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Although the use of the surgical robot facilitates less invasive mitral valve surgery, both real and perceived limitations have slowed the application of this technology. Aim of the present investigation was to report the early and long-term results of robotic mitral valve repair in a single institution over a 10-year period.Between March 2012 and May 2022, a total of 278 consecutive patients underwent robotically assisted mitral valve repair at the Cliniques Universitaires Saint-Luc (Brussels, Belgium). Indications have evolved over time allowing the treatment of complex mitral valve lesions. Clinical and echocardiographic follow-up were 97.8% and 86.1% complete, respectively.Mean age of the study population was 57.8±11.9 years and 221/278 (79.5%) patients were male. Despite being asymptomatic or mildly symptomatic [New York Heart Association (NYHA) class I-II], most of the patients presented with severe mitral regurgitation (MR). Degenerative mitral valve disease was the most common cause of MR. All patients underwent successful mitral valve repair using different techniques, and 25/278 (9.0%) had one or more concomitant procedures associated. The mean cardio-pulmonary bypass and aortic cross clamp times were 153±37 and 106±25 minutes, respectively. There was no operative or in-hospital mortality. Overall survival rate was 97.8%±3.2%, 95.8%±3.2% and 93.7%±3.0% at 3, 7 and 10 years. One early (0.4%) reoperation with re-repair was recorded for ring disruption, while late mitral valve re-repair was necessary in 4/279 (1.4%) patients for recurrent severe MR in three of them and mitral endocarditis in one. The overall freedom from mitral valve reoperation was 98.1%±1.0% at 3, 7 and 10 years. Overall freedom from MR (grade 2+ or more) was 91.7%±3.2%, 77.8%±4.8% and 67.1%±9.2% at 3, 7 and 10 years, respectively.Robotic mitral valve repair is safe and is associated with excellent clinical and echocardiographic results. The use of robotic technologies allows, after an appropriate learning curve, to reproduce all conventional techniques to treat MR, regardless of the complexity of the valve lesion.

Over the past two decades surgical approaches for mitral valve (MV) disease have evolved with the advent of minimally invasive techniques. Robotic mitral valve repair (RMVr) safety and efficacy has been well documented, however, mid- to long-term data are limited. The aim of this review was to provide a comprehensive analysis of the available mid- to long-term data for RMVr.Electronic searches of five databases were performed to identify all relevant studies reporting minimum five-year data on RMVr. Pre-defined primary outcomes of interest were overall survival, freedom from MV reoperation and from moderate or worse mitral regurgitation (MR) at five years or more post-RMVr. A meta-analysis of proportions or means was performed, utilizing a random effects model, to present the data. Kaplan-Meier curves were aggregated using reconstructed individual patient data.Nine studies totaling 3,300 patients undergoing RMVr were identified. Rates of overall survival at 1-, 5- and 10-year were 99.2%, 97.4% and 92.3%, respectively. Freedom from MV reoperation at eight-years post RMVr was 95.0%. Freedom from moderate or worse MR at seven years was 86.0%. Rates of early post-operative complications were low with only 0.2% all-cause mortality and 1.0% cerebrovascular accident. Reoperation for bleeding was low at 2.2% and successful RMVr was 99.8%. Mean intensive care unit and hospital stay were 22.4 hours and 5.2 days, respectively.RMVr is a safe procedure with low rates of early mortality and other complications. It can be performed with low complication rates in high volume, experienced centers. Evaluation of available mid-term data post-RMVr suggests favorable rates of overall survival, freedom from MV reoperation and from moderate or worse MR recurrence.

OBJECTIVES To compare long-term outcomes after bicuspid aortic valve (BAV) repair utilizing the Cabrol annuloplasty versus valve sparing Reimplantation technique. METHODS From 1996 to 2018, 340 consecutive patients underwent BAV repair. Eighty underwent Cabrol annuloplasty and 189 underwent Reimplantation. Exclusion criteria were re-repairs (n = 6), active endocarditis (n = 4), no annuloplasty (n = 41) and ring or suture annuloplasty (n = 20). We compared both groups for survival, reoperations, valve related events and recurrent severe aortic regurgitation (AR > 2+). Inverse probability weighting (IPW) was used to balance the 2 groups. Cox regression analysis was used to identify outcome predictors. RESULTS After weighting, pre- and intraoperative characteristics were similar between groups, except for aorta replacement techniques and operative time, which was longer in the Reimplantation group (P 2+ were significantly lower in the Cabrol group (reoperation IPW: 69 ± 9% vs 91 ± 4%, P = 0.004 and AR > 2+ IPW: 71 ± 8% vs 97 ± 2%, P CONCLUSIONS In this study, comparing 2 annuloplasty strategies for BAV repair, we found statistically significant differences in long-term durability favouring the Reimplantation technique, and no differences in overall survival. The results support our current strategy of Reimplantation technique and repair of AR in patients with BAV. Cabrol annuloplasty is obsolete and should be generally abandoned in patients undergoing BAV repair for AR.

