Thursday, May 4, 2023: 6:30 PM - Friday, May 5, 2023: 6:30 PM
New York Hilton Midtown
Posted Room Name: Grand Ballroom Foyer
Presentations
Title: Mitral Valve Repair – Single Centre experience with 5 year follow up study of operated patients
Objective:
•.To appraise the outcome of Mitral valve repair immediately post operatively and on follow up of patients for 5 years
•.To evaluate the number of Re interventions done following MV Repair.
• To evaluate quality of life of patient / Functional class post mitral valve repair.
• To compare outcome between Rigid and flexible prosthetic rings used for MV repair.
Methods:
Retrospective Observational study with Prospective follow up.
Results:
Pre-operative patient Characteristic revealed 62.2 % of patients were in NYHA Functional class II .81.88 % had severe MR IV + and were symptomatic.MV repair was done for Posterior leaflet prolapse which was for 49.6 % of patients, followed by 19.6 % for Bileaflet repair. 36.2% of patients had associated Moderate tricuspid regurgitation during pre-operative evaluation. Operated patients had a mean of 49 % LVEF pre MV Repair. Mean LVEDD was 60.57 mm and Mean LVESD was 35.93 mm among operated patients All patients underwent MV repair with Prosthetic ring annuloplasty. Triangular resection was the most preferred technique for posterior leaflet repair in 46.31 % of patients for posterior mitral leaflet .For anterior leaflet repair Neochordal reconstruction was the preferred technique in 93.7%.Post operatively 77.3 % of them were in NYHA Functional class I at the end of median follow up of 5 years. 90.4 % of patients showed no evidence of PAH during follow up.92.1 % of patients had mild MR during follow up period after 5 years of surgery. 2 patients underwent Redo MVR during immediate post op period due to persistence of Severe MR IV + post MV repair. Mean LVEF improved to 53 % in patients post MV repair and was preserved during follow up. Freedom from Re operation is at 98.45% in our study.1 patient suffered from CVA, who was receiving Anti coagulation for atrial fibrillation during follow up.62.2 % of patients underwent annuloplasty with flexible prosthetic ring and SJM Taylor prosthetic ring was the the preferred ring in 38.5 %, followed by Duran anncore prosthetic ring in 23.6 %. 37.7 % of patient's annuloplasty was done with rigid prosthetic ring and Physio II prosthetic ring was the most preferred ring in 18.1 % of patients.
Conclusion:
Mitral Valve repair is a procedure which gives long standing remedy ,if we follow the principles of repair regardless of type of annuloplasty.
Poster Presenter
Aakash Joshi, UN MEHTA INSTITUTE OF CARDIOLOGY AHMEDABAD
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Navsari, Gujarat
India
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
Objective
Atrial septal defect (ASD) is one of the most common congenital heart diseases in adult patients, frequently accompanied with tricuspid regurgitation. In this situation, minimally invasive approaches have been used to reduce surgical trauma and improve cosmesis. However, special consideration is needed in the case of situs inversus with dextrocardia. Herein, we present a situs inversus patient who underwent ASD closure, tricuspid repair with totally endoscopic approach.
Case video summary
A 47-year-old female alleged ASD patient presented with dyspnea. A transthoracic echocardiogram showed dextrocardia with a secundum ASD of 25 mm in diameter, moderate degree of the tricuspid valve regurgitation due to annular dilatation. Cardiopulmonary bypass was established via femoral cannulation. A 3-cm mini-thoracotomy incision (working port) was made, and an endoscopic 10mm trocar was inserted. Under induced fibrillatory heart, right atriotomy was performed. The ASD was closed using Gore-Tex patch with 4-0 polypropylene running suture. The tricuspid valve showed an annular dilatation and anterior leaflet prolapse. Because the patient's heart is a mirror image, the usual 3D ring did not fit the tricuspid valve, so flat ring was used. Intraoperative transesophageal echocardiography showed no remnant shunt or tricuspid valve regurgitation. The postoperative course was uncomplicated, and the patient was discharged on postoperative days 5.
Conclusions
Minimally invasive totally endoscopic ASD closure, tricuspid repair were performed safely in a patient with situs inversus.
Poster Presenter
Seung Ri Kang
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South Korea
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
Objective: To compare intra-operative details and post-operative outcomes in resectional vs. preservational mitral repair (MVr) techniques for degenerative mitral regurgitation (DMR).
