Breakfast Abstract Video Session
Activity: Mitral Conclave 2023
Mount Sinai Icahn School of Medicine
New York, NY
United States - Contact Me
Dr. Anyanwu is Professor and Vice-Chairman of the Department of Cardiovascular Surgery in the Icahn School of Medicine at Mount Sinai. His clinical interests include mitral valve surgery, reoperative surgery, and surgery for heart-failure. Dr. Anyanwu has served the AATS in various roles, including serving on the Program Committee for prior Mitral Conclave and Annual Meetings. He currently serves on the AATS Board.
Imperial College London
London, London
United Kingdom - Contact Me
PRAKASH P PUNJABI - Professor: National Heart and Lung Institute IMPERIAL COLLEGE LONDON - Consultant Cardiothoracic Surgeon- Imperial College Healthcare NHS Trust -Hammersmith Hospital, London W12 0HS
HIGHER EDUCTAION:
Fellow Royal College of Surgeons: Eng. – FRCS
Fellow Faculty of Surgical Trainers: Royal College of Surgeons of Edinburgh – FFSTEd
MCh (Cardiothoracic Surgery) –Distinction with 1st rank – University of Bombay - India // Diplomate National Board of Exams (Cardiothoracic Surgery) – Distinction - India
Fellow College of Chest Physicians – FCCP – Gold Medal // MS (General Surgery) - Nagpur University – India - Distinction
MBBS - Nagpur University – India -Distinction - Pathology (Silver Medal) + General Surgery
FELLOWSHIP/MEMBERSHIP:
Member: American Association of Thoracic Surgery
Fellow: European Society of Cardiology - FESC – 2015
Elected Trustee – Society for Cardiothoracic Surgery in GB and Ireland: 2016 – 2019
Member: SAC (Specialty Advisory Committee) - Cardiothoracic Surgery - 2016 – 2022
SAC Liaison Member - North West Deanery + Mersey Deanery – Oct 2016 – Oct 2022
Workforce Lead – SAC - Oct 2017 onwards
EACTS Guideline writing committee Aug 2018 onwards
Nucleus member: Cardiovascular Surgery - ESC – 2017
Nucleus member: Valvular Heart Disease - ESC – 2013- 2017
ESC Guideline writing committee Aug 2016 onwards
Training Programme Director: Cardiothoracic Surgery – London Deanery – 2016 – 2024
Surgical Tutor: Royal College of Surgeons – England – 2008 - 2024
President: European Valve Repair Group (EVRG) 2004 – 2014
Training Programme Director: Core Surgical Training – London Deanery - 2008 - 2011
Society of Thoracic Surgeons (STS) USA 2005
European Association of Cardiothoracic Surgery (EACTS) 2003
Society of Cardiothoracic Surgeons (SCTS) UK - 2000
British Cardiac Society (BCS) - 2002
EDITORIAL ROLES:
Editor in Chief - “Perfusion” since 2008 - IMPACT FACTOR INCREASED – current 1.972
Maria Eleonora Hospital
Palermo, Palermo
Italy - Contact Me
Dr. Khalil fattouch is Associate Professor in Cardiovascular Surgery in the Department of Surgery, Oncology and Stomatology “DICHIRONS” at the University of Palermo. He is Chief Department of Cardiovascular Surgery, at GVM Care and Research, Maria Eleonora Hospital, in Palermo.
Dr. Fattouch completed his undergraduate studies and earned his medical degree in Rome, Italy at the University of Rome, Faculty of Medicine and Surgery in 1994. He subsequently completed his residency in 2002 at the same University and joined the Palermo faculty of medicine in 2003 where he was appointed first as cardiac surgeon and as Aggregate professor in cardiac surgery in 2008. His undergraduate in PhD at the university of Rome between 2003-2006. In 2012, he was elevated to the position of Chief departement in Cardiovascular Surgery.
In addition to his clinical expertise, Dr. Fattouch is currently Professor in Cardiac Surgery and co-founder and Director of the Mitral Academy. Throughout his academic career, Dr. Fattouch has authored more than 120 peer-reviewed journal articles along with numerous book chapters. He is currently the lead investigator of an international, randomized, controlled trial which aims to determine the optimal strategy for concomitant or no tricuspid repair during mitral valve procedures (The PROCIDA trial). He has given expert presentations at national and international meetings to share his exquisite knowledge. He currently serves as the Editor, co-editor, scientific committee member of severals international meeting. He yet member of several committe in scientific societies.
Dr. Fattouch’s interests include all aspects of adult cardiac surgery and he is also specializes in structural heart disease, valvular dysfunction and complex aortic procedures, Valve repair and transcatheter valve terapies.
Friday, May 5, 2023: 7:00 AM - 8:30 AM
New York Hilton Midtown
Posted Room Name: Grand Ballroom
Presentations
MO01. Endoscopic Anterior Leaflet Mitral Valve and Tricuspid Repair
Total Time: 8 Minutes
Objective: To present a case of a complex severe mitral valve regurgitation due to anterior leaflet prolapse and chordae tendinae rupture associated with tricuspid valve severe regurgitation due to annular dilation, treated with a minimally invasive totally 3D endoscopic technique.