Unicuspid aortic valves are rare congenital malformations. Surgical repair is feasible in aortic regurgitation, and in some cases of aortic stenosis. The standard surgical approach is a bicuspidization and symmetrization with pericardial patch augmentation of valve cusps. Herein, we are describing our original technique for bicuspidization of a unicuspid aortic valve without cusp patch augmentation. We also address the surgical management of a commissural diastasis.

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

Background:We report the clinical and echocardiographic results of our experiencein robotic mitral valve repair over a 7‐year period. The outcomes of the earliest andthe latest patients will be compared.Methods:Between March 2012 and October 2019, 226 patients underwent roboticmitral valve repair for severe mitral regurgitation in a single institution. The first113 patients (Group 1) were operated between March 2012 and September 2015and the last 113 patients (Group 2) between October 2015 and October 2019.Conventional techniques employed in open surgery were used. Clinical andechographic follow‐up were 96.0% and 94.2% complete, respectively.Results:Successful mitral repair was achieved in all cases with no hospital mortality.The overall survival rate was 92.7 ± 2.8% and 91.0 ± 3.2% at 3 and 7 years, respec-tively, with no in between groups difference (p= 0.513). The overall freedom frommitral reoperation was 97.4 ± 1.2% at 3 and 7 years and was similar in both groups(p= 0.276). Freedom from mitral regurgitation Grade 2+ at 3 and 7 years were89.1 ± 2.6% and 87.9 ± 2.8%, respectively, with no significant difference betweengroups (p= 0.056).Conclusions:Developing a robotic mitral repair program can be done withoutcompromising the safety and efficacy of repair. After a well‐conducted training,robotic approach allows to perform simple and complex mitral repair using similartechniques as in conventional approach and without additional risk for the patient

NEUROLOGIC COMPLICATIONS still are a major concern after cardiac surgery.1 Moreover, the pathophysiology of neurocognitive function after cardiac surgery remains complex.2 The most currently used noninvasive brain monitors during cardiac surgery are, on one hand, the processed electroencephalogram (EEG) monitors and, on the other hand, the cerebral oximetry monitors providing regional cerebral oxygen saturation (rScO2) by near-infrared spectroscopy technology. The use of these monitors recently has been recommended,3 and their combination gives complimentary information that is useful for improving patient care. [...]

OBJECTIVE: To analyze our long-term experience with valve-sparing reimplantation technique in treating aortic root aneurysm, aortic regurgitation, and aortic dissection in patients with tricuspid aortic valve. METHODS: Between March 1998 and October 2018, 303 consecutive patients underwent valve-sparing reimplantation in our institution. The mean age of this cohort was 52.9 ± 15 years. Time to event analysis was performed with the Kaplan-Meier method. Risk of death, reoperation, and aortic regurgitation (AR) recurrence were analyzed using the cox-regression method. RESULTS: In-hospital mortality was 1% (n = 3) of which two were admitted for acute aortic dissection. Median follow-up was 5.81 years ([IQR]: 2.8–10 years). Thirty-nine patients (14.4%) died during follow-up. At 5 and 10 years, overall survival was 92 ± 2%and 75 ± 4.9%, respectively. Seventeen patients required late aortic valve reoperation. Freedom from valve reoperation was 95 ± 2% and 90 ± 3%. Freedom from AR > 2+ and AR > 1+ at 10 years was 91 ± 4% and 71.5 ± 4.6%, respectively. Significant multivariate predictors of death included age, New York Heart Association dyspnea class (NYHA), type A acute dissection (TAAD), and preoperative left ventricular end-diastolic diameter (LVEDD). Significant multivariate predictors of AR recurrence included indication for surgery, previous cardiac surgery, and presence of preoperative AR. Freedom from events like major bleeding, thromboembolic events, and infective endocarditis at 10 years were 97%, 98%, and 96%, respectively. CONCLUSIONS: Aortic valve-sparing with the reimplantation technique has been performed for over two decades in our institution, and the results in patients with tricuspid aortic valve (TAV) are excellent in terms of survival and freedom from valve-related adverse outcomes including valve reoperation. These results continue supporting the use of valve sparing root replacement using the reimplantation technique (VSRR) in patients with aortic aneurysm, irrespective of whether they have preoperative AR or not. VSRR is safe, durable, and reproducible, but further follow-up, well into the second decade is still necessary.