Methods: Between 2015 and 2020, 567 adult patients underwent MVr at our institution. Of these, 136 were isolated repairs of DMR, with no concomitant procedures. Resectional repairs included quadrangular or triangular resections with annular reduction or sliding plasty, and preservational techniques employed construction of neo-chordae. Data was collected retrospectively from the Society of Thoracic Surgeons database and our institutional EMR. Analysis was conducted in Microsoft Excel and SPSS with two-sided t-tests, assuming unequal variances and Pearson's Chi-square test.
Results: One hundred and one patients with degenerative mitral valve disease had isolated resectional MVr (Group R) and 35 patients received preservational MVr (Group P). Preoperative demographics were similar in each group. Leaflet pathology was posterior or bileaflet in 96.0% of Group R cases, and 71.3% of Group P (p < 0.001). Minimally invasive approaches were employed in 32.7% of Group R cases, compared to 77.1% of Group P cases (p < 0.001). Median cross-clamp time in Group R was 61 minutes, IQR of 50 – 72 minutes, vs. a median of 95 minutes, IQR of 70 – 108 minutes, in Group P (p < 0.001. This difference was independent of incisional approach or leaflet pathology. Post-procedure intra-operative MR on TEE was reduced to mild or less in 100% and 97.1% of R and P patients, respectively (p = 0.257). There were no differences in postoperative morbidity as demonstrated in Table 1 and there was no mortality in either group.
Conclusions: In patients undergoing isolated repair of degenerative MR, resectional and preservational techniques were equally safe and effective. Preservational repair techniques required significantly longer aortic cross-clamp and cardiopulmonary bypass times, although this difference did not influence postoperative morbidity. Preservational techniques were more commonly employed in minimally invasive approaches and for anterior leaflet pathology, and may be helpful in these settings. However, when minimization of operative time is important, either due to patient comorbidity or case complexity, resectional techniques may be more expeditious.
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Poster Presenter
Connor Barrett, NewYork- Presbyterian/Columbia University Medical Center
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New York, NY
United States
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
Objective: Multiple fashions of tricuspid annuloplasty have been introduced to clinical arena; however, residual or recurrent moderate/severe TRs have been documented in unignorable proportion of patients after tricuspid annuloplasty. Kasegawa et al. have introduced a new concept of tricuspid ring annuloplasty (TRA) called anterior leaflet-oriented annuloplasty (ALOA). The purpose of this study is to evaluate preliminary early outcomes of our TRA with ALOA for patients with TR.
Methods: From November 2019 through January 2023, we performed TRA employing ALOA, "Kasegawa method", for 38 patients (66.4±15.8 years, 20 males) with primary or secondary TR. Preoperative data and postoperative echocardiographic indices were retrospectively assessed by chart review. TRA with ALOA is composed of the concept and technical details as follow. The goal for TRA using a flexible ring is to have an annuloplasty ring conform to the configuration of each patient's anterior leaflet. The most important concept of the method is to reduce the size of the tricuspid annulus sufficiently enough by respecting individual configuration of the anterior leaflet to create generous coaptation area for the leaflets without a concomitant additional sub-valvular procedure. The size of the flexible ring is selected based on the measurement of the surface area of the anterior leaflet. Technical knacks include, while inspecting both the annulus and a ring, 5 or 6 narrow mattress stiches are placed 1–2 mm outside of the anterior annulus, and passed through the opposing part of a seated ring, then tied down.
Results: All the TRA procedures were performed under beating heart condition. Concomitant procedures included AVR in 10 patients, MVR in 10, MVP in 18, CABG in 2, and other 32 miscellaneous procedures were also performed. TR grade was significantly mitigated from 3.4±0.6 preoperatively to 1.9±0.7 at 6 months postoperatively (p<0.01). IVC diameter also decreased from 19.4±5.6 to 16.1±3.9 (p<0.05). Of note, tricuspid annular plane systolic excursion, TAPSE, dropped from preoperative 18.7±6.5 mm to immediately postoperative 9.7±3.0 mm, yet gradually improved to 12.7±3.5 at 6 months, 13.3±4.3 at 12 months and 14.8±3.2 mm over the period of 15 months.
Conclusions: Tricuspid flexible ring annuloplasty adopting anterior leaflet-oriented annuloplasty may confer a long-term benefit to right ventricular function in addition to durable control of residual tricuspid regurgitation.