Case Video Summary: A 68 years old patient presented with a worsening mild dyspnea (class NYHA II) and severe mitral and tricuspid regurgitation at trans-thoracic echocardiography. Trans-esophageal Echocardiogram confirmed the presence of severe anterior mitral prolapse, with first order chordae tendinae rupture of A2 scallop and associated flail. After a peripheral arterial and single venous double stage femoral cannulation, Del Nido anterior cardioplegia is infused, after clamping the aorta with Cygnet clamp through a 6 centimeters anterior-lateral incision in the III right intercostal space. Left atrium is opened and a venting line is positioned to keep the field clear. Valve inspection confirms transesophageal echocardiographic findings, associated with clearly thinned chordae tendinae of A3 scallop and concomitant mild prolapse. A 5/0 Goretex artificial chorda tendinea is positioned on the free edge of A2 and the damaged native chorda tendinea is resected; its length is adjusted comparing the length of the native ones. A 5/0 Goretex suture is positioned on the free edge of A3 where the secondary mild prolapse is found, in order to reduce the length of the free margin. A 34 complete prostetic mitral annulus is positioned and no resection of the anterior leaflet is performed. Left atrium is closed with a double running 4/0 Prolene suture and right atrium is opened to perform tricuspid valve annuloplasty with a flexible 32 prosthetic tricuspid ring, without encircling superior and inferior venae cavae. Intraoperative hydrodynamic test showed good continence after repair.
Conclusions: AL prolapse has been considered a more challenging problem and long-term results are not usually as favourable as those for PL prolapse. Many surgical techniques are currently available for the treatment of AL prolapse, involving not only the leaflets but also the subvalvular apparatus. Complex mitral valve repair is feasible even in totally minimally invasive endoscopic CT surgery, with optimal visualization of all the mitral valve apparatus. Even trcuspid valve repair is feasible with a simplified technique: single venous double stage cannulation without encircling venae cavae.
Case Video Summary: A 68 years old patient presented with a worsening mild dyspnea (class NYHA II) and severe mitral and tricuspid regurgitation at trans-thoracic echocardiography. Trans-esophageal Echocardiogram confirmed the presence of severe anterior mitral prolapse, with first order chordae tendinae rupture of A2 scallop and associated flail. After a peripheral arterial and single venous double stage femoral cannulation, Del Nido anterior cardioplegia is infused, after clamping the aorta with Cygnet clamp through a 6 centimeters anterior-lateral incision in the III right intercostal space. Left atrium is opened and a venting line is positioned to keep the field clear. Valve inspection confirms transesophageal echocardiographic findings, associated with clearly thinned chordae tendinae of A3 scallop and concomitant mild prolapse. A 5/0 Goretex artificial chorda tendinea is positioned on the free edge of A2 and the damaged native chorda tendinea is resected; its length is adjusted comparing the length of the native ones. A 5/0 Goretex suture is positioned on the free edge of A3 where the secondary mild prolapse is found, in order to reduce the length of the free margin. A 34 complete prostetic mitral annulus is positioned and no resection of the anterior leaflet is performed. Left atrium is closed with a double running 4/0 Prolene suture and right atrium is opened to perform tricuspid valve annuloplasty with a flexible 32 prosthetic tricuspid ring, without encircling superior and inferior venae cavae. Intraoperative hydrodynamic test showed good continence after repair.
Conclusions: AL prolapse has been considered a more challenging problem and long-term results are not usually as favourable as those for PL prolapse. Many surgical techniques are currently available for the treatment of AL prolapse, involving not only the leaflets but also the subvalvular apparatus. Complex mitral valve repair is feasible even in totally minimally invasive endoscopic CT surgery, with optimal visualization of all the mitral valve apparatus. Even trcuspid valve repair is feasible with a simplified technique: single venous double stage cannulation without encircling venae cavae.
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MO02. A Rare Case of Left Atrial Primary Malignant Nerve Sheath Tumour: Case Report
Total Time: 8 Minutes
Objective:
Malignant peripheral nerve sheath tumor (MPNST) is a rare soft tissue sarcoma, accounting for approximately 2% of all sarcomas. It has a high rate of local recurrence and metastatic dissemination. Amongst all phenotypes of malignant primary cardiac tumors, MPNST is exceedingly rare with an incidence of 0.75% of all cardiac tumors. To date, only a handful of cases have been reported in the literature. Due to its scarcity, little is known about this disease entity and its optimal course of treatment. The current preferred course of treatment is by full surgical resection of the tumor, followed by adjuvant radiotherapy and chemotherapy.
Case video summary:
We report a unique case of a 50-year-old, previously healthy man, presenting with symptoms of congestive heart failure. Investigations revealed a large left atrial (LA) mass prolapsing across the mitral valve into the left ventricle during diastole, resulting in mitral inflow obstruction.
The patient underwent successful surgical resection of the left atrial tumor the next day. Intraoperative evaluation showed an atypical location of the mass arising from the posterolateral wall of the LA, extending into the left pulmonary veins and left atrial appendage. This heightened our suspicion of a malignant cardiac neoplasm. Histological examination confirmed the diagnosis of MPNST. The patient unfortunately had distant metastasis to the brain and vertebral body prior to commencement of chemotherapy.
Conclusions: Despite current aggressive multimodal therapy, the prognosis of patients with MPNST remains dismal with a mean survival ranging from 3 months to 1 year. Even after optimal radical resection, a significant proportion of patients (40-70%) develop local recurrence or distant metastases, usually within 1 year. Available therapies offer very limited benefits to patients with MPNST. Further research is required for new therapies.
Malignant peripheral nerve sheath tumor (MPNST) is a rare soft tissue sarcoma, accounting for approximately 2% of all sarcomas. It has a high rate of local recurrence and metastatic dissemination. Amongst all phenotypes of malignant primary cardiac tumors, MPNST is exceedingly rare with an incidence of 0.75% of all cardiac tumors. To date, only a handful of cases have been reported in the literature. Due to its scarcity, little is known about this disease entity and its optimal course of treatment. The current preferred course of treatment is by full surgical resection of the tumor, followed by adjuvant radiotherapy and chemotherapy.
