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ispartof: INTERACTIVE CARDIOVASCULAR AND THORACIC SURGERY vol:35 issue:6 ispartof: location:England status: published

Introduction Robotic mitral valve surgery has developed for more than 20 years. The main purpose of robotic assistance is to use multiwristed instruments for surgical endothoracic maneuvers on the mitral valve without opening the chest. The surgeon controls the instruments remotely from a console but is virtually immersed into the operative field. Areas covered This review outlines indications and contraindication for the procedure. Intra- and postoperative results as available in the literature are reported. Further areas focus on the technological development, advances in surgical techniques, training methods, and learning curves. Finally we give an outlook on the potential future of this operation. Expert opinion Robotic assistance allows for the surgically least invasive form of mitral valve operations. All variations of robotic mitral valve repair and replacement are feasible and indications have recently been broadened. Improved dexterity of instrumentation, 3D and HD vision, introduction of a robotic left atrial retractor, and adjunct technology enable most complex forms of minimally invasive mitral valve interventions through ports on the patient's right chest wall. Application of robotics results in significantly reduced surgical trauma while maintaining safety and outcome standards in mitral valve surgery.

Objectives Ring annuloplasty reduces the septal-lateral diameter (SLD) indirectly by circumferential annular cinching and frequently results in the recurrence of mitral regurgitation (MR) in patients with functional MR (FMR). Our goal was to report the results from the trial and the 2-year post-trial surveillance data. We evaluated whether direct reduction of the SLD with a transannular mitral bridge could achieve significant and durable MR reduction in patients with FMR. Methods In a prospective trial, 34 consecutive patients with FMR had a mitral bridge implanted surgically. Primary end points were MR ≤1+ at 1, 3 and 6 months postimplant and freedom from subsequent surgical mitral valve repair or replacement. Results Thirty-two of 34 (94.1%) patients met the primary end points with MR ≤1+ at 6 months. At 2 years, there were no strokes or device-related adverse events. At 2 years, MR was reduced from 3.32 ± 0.47 to 0.50 ± 0.83 (P ≤ 0.001) with ≤1+ MR in 33/34 patients, including 4 reinterventions for periprosthetic recurrent MR ≥3 without mitral bridge explants or conventional mitral repair or replacement. At 2 years, the mean mitral gradient was 2.15 ± 0.82 mmHg; the mitral annular SLD decreased from 40.4 ± 2.91 mm to 28.9 ± 1.55 mm (P ≤ 0.001). The left ventricular ejection fraction increased (57.9 ± 10.4-62.4 ± 9.7%; P ≤ 0.001). The New York Heart Association functional class improved (2.19 ± 0.76-1.41 ± 0.61; P ≤ 0.001). Conclusions The single-centre trial data indicate that direct reduction in the SLD with a mitral bridge is feasible, safe and efficacious in patients with FMR. Validation in a larger population of patients and comparison to conventional annuloplasty ring are necessary. Clinical trial registration number NCT03511716.

Aortic dissection occurs in Turner syndrome with substantially higher frequency in comparison to the general population, and its prevention is one of the main aims of cardiologic follow-up. Findings of cystic medial necrosis in the aortic wall and a high prevalence of aortic dilation suggest that a form of aortopathy exists in Turner syndrome. However, little is known about natural development of aortic dilation prior to dissection. We present a 16-year-old girl with Turner syndrome with a bicuspid aortic valve, aortic stenosis, and dilation of ascending aorta, who underwent annual echocardiographic examinations from early childhood. Significant progressions of proximal aortic dilation occurred twice at the age of 10 and 15 years. Thereafter, another rapid progression was observed during 8 months and within 3 weeks preceding dissection. Acute aortic dissection was diagnosed while the girl was waiting for elective surgery. She was successfully operated. Frequent estimations of aortic diameter in Turner patients with abnormal findings may help to anticipate this life-threatening event. Additionally, we learned that rapid progression of aortic dilation should lead to immediate surgery to prevent more risky urgent intervention following the dissection.

Objective: Leukocyte-mediated reperfusion injury to cardiac allograft in the perioperative period is most likely associated with the early and late mortality after heart transplantation (Htx). Our aim is to determine the efficacy and safety of using leukocyte-depleting filters in a cardiopulmonary bypass (CPB) and secondary blood cardioplegia (SBC) circuit in Htx. Methods: A prospective, randomized trial was performed in 40 patients undergoing orthotopic Htx. These patients were divided into two groups, to be treated with either leukocyte-depleted (LD) reperfusion (n = 20) in the LD group, or whole blood reperfusion (n = 20) in the Control group. The SBC was used in both groups. Results: Intraoperatively, the LD group presented the reduced markers of reperfusion injury. The course of the creatine kinase MB (CK-MB) releases was significantly lower in the LD group (p < 0.05). The LD hearts showed better spontaneous rhythm resumption (60% vs 10%; p < 0.001), and lower needfor isoprenaline (0.02 0.01 mg/(kg min)vs0.03 0.02 mg/(kg min);p < 0.05)andepicardialpacing(25%vs60%;p < 0.05) forweaningoff CPB. Postoperatively, lower and shorter need for inotropic support (48 46, median = 35 h vs 131 68, median = 109 h; p < 0.001), shorter temporary epicardial pacing (6 14, median = 0 h vs 25 52, median = 1 h; p < 0.01), and lower 24-h chest drainage (551 274, median = 500 ml vs 973 836, median = 665 ml; p < 0.05) in the LD group contributed to the shorter mechanical ventilation time (8 3, median = 7.5 h vs 14 12, median = 8.5 h; p < 0.05) and the shorter stay at an intensive care unit (ICU) (70 24 h vs 116 73 h; p < 0.05). The30-daymortalitywaszeroinbothgroups.Conclusions:Theuseofleukocytedepletingfiltersinhearttransplantationisan effective,easyand safe method of myocardial protection, reducing significant myocardial reperfusion injury and improving posttransplant graft functional recovery.