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Poster Presenter
*Yoshikatsu Saiki, Tohoku University Graduate School of Medicine
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Sendai
Japan
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
Objective:
In recent years, various minimally invasive approaches have gained increasing recognition as an alternative to traditional median sternotomy in valve surgery and it can be regarded as an option to catheter-based interventions. Here, we aim to describe our experience with a modified technique called the "Miami Method," which involves a right mid-axillary anterolateral mini-thoracotomy.
Methods:
We conducted a clinical study on 25 patients, 15 of whom were male, with an average age of 59.2±15.4 (range 25-87). The study took place from October 2021 to December 2022, and all surgeries were performed using a 3rd or 4th right mid-axillary curved vertical incision with direct visualization.
Results:
Of the 25 patients, 5 received aortic valve replacement, 12 received mitral valve replacement or repair with additional tricuspid valve repair if needed, 1 received combined aortic and mitral valve replacement, 3 underwent tricuspid surgery only, 2 underwent combined mitral valve repair and CABG, 2 were operated on for sinus venosum defect and partial anomalous pulmonary venous return, and 3 received additional ablation procedures for AF. Of the 5 patients who had previously undergone surgery, 3 were operated with CPB support without cross-clamping.
The average cross-clamp time was 114±35 (range 67-207) minutes, and the total bypass time was 175±47 (range 119-299) minutes. There were no deaths, but one patient required revision surgery due to bleeding and one patient experienced a transient stroke that resolved without long-term effects.
Conclusions:
We believe that this surgical method, which allows for direct visualization, can be safely and successfully performed on high-risk patients and is suitable for performing complex mitral repair as well as aortic valve replacement.
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Poster Presenter
Ergun Demirsoy, Sisli Kolan International Hospital
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Istanbul
Turkey
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
OBJECTIVE. To determined possibillities of left atrium (LA)`s reduction by original method of arch plasty of LA (APLA) during mitral valve replacement (MVR) for isolated mitral valve disease (MVD).
METHODS. During 2005 – 2021 yy. 454 adult patients (pts) with MVD and LA`s moderate dilatation of LA (diameter of LA 50 < 60) average 57,1 ± 0,5 mm were operated at Institute. MVR were performed in all pts. There were 194 (42,7%) males, 260 (57,3%) females. Average age was 57,4 ± 6,9 yy. There were 239 (52,7%) in IY NYHA class, 186 (41,0%) in III class and 29 (6,3%) in II class. The main reason of MVD was: rheumatism (69%). Atrial fibrillation was marked in all pts.
All data divided at 2 groups: group A - APLA + ligation of LA`s auriculum was 117 pts and group B – 337 pts only MVR without LA`s plasty or ligation`s auriculum were performed. All operations were used with CPB, moderate hypothermia with crystalloid cardioplegia. Cross-clamping time of aorta (minutes) were: group A - 61,1 ± 6,2 – and group B - 45,1 ± 4,3 (p< 0,05). Absence of using blood product in 64,5%.
RESULTS. The hospital mortality were: in group A - 0,9% (n=1/117) and in group B - 2,1% (n=7/337) (p<0,05). Reasons of deaths: group A - pneumonia (1pts ), group B – brain damage (thrombemboli) (3 pts), heart failure (3 pts), MOF (2 pts). Sinus rhythm was restored at discharge: group A - 21,6% and group B - 5,2%(p<0,05). At the remote period (average was 9,3± 1,4 yy) 437 (93,2%) pts were followed–up. Data of echo for group A were: diameter of LA (mm) - preoperative (PRE) - 57,9 ± 0,7, postoperative (POST) - 48,3 ± 0,4, remote period (RP) - 49,5 ± 0,4; ejection fraction of LV (EFLV): PRE – 0,54 ± 0,03, POST - 0,57 ± 0,03, RP - 0,59 ± 0,02 . At the remote period were marked absence of thromboembolic events and HF and sinus rhythm was occured in 13,5% pts.
Data of echo for group B were: diameter of LA (mm): PRE- 57,4 ± 0,5 , POST - 55,2 ± 0,8, RP - 62,2 ± 1,1; EFLV: PRE – 0,54 ± 0,04 , POST - 0,55 ± 0,03, RP – 0,53± 0,05 . Thrombembolic events and HF were marked at remote period respectively - 4,5% and 13,2%. AF was marked in all cases.
CONCLUSION. The original method of APLA was allowing to improve better clinical results at group A than in B during all postoperative period (p<0,05).