No abstract available

Many authors have reported their results of mitral valve (MV) repair (MVr) in acute and healed endocarditis. However, the results published by different authors highlight the fact that the reparability rate for this indication remains low. Over the last three decades, our group has adopted an early and repair-oriented approach to infective endocarditis with the objective to improve the repair rate and the long-term results.‬ ‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬ In this paper, we describe our institutional experience on mitral valve repair for infective endocarditis.‬‬‬‬‬‬‬‬‬‬‬‬ Data for this paper were extracted from our institutional database on heart valve disease. From 1991 to 2015, 160 consecutive patients in our institution underwent MV surgery for active IE on native MV. The median follow-up was 122 months. This study was approved by the institutional ethics review board, and written informed consent was waived for this study given its retrospective design. Hospital mortality was 11.6% (n = 18). Early MV reoperation before hospital discharge was required in five (3.1%) patients. At 5, 10, and 15 years, overall survival in the MVr for endocarditis in the group was 79% ± 4%, 65% ± 5%, 57% ± 6%, respectively. Freedom from reoperation at 5, 10, and 15 years was 95% ± 2%, 88% ± 4%, and 81% ± 6%, respectively. Mitral infective endocarditis is an insidious pathology and his surgical approach can be challenging. An early and repair-oriented surgical approach can allow to improve reparability rates with good long-term durability and a low recurrence rate of endocarditis.

OBJECTIVES Our goal was to analyse the influence of preoperative aortic regurgitation (AR) on the necessity of cusp repair during valve-sparing reimplantation (VSR). We focused on patients with tricuspid aortic valves (TAV) and evaluated the impact of AR and cusp repair on long-term outcomes. METHODS From March 1998 to December 2018, a total of 512 consecutive patients underwent VSR at our institution; of these, 303 had a TAV. The mean age was 53 ± 15 years, and the median follow-up was 6.12 years. The rate and type of cusp repair were analysed based on preoperative AR. Time-to-event analysis was performed, as well as risk of death, reoperation and AR recurrence. RESULTS Cusp repair was necessary in 168 (55.4%) patients; the rate rose significantly as AR grade increased (P 2+ and AR >1+ at 10 years was 88 ± 4% and 70.4 ± 4.6%, respectively. Independent predictors of death included age, New York Heart Association functional class and type-A aortic dissection. Predictors of AR greater than mild included previous cardiac surgery and severe preoperative AR. CONCLUSION In patients with TAV receiving VSR, the necessity of cusp repair increased with the degree of preoperative AR. Preoperative AR and cusp repair do not impact long-term survival and aortic valve reoperation, but severe preoperative AR and multiple cusp repair increase the risk of recurrent moderate-to-severe AR. Overall, cusp repair seems to attenuate the negative impact of preoperative AR for at least 1 decade in a majority of patients.

Objectives The objectives were to analyze the long-term outcomes of tricuspid aortic valve repair for isolated severe aortic regurgitation and the impact of different annuloplasty techniques. Methods The study cohort consists of 127 consecutive patients who received aortic valve repair for isolated severe aortic regurgitation in the tricuspid aortic valve between 1996 and 2019 in our institution. Exclusion criteria were aorta dilatation (≥45 mm), connective tissue disease, active endocarditis, type A dissection, and rheumatic disease. Mean age of patients was 55.6 ± 16 years, and 80% were male. Median follow-up was 6.4 years. Time-to-event analysis was performed, as well as risk of death, reoperation, and aortic regurgitation recurrence. Results Cusp repair was performed in 117 patients (92%), and annuloplasty was performed in 126 patients (99%) with Cabrol stitch (73%), reimplantation technique (19.7%), or ring annuloplasty (6.3%). There was no hospital mortality. At 10 and 14 years, overall survival was 81% ± 5% and 71% ± 6%, respectively, and freedom from reoperation was 80% ± 5% and 73% ± 6%, respectively. Age and left coronary cusp repair were independent predictors of reoperation. Freedom from recurrent severe aortic regurgitation (>2+) was 73% ± 5% and 66% ± 7% at 10 and 12 years, respectively. Age, left ventricular end-diastolic diameter, and patch repair were independent predictors of recurrent aortic regurgitation. Type of annuloplasty had no impact on survival or reoperation. Conclusions Aortic valve repair for isolated severe aortic regurgitation in the tricuspid aortic valve is a safe procedure, and durability at 14 years is acceptable. In this study, the annuloplasty technique did not influence repair durability as was found in bicuspid aortic valve repair or aortic valve–sparing surgery. Severity of cusp pathology seems to be the main determinant of repair durability.

We present a rare case of a myocardial neuroendocrine metastasis in a 45-year-old male patient. The tumor was localized on the left side of the interventricular septum. Complete surgical excision of the tumor was successfully performed robotically through a left atriotomy, using a transmitral approach. The patient's postoperative course was uneventful. A robotic mini-invasive approach is a safe and feasible alternative to conventional surgery and should be considered when the anatomy is suitable for a minimally invasive procedure.