Case video summary:
We report a unique case of a 50-year-old, previously healthy man, presenting with symptoms of congestive heart failure. Investigations revealed a large left atrial (LA) mass prolapsing across the mitral valve into the left ventricle during diastole, resulting in mitral inflow obstruction.
The patient underwent successful surgical resection of the left atrial tumor the next day. Intraoperative evaluation showed an atypical location of the mass arising from the posterolateral wall of the LA, extending into the left pulmonary veins and left atrial appendage. This heightened our suspicion of a malignant cardiac neoplasm. Histological examination confirmed the diagnosis of MPNST. The patient unfortunately had distant metastasis to the brain and vertebral body prior to commencement of chemotherapy.
Conclusions: Despite current aggressive multimodal therapy, the prognosis of patients with MPNST remains dismal with a mean survival ranging from 3 months to 1 year. Even after optimal radical resection, a significant proportion of patients (40-70%) develop local recurrence or distant metastases, usually within 1 year. Available therapies offer very limited benefits to patients with MPNST. Further research is required for new therapies.
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MO04. Totally Endoscopic, Robotic-Assisted Tricuspid Valve Repair and Biatrial Cryo-MAZE
Total Time: 8 Minutes
Objective: We present the case of a 66-year-old male with sick sinus syndrome, atrial fibrillation, and a recent history of right ventricular pacemaker lead extraction after which he experienced progressive fatigue and decreased endurance. He was referred to our institution for isolated, iatrogenic, severe tricuspid regurgitation due to torn septal tricuspid leaflet.
Case Video Summary: Ports configuration consisted of the working port being placed in the third intercostal space at the anterior axillary line, the left robotic arm port placed in the second intercostal space, halfway between the anterior axillary line and the midclavicular line, the right robotic arm port placed in the fifth intercostal space, slightly below the anterior axillary line, and the atrial retractor placed in the fourth intercostal space, two centimeters medial to the midclavicular line. Cardiopulmonary bypass was achieved by percutaneous femoral artery cannulation and by percutaneous femoral and internal jugular veins cannulation. Aortic cross-clamp was performed with the Chitwood endothoracic clamp. After snaring of the venae cavae, the left atrium was accessed via the Waterson's groove. We closed the left atrial appendage and we then performed left-sided CryoMAZE (epicardial coronary sinus line, mitral valve line, pulmonary vein line, base of the atrial appendix). After closure of the left atriotomy, a right atriotomy was performed and the tricuspid valve was accessed and inspected, showing torn septal leaflet. The tricuspid valve was repaired by reimplanting the tip of the leaflet to a papillary muscle-like structure on the right ventricular wall, multiple clefts closure (Video), and placement of a 34-mm annuloplasty band. We then performed right-sided CryoMAZE (isthmus line, superior and inferior venae cavae, and right atrial appendage). At the end of the procedure, transesophageal echocardiography revealed trace tricuspid regurgitation and a mean gradient of 1 mmHg. The patient was discharged home on sinus rhythm.
Conclusions: Our case demonstrates the safety and effectiveness of a totally endoscopic, robotic-assisted approach for the treatment of iatrogenic, severe tricuspid regurgitation and atrial fibrillation.
Case Video Summary: Ports configuration consisted of the working port being placed in the third intercostal space at the anterior axillary line, the left robotic arm port placed in the second intercostal space, halfway between the anterior axillary line and the midclavicular line, the right robotic arm port placed in the fifth intercostal space, slightly below the anterior axillary line, and the atrial retractor placed in the fourth intercostal space, two centimeters medial to the midclavicular line. Cardiopulmonary bypass was achieved by percutaneous femoral artery cannulation and by percutaneous femoral and internal jugular veins cannulation. Aortic cross-clamp was performed with the Chitwood endothoracic clamp. After snaring of the venae cavae, the left atrium was accessed via the Waterson's groove. We closed the left atrial appendage and we then performed left-sided CryoMAZE (epicardial coronary sinus line, mitral valve line, pulmonary vein line, base of the atrial appendix). After closure of the left atriotomy, a right atriotomy was performed and the tricuspid valve was accessed and inspected, showing torn septal leaflet. The tricuspid valve was repaired by reimplanting the tip of the leaflet to a papillary muscle-like structure on the right ventricular wall, multiple clefts closure (Video), and placement of a 34-mm annuloplasty band. We then performed right-sided CryoMAZE (isthmus line, superior and inferior venae cavae, and right atrial appendage). At the end of the procedure, transesophageal echocardiography revealed trace tricuspid regurgitation and a mean gradient of 1 mmHg. The patient was discharged home on sinus rhythm.
Conclusions: Our case demonstrates the safety and effectiveness of a totally endoscopic, robotic-assisted approach for the treatment of iatrogenic, severe tricuspid regurgitation and atrial fibrillation.
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Case Video Presenter
Andrea Amabile, University of Pittsburgh Medical Center - Contact Me PITTSBURGH, PAUnited States
MO05. Totally Endoscopic and Percutaneously approached Robotic Mitral Valve Re-repair after the failure of Transcatheter Mitral Valve Repair
Total Time: 8 Minutes
Objective: We demonstrate robotic mitral valve (MV) re-repair after the failure of transcatheter MV repair.
