who underwent sternal reconstruction, 40 were selected; 20 underwent sternal reconstruction with bilateral pectoralis muscle flaps (Group 1) and 20 underwent sternal rewiring (Group 2). Survival and failure rates were evaluated by in-hospital records and at follow-up. Respiratory function measures, including vital capacity (VC), were evaluated both by spirometry and computed tomography (CT) volumetry. Chronic pain was evaluated by the visual analogue pain scale.
RESULTS:
At 85 ± 24 months of follow-up, survival and procedure failure were 95 and 90% in Group 1 and 60 and 55% in Group 2, respectively (P < 0.01, for both comparisons). Based on CT-scan volumetry, in Group 1, severe non-union and hemisternal paradoxical movement occurred less frequently (2 vs 7, P = 0.01). At spirometry assessment, postoperative VC was greater in Group 1 (3220 ± 290 vs 3070 ± 290 ml, P = 0.04). The same trend was detected by CT-scan in-expiratory measures (4034 ± 1800 vs 3182 ± 862 mm3, P < 0.05). Correspondingly, in Group 1, less patients presented in NYHA Class III (P < 0.05), and both chronic persistent pain score and physical health quality-of-life score were significantly better in the same group.
CONCLUSIONS:
In our study, muscle flap reconstruction guaranteed better early and late-term results as shown by lower rates of mortality, procedure failure and hemisternum stability. Moreover, Group 1 patients had greater postoperative VC, lower NYHA class and better quality of life. These results suggest that, in patients with multiple bone fracture, the rewiring approach does not promote physiological bone consolidation, whereas the muscle flap reconstruction can assure more physiological ventilatory dynamics
The effect of bilateral internal thoracic artery harvesting on superficial and deep sternal infection: The role of skeletonization
Objective: To determine the relative risk of sternal dehiscence in patients undergoing bilateral internal thoracic artery harvesting and to assess whether and to what extent the technique of artery skeletonization might reduce this risk. Methods: Prospectively collected data on patients undergoing coronary artery bypass operations with at least a single internal thoracic artery were reviewed. The last 450 patients receiving bilateral internal thoracic artery grafts were compared with 450 patients who received a single internal thoracic artery during the same period. The left internal thoracic artery was always harvested in a pedicled fashion. Among patients receiving a bilateral internal thoracic artery, both arteries were harvested in a pedicled fashion in 300 cases, whereas both internal thoracic arteries were skeletonized in the remaining 150 cases. Results: Compared with a single internal thoracic artery, harvesting both internal thoracic arteries either in a skeletonized or in a pedicled fashion increased the chance of deep (1.1% vs 3.3% vs 4.7%; P =. 01) or superficial (4.8% vs 7.8% vs 12%; P =. 002) sternal infection. However, the technique of artery harvesting (odds ratio, 4.1; 95% confidence interval, 1.4-12.1); the presence of peripheral arteriopathy (odds ratio, 3.1; 95% confidence interval, 1.2-8.5), and resternotomy for bleeding (odds ratio, 8.2; 95% confidence interval, 2.0-33.6) were the only independent predictors for deep sternal infection, whereas the technique of artery harvesting (odds ratio, 3.0; 95% confidence interval, 1.6-5.4), female sex (odds ratio, 2.2; 95% confidence interval, 1.2-4.2), and diabetes (odds ratio, 1.7; 95% confidence interval, 1.0-2.9) were the only independent predictors of superficial sternal infection. In diabetic patients, there was no difference in the incidence of deep sternal infection among patients receiving a single internal thoracic artery or double skeletonized internal thoracic arteries (P =. 4). Conclusions: Bilateral internal thoracic artery harvesting carries a higher risk of sternal infection than harvesting a single internal thoracic artery. Skeletonization of both internal thoracic arteries significantly decreases this risk. A strategy of bilateral thoracic artery grafting can also be offered to patients at high risk for wound infection. Copyright © 2005 by The American Association for Thoracic Surgery
DISPOSITIVO PER PLASTICA DELLA VALVOLA MITRALE
Dispositivo per plastica della valvola mitrale da impiantarsi in soggetti affetti da valvulopatie causanti stenosi e/o insufficienza, comprendente almeno un corpo curvo, da impiantare complanarmente all’anulus mitralico nativo, caratterizzato dal fatto che detto corpo curvo presenta almeno due porzioni estese
in piani diversi da quello in cui giace detto corpo curvo, atte ad agevolare il
cardiochirurgo nelle riperazioni di riparazione dell’apparato mitralico di un
paziente affetto da stenosi e/o insufficienza, detto corpo curvo presentando
almeno due porzioni discendenti da inserirsi all’interno dell’orifizio mitralico, atte a fornire appiglio per l’ancoraggio di un lembo prolassato e/o di un tessuto biologico biocompatibile con l’organismo umano e/o di elementi tendinei,
quando detto dispositivo è applicato all’apparato mitralico danneggiato di un
paziente
dispositivo di rinforzo sternale post sternotomia o frattura sternale
Dispositivo disegnato di garantire stabilita' sternale dopo una sternotomia ed in particolare indicato per pazienti ad alto rischio per deiscenz
Dispositivo para cirurgia plástica da válvula mitral para ser implantado em indivíduos afetados por doenças cardíacas valvulares que causam estenose e/ou insuficiência; e uso do dispositivo para cirurgia plástica da válvula mitra
The present invention relates to a device and method for correcting mitral valve insufficiency, and more particularly, to a device capable of restoring valve leaflet coaptation
Mitral regurgitation (MR) - also referred to as mitral insufficiency or mitral incompetence - is a common disorder caused by insufficient closure (coaptation) of the mitral valve leaflets when the left ventricle contracts. This leads to abnormal leaking of blood backwards from the left ventricle, through the mitral valve and into the left atrium.
In the western world, MR is most commonly due to degenerative disease caused by morphological or functional changes to the leaflets, the valve annulus (which forms a ring around the valve leaflets), the papillary muscles and/or the chordae tendineae (which connect the valve leaflets to the papillary muscles). Morphological changes are classified under Degenerative Mitral Regurgitation (DMR) while functional changes are classified under functional mitral regurgitation (FMR).
Treatment of mitral valve regurgitation includes medication such as diuretics beta blockers, heart rhythm regulators and/or surgery for augmenting or replacing mitral valve function.
Mitral valve augmentation is typically effected via implantation of a ring-like device at the valve annulus. The procedure, termed annuloplasty, reshapes the the
mitral valve annulus to reestablish the physiological configuration and improve leaflet coaptation.
Mitral valve repair can be achieved by ring implantation alone, however, cases involving leaflets with sever anomalies and/or chordate elongation or damage to papillary muscles oftentimes requires additional repair procedures.
One such procedure utilizes artificial chords which are sutured between the papillary muscles in the left ventricle (LV) and the free margin of the valve leaflet in order to recover the coaptation line. However, left ventricle remodeling in the post-operative period might negatively affect early results and lead to recurrence of mitral regurgitation. In addition to LV remodeling, suturing of artificial chord to the papillary muscle can be difficult to perform since the surgeon has limited access through the valve, making surgery more complex and time consuming and since it is oftentimes difficult to determine the correct length of artificial chords needed. In addition, the papillary muscle might be damaged by the procedure risking rupture of suturing site.
There is thus a need for, and it would be highly advantageous to have, a device for repairing mitral valve regurgitation devoid of the above limitations
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