Background: In the past two decades, the introduction of robotic technology has facilitated minimally invasive cardiac surgery, allowing surgeons to operate endoscopically rather than through a median sternotomy. This approach has facilitated procedures for several structural heart conditions, including mitral valve repair, atrial septal defect closure and multivessel minimally invasive coronary artery bypass grafting. In this rapidly evolving field, we review the status of robotic cardiac surgery in Europe with a focus on mitral valve surgery and coronary revascularization. Methods: Structured searches of MEDLINE, Embase, and Cochrane databases were performed from their dates of inception to June 2016. All original studies, except case-reports, were included in this qualitative review. Studies performed in Europe were presented quantitatively. Data provided from Intuitive Surgical Inc. are also presented. Results: Fourteen papers on coronary surgery were included in the analysis and reported a mortality rate ranging between 0–1%, revision for bleeding between 2–7%, conversion to a larger incision between 2–15%, and patency rate between 92–98%. The number of procedures ranged between 23 and 170 per year. There were only a small number of published reports for robotic mitral valve surgery from European centers. Conclusions: Coronary robotic surgery in Europe has been performed safely and effectively with very few perioperative complications in the last 15 years. On the other hand, mitral surgery has been developed later with increasing applications of this technology only in the last 5–6 years.

Objectives Despite the controversy, the aortic homograft is supposedly the best option in acute infective endocarditis (AIE), due to its resistance to reinfection. However, the technical complexity and the risk of structural deterioration over time have limited its utilization. The aim of this study was to evaluate the long-term results of aortic homograft for the treatment of infective endocarditis in our institution with particular attention to predictors of survival and homograft reoperation. Methods The cohort includes 112 patients who underwent aortic valve replacement with an aortic homograft for AIE between January 1990 and December 2014. Results Fifteen patients (13.4%) died during the first 30 days after the operation. Two patients were lost to follow-up after discharge from the hospital; therefore, 95 patients were available for long-term analysis. The median duration of follow-up was 7.8 years (IQR 4.7-17.6). Five patients (5.3%) suffered a recurrence of infective endocarditis (1 relapse and 4 new episodes). Sixteen patients (16.8%) were reoperated for structural valve degeneration (SVD; n = 14, 87.5%) or for infection recurrence (n = 2, 12.5%). Freedom from homograft reoperation for infective endocarditis or structural homograft degeneration at 10 and 15 years postoperatively was 86.3 ± 5.5 and 47.3 ± 11.0%, respectively. For patients requiring homograft reoperation, the median interval to reintervention was 11.6 years (IQR 8.3-14.5). Long-term survival was 63.6% (95% CI 52.4-72.8%) and 53.8% (95% CI 40.6-65.3%) at 10 and 15 years, respectively. Conclusions The use of aortic homograft in acute aortic valve endocarditis is associated with a remarkably low risk of relapsing infection and very acceptable long-term survival. The risk of reoperation due to SVD is significant after one decade especially in young patients. The aortic homograft seems to be ideally suited for reconstruction of the aortic valve and cardiac structures damaged by the infective process especially in early surgery.

PURPOSE: Infective endocarditis (IE) remains a prevalent and life-threatening disease. The choice to repair or replace the infected valve still remains a matter of debate, especially in aortic valve (AV) infections. We retrospectively analyze our two decades of experience in aortic valve repair (AVr) in IE. Long-term outcomes are described with particular attention to the impact of valve configuration and the use of patch techniques. METHODS: From September 1998 to June 2017, 42 patients underwent AVr in a single center for IE. Techniques include leaflet patch repair and resuspension and aortic annulus stabilization. RESULTS: Hospital mortality was 2.4% (n = 1). The median follow-up was 90.6 months. Survival was 89 ± 9.4% and 76.6 ± 16% at 5 and 10 years, respectively, with no significant differences between tricuspid aortic valve (TAV) and bicuspid aortic valve (BAV). Freedom from reoperation was 100% and 92.9 ± 7.1% in TAV and 81.8 ± 18.2% and 46.8 ± 28.8% in BAV at 5 and 10 years, respectively (TAV vs BAV, p = 0.02). BAV, degree of preoperative aortic insufficiency, and AVr including patch were factors predicting a higher risk of reoperation during the follow-up. CONCLUSION: In our experience, AVr is a safe, feasible, and efficient choice in selected patients with healed or active IE. Durability of the repair is excellent in patients with limited lesions and in patients with TAV even with patch repair. Reoperations occurred principally in patients with BAV and severe preoperative AI, in whom patch repair was performed. In those patients, we actually recommend to replace the valve in case of active endocarditis.