Case Video Summary: The patient was an 82-year-old woman with a history of transcatheter MV repair with two clips four years ago for severe mitral regurgitation (MR) due to P2 prolapse with torn chordae. She was indicated for the surgery because of symptomatic severe residual MR, severe tricuspid regurgitation, and paroxysmal atrial fibrillation. Preoperative transesophageal echocardiogram (TEE) showed P2 prolapse with MR jet medial to P2. Four 8-mm robotic ports and one 8-mm working port were on the right-side chest. Peripheral cannulation was performed percutaneously. Cardiac arrest was achieved with intra-aortic balloon clamping followed by delivery of antegrade cardioplegia. The left atriotomy was performed. Iatrogenic patent foramen ovale by previous transcatheter procedure was directly closed. The left atrial cryo maze was performed followed by the left atrial appendage closure. Re-endothelialization between A2 and P2 was dissected with electrocautery and previous repair clips were exposed. A 2-0 Ethibond suture needle was passed through the loop of the locking mechanism. Retraction forces of the suture on the locking mechanism were applied by a bedside assistant with simultaneous use of two robotic instruments to open both arms of the clip. Once the device was unlocked and clip were opened, the clip was gently separated from the leaflets. Two clips were removed out of the body through an 8 mm working port. P2 prolapse with torn chordae was noted on water saline test. Two sets of CV-4 neochordae were placed to medial and lateral sides of the P2 from posteromedial and anterolateral papillary muscle, respectively. MV annuloplasty was performed with 32 mm flexible partial band. MV was competent on water saline test. The left atrium was closed. Subsequently, tricuspid valve annuloplasty was performed with 28 mm flexible partial band. Cross clamp time was 178 minutes. The patient was weaned off cardiopulmonary bypass without difficulties. Post-repair TEE showed no residual MR. She was extubated in the operating room. Although her hospital stay was extended due to bradycardia with junctional rhythm, she recovered sinus rhythm and was discharged on postoperative day 7 without pacemaker implantation.
Conclusions: MV is repairable even after the failure of transcatheter MV repair via totally endoscopic and percutaneous robotic approach.
Case Video Summary: The patient was an 82-year-old woman with a history of transcatheter MV repair with two clips four years ago for severe mitral regurgitation (MR) due to P2 prolapse with torn chordae. She was indicated for the surgery because of symptomatic severe residual MR, severe tricuspid regurgitation, and paroxysmal atrial fibrillation. Preoperative transesophageal echocardiogram (TEE) showed P2 prolapse with MR jet medial to P2. Four 8-mm robotic ports and one 8-mm working port were on the right-side chest. Peripheral cannulation was performed percutaneously. Cardiac arrest was achieved with intra-aortic balloon clamping followed by delivery of antegrade cardioplegia. The left atriotomy was performed. Iatrogenic patent foramen ovale by previous transcatheter procedure was directly closed. The left atrial cryo maze was performed followed by the left atrial appendage closure. Re-endothelialization between A2 and P2 was dissected with electrocautery and previous repair clips were exposed. A 2-0 Ethibond suture needle was passed through the loop of the locking mechanism. Retraction forces of the suture on the locking mechanism were applied by a bedside assistant with simultaneous use of two robotic instruments to open both arms of the clip. Once the device was unlocked and clip were opened, the clip was gently separated from the leaflets. Two clips were removed out of the body through an 8 mm working port. P2 prolapse with torn chordae was noted on water saline test. Two sets of CV-4 neochordae were placed to medial and lateral sides of the P2 from posteromedial and anterolateral papillary muscle, respectively. MV annuloplasty was performed with 32 mm flexible partial band. MV was competent on water saline test. The left atrium was closed. Subsequently, tricuspid valve annuloplasty was performed with 28 mm flexible partial band. Cross clamp time was 178 minutes. The patient was weaned off cardiopulmonary bypass without difficulties. Post-repair TEE showed no residual MR. She was extubated in the operating room. Although her hospital stay was extended due to bradycardia with junctional rhythm, she recovered sinus rhythm and was discharged on postoperative day 7 without pacemaker implantation.
Conclusions: MV is repairable even after the failure of transcatheter MV repair via totally endoscopic and percutaneous robotic approach.
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Case Video Presenter
Daisuke Kaneyuki, NewYork- Presbyterian/Columbia University Medical Center - Contact Me Greensburg, PAUnited States
MO06. Minimally Invasive Mitral Valve Repair in Patients with Pectus Excavatum and Complex Mitral Pathology − The Usefulness of the Sternal Lifting Technique and the Modified Tourniquet Technique
Total Time: 8 Minutes
Objectives
The patient with chest deformity is generally not a good candidate for minimally invasive mitral valve repair (MIMVR) because poor visualization of the mitral valve (MV) is concerned. We report a successful case of MIMVR in a patient with pectus excavatum and a complex mitral regurgitation (MR). Our simple sternal lifting technique and modified tourniquet technique were helpful in improving the visualization of the MV and facilitating complex neochordal repair.
Case Video Summary:
A fifty-year-old woman with severe MR was referred to us for MIMVR. Physical examination showed that she had pectus excavatum. Preoperative computed tomography showed the heart was displaced to the left side with a narrowing thoracic anterior-posterior distance (5.8 cm). The preoperative trans-esophageal echocardiography (TEE) showed anterior mitral leaflet (AML) prolapse and posterior mitral leaflet with restricted motion and mitral annular disjunction.