The following case report describes an unusual example of aortic valve damage caused by iatrogenic stent-graft rupture (disconnection of the proximal uncovered part of a stent-graft) during delivery of a proximal extension, resulting in the displacement of a stent-graft wire to the aortic root. The wire was extracted under cardiopulmonary bypass, using circulatory arrest, and the damaged aortic valve replaced by a mechanical valve.

We present our initial experience in 10 patients operated on using a modified Ross operation. In our modification of the Ross operation the pulmonary autograft root was inserted in the Gelweave Valsalva graft to prevent dilatation of the neoaortic root. This type of graft was selected to match the discrepancy between diameters of the annulus and the sinotubular junction of the autograft and to preserve the characteristic configuration of the native root. In our group of 10 patients operated consecutively by this technique there was no change in the geometry of the neoaortic root in the follow-up 3-19 months (mean 14.6 months).

Two patients with congenital atresia of the left coronary artery ostium underwent myocardial revascularization at the age of three years and three months, respectively. The patients were admitted to the hospital with a clinical history of sudden chest pain or short apnea not necessitating resuscitation. Non-invasive examinations and hemodynamic studies revealed dysfunction of the left ventricle and ostial atresia of the left coronary artery. Surgical revascularization-bypass grafts were performed using the left internal mammary artery and saphenous vein graft in the first case and the left internal mammary artery in the second child. Both patients survived surgery and good patency of the grafts was confirmed by coronary angiograms during hospital stay. These cases are interesting because of their rarity and diagnostic and therapeutic difficulties.

Uncontrolled bleeding post root, ascending aorta and aortic arch operations can occur. Various techniques for getting bleeding under control have already been published in the literature. This life-threatening complication happens especially during acute aortic dissection and acute endocarditis operations, the former sometimes requiring complex mobilization of the aortic arch and the use of branched prosthetic grafts. In this report we describe the simple innovation of the technique which creates a relatively small space surrounding the aortic graft by its wrapping with use of the pericardium. Decompression of this space is maintained to a low-pressure system.

Objetivo No hay informacion sustancial sobre el papel de la «trompa de elefante congelada» en la diseccion aguda de aorta tipo A (DATA). Presentar resultados iniciales con la tecnica en esta enfermedad. Material y metodos Entre enero de 2005 y diciembre de 2009, se han reparado 184 pacientes con enfermedad aortica compleja con endoprotesis integrada E-Vita Open®. En 60 se reparo una DATA. Edad media 58 ± 12; 47 varones (79%) y 4 Marfan (7%). Intervencion en menos de 24 h en 53 (88%); 28 (47%) malperfusion. Taponamiento 15 (25%), insuficiencia aortica 39 (65%), inotropicos 24 (40%). Un 100% sustitucion de aorta ascendente, 87% arco completo, 13% arco subtotal; reimplantacion de vasos 44 (73%). Resuspension valvular 22 (36%); derivacion coronaria 14 (23%). Duracion de CEC 244 ± 57, isquemia cardiaca 137 ± 41, perfusion cerebral bilateral selectiva anterograda 66 ± 18 min. Resultados Mortalidad hospitalaria 13% (8/60). Intubacion superior a 72 h 42%. Reexploracion 12 (20%). Dos accidentes cerebrovasculares (ACV) permanentes (3%), cuatro regresivos (7%). No paraplejia/paresia. Trombosis ide postoperatoria periprotesica 47/53 (89%), 38/41 (93%) en seguimiento. Trombosis completa distal a la endoprotesis 15/53 (28%), parcial 16/53 (30%); trombosis distal parcial 16 (30%) y 19 (46%). Supervivencia Kaplan-Meier 74% a 60 meses. Cuatro requirieron EVAR inferior a 30 dias; 3 en seguimiento. Libertad de intervenciones secundarias en la aorta distal 80% a 60 meses. Seguimiento medio 22 ± 17 meses. Conclusion La «trompa de elefante congelada» con la endoprotesis E-Vita Open® parece un abordaje efectivo en la DATA.

Objective In acute type A aortic dissection, the extension of repair to downstream aorta has been controversially discussed. We present the early results of a multicenter study using a hybrid stent graft prosthesis. Methods Between January 2005 and January 2010, the data from 191 patients after combined proximal aortic replacement and antegrade stent grafting were collected in the database of the International E-vita open Registry. Of the 191 patients, 68 underwent surgery for acute aortic dissection and were included in the present study. Hypothermic circulatory arrest and selective cerebral perfusion were routinely used. Computed aortic imaging was performed for false lumen evaluation during follow-up. Results The in-hospital mortality rate was 13% (9/68). Along the stent graft, the rate of immediate complete false lumen thrombosis was 86% (51/59) and increased during follow-up (23 ± 17 months) to 94% (46/49). Distally, complete or partial false lumen thrombosis was initially observed in 61% (36/59) and in 82% (40/49) after follow-up. The 1- and 3-year actuarial survival rate was 82% and 74%, respectively. Conclusions Extended thoracic aortic repair of acute aortic dissection with a hybrid stent graft is feasible at acceptable early mortality and promotes false lumen thrombosis around the stent graft and below.