Aortic valve (AV) sparing and repair procedures are advantageous alternatives to valve replacement in patients with aortic aneurysm and/or aortic regurgitation. A successful sparing or repair strategy proceeds first from a clear understanding of the peculiar anatomy and function of the AV and of the possible mechanisms of valve dysfunction. The AV is a functional unit composed of the valve cusps and the functional aortic annulus (FAA). Lesion on any or more of these components can induce aortic insufficiency. A functional classification of aortic regurgitation identifies three main mechanisms of AV regurgitation although more than one type of lesion can coexist in a patient. The goal of AV repair is to restore a normal surface of coaptation by restoring normal geometry between the leaflets and the FAA, while preserving normal mobility of the AV cusps. We present in detail our preferred surgical techniques for valve-sparing root replacement (VSRR) and repair of the AV cusps in the context of tricuspid AV. Further, we discuss the peculiarities of the VSRR and repair techniques in the context of bicuspid AV including our preferred approach to the bicuspid aortic dilatation.

OBJECTIVES Our goal was to assess the aortic leaflet free margin length (FML) and geometric height (gH) in a normal aortic valve (AV), aorta dilatation and aortic leaflet prolapse. METHODS We measured the FML and gH intraoperatively in 132 patients operated on for aortic insufficiency, aortic dilatation, endocarditis or fibroelastoma. Patients were divided into 3 groups: normal tricuspid AV (group 1, n = 12), aortic dilatation (group 2, tricuspid = 43, bicuspid = 18) and leaflet prolapse (group 3, tricuspid = 32, bicuspid = 27). The FML and gH were compared between the groups and between the leaflets within each group. RESULTS In a normal tricuspid AV, the mean FML and gH were 34.7 ± 3.1 mm and 18.8 ± 1.7 mm, respectively. In group 2 tricuspid, the FML and gH were greater than those in group 1 (FML 43.7 ± 4.4, P CONCLUSIONS In aortic dilatation and leaflet prolapse, FML and, to a lesser extent, gH increased significantly compared to those of normal AV function. FML and gH dimensions also depended on the valve configuration (tricuspid/bicuspid). These data provide new insight into the pathomorphology of AV disease and will serve to further develop new methods of AV repair based on intraoperative measurements of the FML.

Objective To analyze our long-term experience with valve-sparing reimplantation technique for the treatment of isolated root aneurysm, aneurysm with significant aortic regurgitation, and for isolated aortic regurgitation. Methods Between 1999 and 2017, 440 consecutive patients underwent valve-sparing reimplantation in our institution. The mean age of this cohort was 49 ± 15 years. Time-to-event analysis was performed with the Kaplan-Meier method, whereas significant predictors of late outcomes were explored with Cox proportional hazard model. Results In-hospital mortality was 0.7% (n = 3). Four hundred fourteen patients were available for long-term analysis. Median duration of follow-up was 5 years (interquartile range, 2-8.5 years). Thirty-six patients (8.5%) died during follow-up; therefore, survival was 79.7% ± 3.8% at 10 years. During follow-up we observed a linearized rate of 0.37%, 0.73%, and 0.2% patient-year, respectively, for major bleeding, thromboembolic events, and infective endocarditis. Nineteen patients required late aortic valve reoperation and freedom from valve reoperation was 89.6% ± 2.9% at 10 years and was not significantly different between groups or between tricuspid or bicuspid valve phenotypes. Conclusions Our study shows that valve-sparing reimplantation is associated with low perioperative mortality, a remarkably low rate of valve-related complications, and excellent long-term durability. Further, it can be safely performed also in patients with isolated aortic regurgitation and the durability of valve repair is similar regardless of the indication for surgery of valve phenotype.

Objectives Mitral valve (MV) repair is the gold standard for treatment of degenerative mitral regurgitation. A variety of surgical techniques allow surgeons to achieve a high rate of MV repair even with MV diseases of other aetiologies. However, a certain number of repairs fail over time. The aim of this study was to review our single-centre experience of MV re-repair and analyse the mode of repair failure, re-repair safety and efficiency in relation to the initial aetiology. Methods Between 1997 and 2015, 91 patients underwent redo MV re-repair. The first MV repair was performed in our institution in 59% of cases. Follow-up information was available for 93% of our patients. The median follow-up was 56 months. Results The initial aetiology was degenerative disease in 40 (44%) patients, rheumatic disease in 25 (27.5%), endocarditis in 10 (11%), ischaemic in 6 (7%), severe mitral annulus calcification in 5 (5.5%), congenital disease in 4 (4%) and unknown in 1 (1%). The mean age was 58 ± 15 years. The median delay between the 1st and 2nd repair was 49 months with 6 early re-repairs. Re-repair was urgent or emergent in 19% of cases; indications for surgery were mitral regurgitation in 48%, stenosis in 19%, endocarditis in 19%, mitral disease in 11%, ring thrombosis in 2% and systolic anterior motion in 1%. The main mechanisms of failure included technical error (30%), progression of disease (35%), new disease (29%) and unknown (6%.) Re-repair was performed through a median sternotomy in 96% of cases, and 34% of patients had concomitant procedures. Eight (9%) postoperative deaths (4 of mitral annulus calcification, 2 of endocarditis, 1 of degenerative disease, 1 of ischaemia) and 5 (6%) early failures occurred (3 of rheumatic disease, 1 of degenerative disease, 1 of a congenital condition), requiring MV replacement in 4 and new repair in 1. Overall survival at 5 and 10 years was 76% and 57%, 83% and 49% in patients with degenerative diseases and 95% and 95% in patients with rheumatic disease. Overall freedom from reoperation at 5 and 10 years was 82% and 61%, 94% and 87% with degenerative disease and 60% and 45% with rheumatic disease. Conclusions MV re-repair is feasible and has good mid-term results in patients with degenerative MV disease. Rheumatic MV disease is associated with a certain risk of failure over time; nevertheless, these patients show excellent survival after re-repair.