We performed MIMVR through a right lateral minithoracotomy. To enhance the visual field of the heart, the sternum was lifted by a right angle retractor inserted into the medial border of the thoracotomy. This maneuver significantly improved the visualization of the MV, even with a direct vision. The MV showed A2-A3 prolapse with markedly degenerated leaflets and subvalvular apparatus, which had an abnormal attachment to the leaflet. P3 segment was tethered with restricted leaflet motion. First, several ink dots were made to mark the expected leaflet coaptation line. Then, a short CV4 ePTFE loop was fixed to the anterior head of the posteromedial papillary muscle. Three ePTFE sutures were passed to the short loop, and each end was passed onto the prolapsing leaflet segment and temporally fixed using a small tourniquet. After seating an annuloplasty band, the neochordal length was adjusted with the left ventricle filled with saline until the valve was fully competent and the previously marked ink dots were well aligned on the coaptation line. Post-bypass TEE showed no MR.
Conclusions:
Our simple sternum lifting technique and modified tourniquet technique may be useful in patients with thoracic deformity and complex mitral pathology.
The patient with chest deformity is generally not a good candidate for minimally invasive mitral valve repair (MIMVR) because poor visualization of the mitral valve (MV) is concerned. We report a successful case of MIMVR in a patient with pectus excavatum and a complex mitral regurgitation (MR). Our simple sternal lifting technique and modified tourniquet technique were helpful in improving the visualization of the MV and facilitating complex neochordal repair.
Case Video Summary:
A fifty-year-old woman with severe MR was referred to us for MIMVR. Physical examination showed that she had pectus excavatum. Preoperative computed tomography showed the heart was displaced to the left side with a narrowing thoracic anterior-posterior distance (5.8 cm). The preoperative trans-esophageal echocardiography (TEE) showed anterior mitral leaflet (AML) prolapse and posterior mitral leaflet with restricted motion and mitral annular disjunction.
We performed MIMVR through a right lateral minithoracotomy. To enhance the visual field of the heart, the sternum was lifted by a right angle retractor inserted into the medial border of the thoracotomy. This maneuver significantly improved the visualization of the MV, even with a direct vision. The MV showed A2-A3 prolapse with markedly degenerated leaflets and subvalvular apparatus, which had an abnormal attachment to the leaflet. P3 segment was tethered with restricted leaflet motion. First, several ink dots were made to mark the expected leaflet coaptation line. Then, a short CV4 ePTFE loop was fixed to the anterior head of the posteromedial papillary muscle. Three ePTFE sutures were passed to the short loop, and each end was passed onto the prolapsing leaflet segment and temporally fixed using a small tourniquet. After seating an annuloplasty band, the neochordal length was adjusted with the left ventricle filled with saline until the valve was fully competent and the previously marked ink dots were well aligned on the coaptation line. Post-bypass TEE showed no MR.
Conclusions:
Our simple sternum lifting technique and modified tourniquet technique may be useful in patients with thoracic deformity and complex mitral pathology.
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MO07. Totally Endoscopic Minimally Invasive Mitral Valvuloplasty with Beating Heart for Treatment of Acute Myocardial Infarction Complicated with Papillary Muscle Rupture
Total Time: 8 Minutes
Objective: Papillary muscle rupture after coronary stent implantation in acute myocardial infarction is a life-threatening complication. Totally endoscopic minimally invasive mitral valvuloplasty (TEMI-MVP)with beating heart is a viable and effective option.
Case Video Summary: A male Patient(64y) was emergently transferred to our hospital with the support of IABP and ECMO, who underwent stent implantation 3 days ago for acute total occlusion of right coronary. Echocardiography showed severe mitral regurgitation with posterior leaflet flail associated with a highly mobile mass representing ruptured papillary muscle head. TEMI-MVP on beating heart was performed. Cardiopulmonary bypass(CPB) was established with previous cannulations of the femoral artery and vein of ECMO, and ECMO system maintained a self-circulation. The minimally invasive approach was adopted, thoracic cavity was flushed continuously by CO2. Excellent mitral valve exposure could be obtained through the incision of the interatrial groove with left atrial retractor. Intraoperative exploration revealed rupture of the complete posteromedial papillary muscle, and posterior leaflet prolapse. Ruptured papillary muscle heads was removed, and two groups of artificial chordae were anchored using 5-0 ePTFE suture; the posterior internal commissure was closed by continuous suture using 5-0 suture and strengthened by two pledgetted mattress sutures; finally, 28# annuloplasty full ring was implanted. Saline injection test showed good function of mitral valve, then the left atrial was closed. Left ventricular drainage tube was not removed for decompression, and the other end of the tube was connected to the cannulation of femoral vein through the chest wall via the major operating port. Postoperative transesophageal echocardiography (TEE) showed trivial regurgitation, the mean mitral valve pressure gradient was 4mmHg. CPB was weaned off smoothly, the cannulations of femoral artery and vein were reconnected to ECMO. The patient was conscious on postoperative day 2, weaned from ECMO, IABP, and ventilator on postoperative day 5, 7, 21, respectively.
Conclusions: For the patients in the early stage of coronary stent implantation for acute myocardial infarction complicated with papillary muscle rupture, beating heart technique was helpful to reduce myocardial injury. Minimally invasive mitral valve repair could improve surgery outcomes. However, pulmonary edema had adverse effect on surgical vision.