OBJECTIVES: We retrospectively analysed our 20-year experience on surgical treatment of native mitral valve (MV) endocarditis in a single institution using an early and repair-oriented surgical approach. METHODS: From August 1991 to December 2015, 192 consecutive patients underwent MV surgery for active endocarditis. Of these, 81% (n = 155) had MV repair while 19% had MV replacement. In-hospital and late outcomes were analysed in the 2 groups and in the subgroups of repair with and without the use of a patch. Study end points were overall survival, MV reoperation and valve-related events. The median follow-up was 122 and 146 months in the repair and replacement groups, respectively. RESULTS: Patients undergoing MV replacement were significantly older with more severe preoperative comorbidities and clinical conditions compared to patients undergoing MV repair (P < 0.05). When the repair and replacement groups were compared, hospital mortality was 11.6% and 29.7%, respectively (P = 0.006); at 15 years, overall survival was 57 ± 6% and 36 ± 12%, respectively (P = 0.03); freedom from MV reoperation was 81 ± 6% and 73 ± 18%, respectively (P = 0.46); linearized rate of recurrent endocarditis was 0.1% and 2.4%, respectively. Fifteen-year freedom from reoperation was 75.4 ± 8.6% vs 92 ± 4.5% in the patch versus no-patch repair subgroups, respectively (P = 0.33). CONCLUSIONS: Active MV endocarditis remains a life-threatening disease. In experienced centres, an early and repair-oriented surgical approach can achieve relatively high reparability rates with good long-term durability of the repair and a very low recurrence rate of endocarditis. Patients could benefit from MV repair even if patch material is necessary to repair the valve.

We have recently shown that valve sparing reimplantation (VSR) improves the durability of bicuspid aortic valve repair in comparison with subcommissural annuloplasty. The aim of this study was to assess the degree of annular reduction provided by these techniques and to correlate these findings with repair durability.From 1995 to 2010, 161 patients underwent bicuspid valve repair. We included only patients with subcommissural annuloplasty or reimplantation having intraoperative pre- and post-repair transoesophageal echocardiography images. Pre- and post-repair ventriculo-aortic junction (VAJ) diameters were measured on long axis views. Inclusion criteria were met by 53 patients with subcommissual annuloplasty and 65 with reimplantation. Median follow-up was 53 months in the subcommissual annuloplasty group and 42 months in the reimplantation group. Follow-up completeness was 100% in subcommissural annuloplasty and 94% in reimplantation.There was no operative or late mortality. Mean preoperative VAJ was similar in both groups (reimplantation: 28 ± 3 mm vs subcommissural annuloplasty: 28 ± 3, P = 0.16). Preoperative VAJ was larger in patients40 years and with aortic regurgitation (AR) ≥ 3+ (P0.01). Mean postoperative VAJ was smaller in reimplantation compared with subcommissural annuloplasty (21 ± 2 mm vs 24 ± 3 mm, P0.01). In univariate analyses, subcommissural annuloplasty, preoperative VAJ ≥ 30 mm, postoperative VAJ ≥ 25 mm and cusp repair with patch were predictive of recurrent AR1+. In the subcommissural annuloplasty group, VAJ≥ 30 mm preoperatively and ≥ 25 mm postoperatively were associated with decreased 6 years freedom from recurrent AR1+ (30 mm: 74% vs ≥ 30 mm: 39%, P = 0.01;25 mm: 80% vs ≥ 25 mm 31%, P = 0.02) In the reimplantation group, VAJ dimension had no effect on recurrent AR1+ (P = 0.93).In bicuspid aortic valve repair, the circumferential annuloplasty of VSR offers greater reduction of VAJ compared with the non-circumferential annuloplasty provided by the subcommissural annuloplasty. The degree and extent of VAJ reduction in reimplantation seem to be factors among others that positively influence repair durability particularly in patients with a large VAJ (≥ 30 mm).