Case Video Summary: A male Patient(64y) was emergently transferred to our hospital with the support of IABP and ECMO, who underwent stent implantation 3 days ago for acute total occlusion of right coronary. Echocardiography showed severe mitral regurgitation with posterior leaflet flail associated with a highly mobile mass representing ruptured papillary muscle head. TEMI-MVP on beating heart was performed. Cardiopulmonary bypass(CPB) was established with previous cannulations of the femoral artery and vein of ECMO, and ECMO system maintained a self-circulation. The minimally invasive approach was adopted, thoracic cavity was flushed continuously by CO2. Excellent mitral valve exposure could be obtained through the incision of the interatrial groove with left atrial retractor. Intraoperative exploration revealed rupture of the complete posteromedial papillary muscle, and posterior leaflet prolapse. Ruptured papillary muscle heads was removed, and two groups of artificial chordae were anchored using 5-0 ePTFE suture; the posterior internal commissure was closed by continuous suture using 5-0 suture and strengthened by two pledgetted mattress sutures; finally, 28# annuloplasty full ring was implanted. Saline injection test showed good function of mitral valve, then the left atrial was closed. Left ventricular drainage tube was not removed for decompression, and the other end of the tube was connected to the cannulation of femoral vein through the chest wall via the major operating port. Postoperative transesophageal echocardiography (TEE) showed trivial regurgitation, the mean mitral valve pressure gradient was 4mmHg. CPB was weaned off smoothly, the cannulations of femoral artery and vein were reconnected to ECMO. The patient was conscious on postoperative day 2, weaned from ECMO, IABP, and ventilator on postoperative day 5, 7, 21, respectively.
Conclusions: For the patients in the early stage of coronary stent implantation for acute myocardial infarction complicated with papillary muscle rupture, beating heart technique was helpful to reduce myocardial injury. Minimally invasive mitral valve repair could improve surgery outcomes. However, pulmonary edema had adverse effect on surgical vision.
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MO08. Repair of Posterior Leaflet Prolapse: "detachment and non-sliding plasty technique".
Total Time: 8 Minutes
Objective: We describe an alternative surgical technique to treat severe mitral regurgitation due to a big (height and width =/> 3 cm) posterior leaflet prolapses.
Case Video Summary: A 65 years old female patient asymptomatic, in sinus rhythm with severe mitral regurgitation due to posterior leaflet prolapse, good ventricular function and no coronary lesions. Echocardiogram shows prolapse of posterior leaflet with chordal rupture at P2 level with an excess of tissue. Regurgitant jet anterior directed. Valve analysis identified small P1 one with no prolapse. A huge posterior leaflet prolapses with chordal rupture and with an excess tissue (height and width =/>3 cm) over P2 and P3. Anterior leaflet with no prolapse, a scar lesion secondary to an old infection process was identified with no leaflet perforation. We decide to detach almost the entire posterior leaflet from the annulus. In order to lower the height of the posterior leaflet we resect around a cm from the base of the leaflet. Without using sliding technique, we re-attach de posterior leaflet to the annulus with double running technique. Two set of PTFE neochords were place over posterior and anterior papillary muscles. Water test analysis without and with an incomplete posterior ring probe good results with posterior line of coaptation. Final length adjustment of the artificial chords was performed. Post operative echo shows no regurgitation with good surface of coaptation.
Conclusions: A huge posterior leaflet prolapse with an excess tissue (height and width =/> 3 cm) can be treated with detachment, resection and re-attachment to the annulus, without the use of sliding technique.
Case Video Summary: A 65 years old female patient asymptomatic, in sinus rhythm with severe mitral regurgitation due to posterior leaflet prolapse, good ventricular function and no coronary lesions. Echocardiogram shows prolapse of posterior leaflet with chordal rupture at P2 level with an excess of tissue. Regurgitant jet anterior directed. Valve analysis identified small P1 one with no prolapse. A huge posterior leaflet prolapses with chordal rupture and with an excess tissue (height and width =/>3 cm) over P2 and P3. Anterior leaflet with no prolapse, a scar lesion secondary to an old infection process was identified with no leaflet perforation. We decide to detach almost the entire posterior leaflet from the annulus. In order to lower the height of the posterior leaflet we resect around a cm from the base of the leaflet. Without using sliding technique, we re-attach de posterior leaflet to the annulus with double running technique. Two set of PTFE neochords were place over posterior and anterior papillary muscles. Water test analysis without and with an incomplete posterior ring probe good results with posterior line of coaptation. Final length adjustment of the artificial chords was performed. Post operative echo shows no regurgitation with good surface of coaptation.
Conclusions: A huge posterior leaflet prolapse with an excess tissue (height and width =/> 3 cm) can be treated with detachment, resection and re-attachment to the annulus, without the use of sliding technique.
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MO09. A Novel Technique in Complex Primary Mitral Valve Repair using an Inverted Basal Triangular Posterior Leaflet Resection plus Neo Chordae in Severe Mitral Regurgitation
Total Time: 8 Minutes
Objective: To share a new technique in complex primary MV repair using an inverted basal triangular P2 resection plus neo-chordae in a symptomatic patient with severe MR secondary to P2 prolapse with chordal rupture.