Objectives We report the outcomes of robotic valve repair for degenerative mitral regurgitation (MR) in our Institution. Methods Between February 2012 and July 2016, 134 patients underwent robotic mitral valve (MV) repair with the da Vinci Si system. All the operations were performed through a mini-thoracotomy in the fourth right intercostal space, cardiopulmonary bypass and mild hypothermia. The clinical and echocardiographic follow-up was 100% complete. Results There was no hospital death. The mean cross-clamp and cardiopulmonary bypass time were 112±23 and 159±33 min, respectively. Pre-discharge echocardiograms showed none-to-mild residual MR in all patients. Median follow-up was 24.1 months. We observed 1 early and 4 late reoperations on the MV for an overall freedom from reoperation of 98.2% and 94.1% at 12 and 36 months, respectively. Furthermore, echocardiographic follow-up revealed freedom from recurrence of MR greater than Grade 1+ of 92.5% and 80.7% at 12 and 36 months, respectively. Nevertheless freedom from recurrence of MR greater than Grade 2+ was 97.2% at 12 and 36 months. Conclusions Robotic MV repair is a feasible and safe option for the treatment of degenerative MR in selected patients with excellent perioperative outcomes. Early and midterm results are remarkable and are associated with low risk of late recurrence of MR and reoperation. Long-term follow-up is needed to confirm the durability of valve repair.

Supplemental Digital Content is available in the text., Background— Bilateral internal thoracic arteries (BITA) have demonstrated superior patency and improved survival in patients undergoing coronary artery bypass grafting. However, the optimal configuration for BITA utilization and its effect on long-term outcome remains uncertain. Methods and Results— We randomly assigned 304 patients undergoing coronary artery bypass grafting using BITA to either in situ or Y grafting configurations. The primary end point was 3-year angiographic patency. Secondary end points included major adverse cardiac and cerebrovascular events (ie, death from any cause, stroke, myocardial infarction, or repeat revascularization) at 7 years. More coronary targets were able to be revascularized using internal thoracic arteries in patients randomized to Y grafting versus in situ group (3.2±0.8 versus 2.4±0.5 arteries/patient; P

Background Late survival and freedom from retreatment on the descending aorta was evaluated after ascending aortic repair for type A acute aortic dissection (TAAAD). Methods Between March 1992 and January 2006, 189 TAAAD patients (mean age, 52 ± 11; range, 17 to 83 years) were included; of these, 58 had a patent false lumen, and 49 had Marfan syndrome. The descending aorta was evaluated postoperatively with computed tomography (CT). Late outcomes were assessed by Cox regression analysis and actuarial survival and freedom from retreatment by the Kaplan-Meier method. Mean follow-up was 88 ± 44 months. Results There were 38 (20%) late deaths. At 10 years, survival was 89.8% ± 2.1% for patients with an occluded false lumen and 59.8% ± 3.5% for patients with a patent false lumen ( p = 0.001), and freedom from retreatment on the descending aorta was 94.2% ± 3.1% for an occluded false lumen and 63.7% ± 2.6% for a patent false lumen ( p p = 0.002) and a patent false lumen ( p = 0.001) were predictors for late death. Patent false lumen ( p = 0.0001), Marfan syndrome ( p = 0.03), and descending aortic diameter 4.5 cm or larger ( p = 0.002) were predictors for retreatment. Conclusions A patent false lumen was a predictor for late death and retreatment on the descending aorta. Marfan syndrome and aortic size exceeding 4.5 cm were predictors for late retreatment. These patients require very close follow-up and a plan for retreatment on the descending aorta to prevent sudden rupture and late death.

A 56-year-old man presented to the emergency department of our institution complaining of sudden onset chest pain, shortness of breath and palpitations. His past medical history was significant for hypertension and paroxysmal atrial fibrillation. Physical examination revealed a blood pressure of 150/80 mmHg, heart rate of 120 bpm, normal heart sounds and lungs auscultation and normal distal arterial pulses. An urgent computed tomography (CT) scan of the chest and abdomen revealed an acute type A aortic dissection extending from the ascending aorta till the origin of the superior mesenteric artery with a maximum diameter of 51 mm at the level of the ascending aorta. The patient was therefore referred for emergency surgery.

Transcatheter aortic valve implantation was introduced into clinical practice in 2002 as a rescue approach in patients presenting with symptomatic severe aortic stenosis but not eligible for conventional aortic valve replacement. This technique allows implantation of a balloon expandable bioprosthesis without resection of the native aortic valve. Several complications are described as a consequence of the residual highly calcified valve being squeezed against the aortic wall by the stent of the implant. This can result in deformation of the metal stent and paravalvular leakage, risk of occlusion of the coronary ostia, or central and peripheral embolization of valvular debris. To avoid these complications, many authors suggest the possibility to resect and remove the native aortic valve before transcatheter aortic valve implantation. In this field, different authors have described possible techniques and different sources of energy to resect the calcified valve. In this article, we review the development of these experimental techniques and discuss future prospects in this field.