Methods: A video presentation of P2 prolapse MV repair. Pre-operative echo was scrutinised to establish the mechanism of MR and the risk of SAM as well as LV function and presence of TR. Operation: Median sternotomy approach. Bicaval cannulation instituted for CPB with access to the MV via Sondergaard's groove. The patient was cooled to 28 degrees. Annuloplasty sutures are placed initially to gain adequate exposure for valve inspection. The valve is fully assessed and interrogated for the assessment of the mechanism of MV regurgitation prior to choosing a repair technique. The MV Repair technique chosen in this case combines posterior leaflet resection with neo-chordae. Basal inverted triangular resection is performed centred on the annular aspect of P2 leaflet to reduce P2 height. The leaflet is extended to its full length by temporarily anchoring the free margin of the leaflet to the anterior annulus with a sliding stay suture. This slight tension extending the leaflet aids with the resection of myxomatous tissue whilst preserving the main body of the MV leaflet tissue anteriorly. The width and height of the triangular resection can be adjusted accordingly and adapted to the requirements of the repair. Leaflet continuity is restored by approximating the 2 sides of the to base of the triangle at the annular leaflet attachment. In this case the leaflet height is reduced to 15mm as the sides of the triangle are approximated. A 5/0 Prolene running suture is used to close the defect and the deep cleft between P1 and P2 noted on the initial interrogation of the valve is also closed. We can now turn our attention to the neo-chordae. In this particular complex repair case three Goretex neo-chord to P2, A1 and A2 were inserted. This is followed by stabilisation of the annulus with a 36mm Annuloplasty Ring secured using a suture device. Water test confirms a satisfactory repair and fine adjustment to the neo- chordae lengths complete the repair. The atrium is then closed with a running suture and the operation is completed following de-airing manoevres and cross-clamp removal. The patient came off CPB easily and our post operative echo confirms absence of MR.
Results: A stable repair was achieved with this novel technique.
Methods: A video presentation of P2 prolapse MV repair. Pre-operative echo was scrutinised to establish the mechanism of MR and the risk of SAM as well as LV function and presence of TR. Operation: Median sternotomy approach. Bicaval cannulation instituted for CPB with access to the MV via Sondergaard's groove. The patient was cooled to 28 degrees. Annuloplasty sutures are placed initially to gain adequate exposure for valve inspection. The valve is fully assessed and interrogated for the assessment of the mechanism of MV regurgitation prior to choosing a repair technique. The MV Repair technique chosen in this case combines posterior leaflet resection with neo-chordae. Basal inverted triangular resection is performed centred on the annular aspect of P2 leaflet to reduce P2 height. The leaflet is extended to its full length by temporarily anchoring the free margin of the leaflet to the anterior annulus with a sliding stay suture. This slight tension extending the leaflet aids with the resection of myxomatous tissue whilst preserving the main body of the MV leaflet tissue anteriorly. The width and height of the triangular resection can be adjusted accordingly and adapted to the requirements of the repair. Leaflet continuity is restored by approximating the 2 sides of the to base of the triangle at the annular leaflet attachment. In this case the leaflet height is reduced to 15mm as the sides of the triangle are approximated. A 5/0 Prolene running suture is used to close the defect and the deep cleft between P1 and P2 noted on the initial interrogation of the valve is also closed. We can now turn our attention to the neo-chordae. In this particular complex repair case three Goretex neo-chord to P2, A1 and A2 were inserted. This is followed by stabilisation of the annulus with a 36mm Annuloplasty Ring secured using a suture device. Water test confirms a satisfactory repair and fine adjustment to the neo- chordae lengths complete the repair. The atrium is then closed with a running suture and the operation is completed following de-airing manoevres and cross-clamp removal. The patient came off CPB easily and our post operative echo confirms absence of MR.
Results: A stable repair was achieved with this novel technique.
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Case Video Presenter
Ian Cummings, Royal Sussex County Hospital, Brighton - Contact Me London, UKUnited Kingdom
MO10. Flip-over for Mitral Valve Repair without Heterologous Material in a Reintervention for Failed Previous Repair with Heterologous Patch: is it possible?
Total Time: 8 Minutes
Objective: Mitral valve repair should be the first choice in severe mitral valve insufficiency. Avoiding heterologous material in leaflet repair could be better, especially in young patients. The aim of this case presentation is to show that mitral valve repair without using heterologous material on leaflets is also possible in reintervention for failed post-endocarditis mitral repair.
Case video summary: A 29 years old man presented with severe mitral insufficiency five years after Staphylococcus Aureus endocarditis, treated by mitral valve repair with heterologous patch on the anterior leaflet, between A2 and A3 areas according to Carpentier's classification. Recently, the patient experienced dyspnea and echocardiography revealed a severe mitral insufficiency (regurgitation volume 97 milliliters) and dilatation of left ventricle (end systolic diameter 65 millimeters) with a preserved ejection fraction (64%).
A reintervention was performed: the mitral valve presented a big cleft on the anterior leaflet between A2 and A3, where the previous patch was placed; in contrast, it seemed to be disappeared. A triangular resection of P2 was performed and the gap sutured with a continuous 4/0 polypropylene suture. By using the flip-over technique the resect tissue was a patch for the anterior leaflet, sutured with two continuous 4/0 polypropylene sutures between A2 and A3. Secondary order chordae were cut, and posterior papillary muscle was split, to improve the leaflet motion. Moreover, an annuloplasty with a semi-rigid ring of 30 millimeters of diameter was done with 2/0 braided polyester sub-annular single stitches. Total bypass time for procedure was 84 minutes and total cross clamp time 71 minutes. The heart had a perfect recovery from extracorporeal circulation and transesophageal echocardiography showed a good result of mitral repair. The man had an excellent post-operative recovery. In addition, echocardiography at discharge and at follow-up confirmed a good result of mitral repair.
Conclusions: This case showed a good result of mitral valve repair without heterologous material for the leaflets, in reintervention for failed previous mitral repair with a heterologous patch for endocarditis. This kind of repair should be the first choice especially for young patients, to avoid heterologous material deterioration or endocarditis recurrence, also in reinterventions. Further studies are required to verify the long-term outcome of this kind of repair.
Case video summary: A 29 years old man presented with severe mitral insufficiency five years after Staphylococcus Aureus endocarditis, treated by mitral valve repair with heterologous patch on the anterior leaflet, between A2 and A3 areas according to Carpentier's classification. Recently, the patient experienced dyspnea and echocardiography revealed a severe mitral insufficiency (regurgitation volume 97 milliliters) and dilatation of left ventricle (end systolic diameter 65 millimeters) with a preserved ejection fraction (64%).
A reintervention was performed: the mitral valve presented a big cleft on the anterior leaflet between A2 and A3, where the previous patch was placed; in contrast, it seemed to be disappeared. A triangular resection of P2 was performed and the gap sutured with a continuous 4/0 polypropylene suture. By using the flip-over technique the resect tissue was a patch for the anterior leaflet, sutured with two continuous 4/0 polypropylene sutures between A2 and A3. Secondary order chordae were cut, and posterior papillary muscle was split, to improve the leaflet motion. Moreover, an annuloplasty with a semi-rigid ring of 30 millimeters of diameter was done with 2/0 braided polyester sub-annular single stitches. Total bypass time for procedure was 84 minutes and total cross clamp time 71 minutes. The heart had a perfect recovery from extracorporeal circulation and transesophageal echocardiography showed a good result of mitral repair. The man had an excellent post-operative recovery. In addition, echocardiography at discharge and at follow-up confirmed a good result of mitral repair.
Conclusions: This case showed a good result of mitral valve repair without heterologous material for the leaflets, in reintervention for failed previous mitral repair with a heterologous patch for endocarditis. This kind of repair should be the first choice especially for young patients, to avoid heterologous material deterioration or endocarditis recurrence, also in reinterventions. Further studies are required to verify the long-term outcome of this kind of repair.
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MO11. The Sole Use of Ring Can Repair Barlow's Bi-leaflet Prolapse
Total Time: 8 Minutes
Objective: Barlow's disease is characterized by diffuse excess tissue, quite a large valve size, multiple segments affected with myxomatous pathological changes, and diffuse chordal elongation in addition to chordal rupture. Therefore, mitral valve repair for Barlow's disease is usually demanding. In a subpopulation of Barlow patients with bileaflet prolapse, central regurgitant jet without chordal rupture, we performed mitral repair using only a semi-rigid annuloplasty ring. Clinical outcomes were evaluated.
Methods: Of a total of 170 consecutive patients who underwent MVP, 13 patients who had anatomical features of Barlow's disease underwent MVP. The mean age was 60 years. All patients presented with large annulus size, myxomatous bileaflet prolapse, and multiple chordal elongations with(n=6) or without chordal ruptures (n=7) and were considered to have Barlow's disease. Patients were evaluated at discharge and after a mean follow-up of 26 ± 19 months by echocardiography.
Results: All patients received full ring, including CG future in 5 (32 mm:1, 34 mm: 2, 36 mm: 2), CE Physio Ⅱ in 8 (34 mm: 1, 36mm: 4, 38 mm: 3 ). Of these 13 patients, 4 were cured only by using a mitral annuloplasty semi-rigid ring. Additionally, the remaining 9 patients underwent leaflet plication and/or artificial chordal replacement. Concomitant procedures included TAP in 6, Maze in 4, LAAC in 6, PVR in 1. Hospital mortality was 0%. Postoperative echocardiography revealed no or trace MR in 9 patients and mild in 3 patients. The mean follow-up duration was 26 months. We encountered mild to moderate MR in 1 patient. No patient required reoperation for recurrent more than moderate MR. Among 7 patients who presented with large annulus size, myxomatous bileaflet prolapse, and multiple chordal elongations without chordal ruptures, early 3 cases were cured by a mitral annuloplasty and leaflet plication and/or artificial chordal replacement and the latest 4 cases were cured only by a mitral annuloplasty. At the latest follow-up, residual mitral regurgitation was trivial in 6 and mild in 1 case．
Conclusions: Severe mitral regurgitation due to Barlow's disease with multiple central jet and without chordal rupture can be effectively treated by mitral annuloplasty.
Methods: Of a total of 170 consecutive patients who underwent MVP, 13 patients who had anatomical features of Barlow's disease underwent MVP. The mean age was 60 years. All patients presented with large annulus size, myxomatous bileaflet prolapse, and multiple chordal elongations with(n=6) or without chordal ruptures (n=7) and were considered to have Barlow's disease. Patients were evaluated at discharge and after a mean follow-up of 26 ± 19 months by echocardiography.
Results: All patients received full ring, including CG future in 5 (32 mm:1, 34 mm: 2, 36 mm: 2), CE Physio Ⅱ in 8 (34 mm: 1, 36mm: 4, 38 mm: 3 ). Of these 13 patients, 4 were cured only by using a mitral annuloplasty semi-rigid ring. Additionally, the remaining 9 patients underwent leaflet plication and/or artificial chordal replacement. Concomitant procedures included TAP in 6, Maze in 4, LAAC in 6, PVR in 1. Hospital mortality was 0%. Postoperative echocardiography revealed no or trace MR in 9 patients and mild in 3 patients. The mean follow-up duration was 26 months. We encountered mild to moderate MR in 1 patient. No patient required reoperation for recurrent more than moderate MR. Among 7 patients who presented with large annulus size, myxomatous bileaflet prolapse, and multiple chordal elongations without chordal ruptures, early 3 cases were cured by a mitral annuloplasty and leaflet plication and/or artificial chordal replacement and the latest 4 cases were cured only by a mitral annuloplasty. At the latest follow-up, residual mitral regurgitation was trivial in 6 and mild in 1 case．
Conclusions: Severe mitral regurgitation due to Barlow's disease with multiple central jet and without chordal rupture can be effectively treated by mitral annuloplasty.