Congenitally corrected transposition of the great vessels (CCTGV) is a rare congenital heart defect associated with multiple cardiac morphological abnormalities and conduction defects. Complete atrioventricular (AV) block occurs in 30% of patients and it may be present at birth or develop later with a rate of 2% per year; moreover, a systemic right ventricle is frequently characterized by heart failure in adult life. We used a bifocal cardiac stimulation for a young woman affected by CCTGV and atrioventricular Mobitz 2 and 2:1 block, considering structural, anatomic condition, and the high rate of pacing she underwent. (PACE 2012; 35:e296–e298)

Coronary artery fistulas are rare congenital anomalies arising from an abnormal direct connection between any coronary arteries and a cardiac chamber, a great vessel or the coronary sinus. In this case report we present a rare case of a giant fistula between the f irst marginal branch of the circumflex coronary artery and the coronary sinus in a patient symptomatic for dyspnea and palpitation. A selective coronary angiography revealed the presence of a fistula between a coronary artery and the coronary sinus. A contrast-enhanced ECG-gated multi-doctor computed tomography confirmed the presence of a giant coronary artery fistula between the first obtuse marginal branch of the circumflex coronary artery and coronary sinus. Due to the rapid progression of the fistula diameter and symptoms, the patient underwent to a surgical closure of the fistula. At six months follow up, the patient was in excellent condition and asymptomatic for dyspnea, palpitation or chest pain. A control contrast-enhanced ECG-gated multi-dector computed tomography showed a complete closure of the fistula without residual shunt.

Congenitally corrected transposition of the great vessels (CCTGV) is a rare congenital heart defect associated with multiple cardiac morphological abnormalities and conduction defects. Complete atrioventricular (AV) block occurs in 30% of patients and it may be present at birth or develop later with a rate of 2% per year; moreover, a systemic right ventricle is frequently characterized by heart failure in adult life. We used a bifocal cardiac stimulation for a young woman affected by CCTGV and atrioventricular Mobitz 2 and 2:1 block, considering structural, anatomic condition, and the high rate of pacing she underwent.

ObjectiveSurgical management of moderate chronic ischemic mitral valve regurgitation is still debated. The aim of this study was to evaluate the effect of adding mitral valve repair to coronary artery bypass grafting on clinical outcomes and left ventricular remodeling in patients who underwent coronary artery bypass grafting alone versus coronary artery bypass grafting plus mitral valve repair in a randomized trial.MethodsBetween February 2003 and May 2007, 102 patients were eligible for this study and were randomly assigned to one of 2 groups by means of card allocation: coronary artery bypass grafting plus mitral valve repair (CABG plus MVR group; 48 patients, 47%) or coronary artery bypass grafting alone (CABG group; 54 patients, 53%). The 2 groups were similar regarding demographics, perioperative clinical data, and outcomes. There were differences regarding cardiopulmonary bypass (P < .0001) and aortic crossclamp (P < .0001) times. Exercise tests were performed for all survivors to evaluate tolerance to exercise and variability on grade of mitral regurgitation and systolic pulmonary arterial pressure. The study was blinded for physicians and nurses involved in postoperative care and clinical follow-up. The mean follow-up was 32 ± 18 months.ResultsOverall in-hospital mortality was 3% (3 patients). One (1.8%) patient died in the CABG group, and 2 (4.1%) patients died in the CABG plus MVR group. Survival rates ± standard error at 5 years for patients in the CABG and CABG plus MVR groups were 88.8% ± 3.2% and 93.7% ± 3.1%, respectively. A significant difference was found between the 2 groups with regard to mean New York Heart Association class (P < .0001), left ventricular end-diastolic diameter (P < .01), left ventricular end-systolic diameter (P < .01), pulmonary arterial pressure (P < .0001), and left atrial size (P < .01). At follow-up, coronary artery bypass grafting alone was able to reduce mitral regurgitation grade in 40% of patients, whereas in the remaining patients mitral regurgitation grade remained stable or worsened. In the CABG group, among the 17 patients with mild mitral regurgitation and 12 patients with moderate mitral regurgitation at rest, 7 (40%) and 9 (75%) patients, respectively, had worsening in mitral regurgitation grade and pulmonary artery pressure during exercise.ConclusionsThe efficacy of adding mitral valve repair to coronary artery bypass grafting is well demonstrated by the improvement of New York Heart Association functional class and percentage of left ventricular ejection fraction and by the decrease of mitral regurgitation grade, left ventricular end-diastolic diameter, left ventricular end-systolic diameter, pulmonary artery pressure, and left atrial size. Moreover, coronary artery bypass grafting alone left more patients with heart failure symptoms at rest and during exercise. Combined coronary artery bypass grafting and mitral valve repair have no effect on survival at short-term follow-up, and the trends that are evident will likely become more significant with time.