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Poster Presenter
Volodymyr Popov, National Institute of cardio-vascular surgery named after Amosov
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Kiev, Kiev
Ukraine
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
Objective: Conventional mitral valve repair for degenerative mitral regurgitation (MR) requires cardiopulmonary bypass, aortic cross-clamping, cardioplegia and a thoracotomy or sternotomy. We report the outcome of our single-center first experience with transapical Beating Heart Mitral Valve Repair (BHMVR) with a novel device. Transapical BHMVR enables transoesophageal echo-guided implantation of artificial expanded polytetrafluoroethylene (ePTFE) chords on the beating heart. This minimally invasive surgical procedure is intended for anatomical mitral valve repair in patients with severe degenerative MR caused by posterior mitral valve prolapse.
Methods: A single-center prospective evaluation of transapical BHMVR for symptomatic severe degenerative MR with suitable anatomy was performed. Procedural suitability was based on isolated prolapse of the middle scallop of the posterior mitral valve leaflet (scallop P2), sufficient tissue-to-gap ratio and ample concavity of the prolapsing scallop. Procedural success was defined as successful valvular repair with ≤ mild residual MR and sufficient leaflet coaptation. Echocardiographic and clinical outcome was evaluated.
Results: Eight patients (mean age 75 ± 6 years) underwent transapical BHMVR in our center between July 2021 and November 2022. Three to five ePTFE chords were needed to correct mitral valve dysfunction. Procedural success was 88% (7 patients); one patient was converted to port-access mitral replacement because of pull-out of the ePTFE chords from the posterior mitral leaflet. Coaptation was 6 ± 2 mm after repair. Mean procedural time was 107 ± 25 minutes. Residual MR was ≤ mild in all patients at discharge. There was no hospital mortality or morbidity. Patients were discharged after a mean stay of 5 ± 2 days. During 1-year follow-up, two patients showed more than moderate recurrent MR for which re-intervention with additional ePTFE chord implantation or re-tensioning of the implanted chords was performed.
Conclusions: For the first time reporting single-center outcome, we show that transapical BHMVR with a novel device is feasible for correction of degenerative MR, with high initial procedural success and short duration of hospital stay. Based on this small series, recurrence of MR at early follow-up appears to be higher compared to conventional mitral repair. However, correction can be accomplished through the same minimally invasive approach by adding or re-tensioning the ePTFE chords.
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Poster Presenter
Romy Hegeman
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Netherlands
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
Objective: Report a case of mitral valve replacement (MVR) with tissue valve in a pediatric patient with Loey's Dietz syndrome in the setting of a previous mitral valve repair.
Methods: A 12-year-old female patient with a past medical history of mitral valve valvuloplasty in the setting of mixed mitral valve stenosis and regurgitation was admitted for MVR due to the reemergence of mixed mitral valve stenosis and regurgitation.
Results: The patient underwent a MVR with a 25 millimeters Edwards Mitris Resilia valve. Completion echocardiogram revealed good biventricular function with no left ventricular outflow tract obstruction, no prosthetic valve insufficiency or stenosis and no periprosthetic valve leak. The mean gradient was 5 mmHg.
Conclusions: There are several dilemmas that need to be addressed when performing MVR in pediatric patients. The small size of the native valve annulus and the limited growth potential of the available prostheses often demand intentional oversizing of the prosthesis to meet the patient's somatic growth. Nevertheless, utilization of a large prosthesis is associated with increased intraoperative and early postoperative mortality rates due to adverse events related with left ventricular outflow tract obstruction, myocardial ischemia due to nearby coronary artery compression, and electrical conduction block. The optimal type of prosthesis in this age group is unclear. Mechanical valves, although credited to be more durable, require lifelong anticoagulation which is problematic in pediatric patients. Lifelong anticoagulation with Vitamin K antagonists (VKA) is inherently associated with several diet restrictions and poor-compliance increases the risk of both thromboembolic and hemorrhagic events. VKA medications require abstinence from several everyday activities and have a direct impact on the quality of life of these patients. Moreover, VKA are associated with menstruation related complications raising extra concerns in female patients. Edwards Mitris Resilia prosthesis is a bioprosthetic valve credited to offer better postoperative hemodynamic profile as well as longer valve longevity with decreased structural valve deterioration rates compared to other bioprostheses. The notion behind opting for this valve in our patient was to offer her a good hemodynamic profile that will protect her from future cardio- and cerebro-vascular events as well as to avoid the need to subject her to lifelong anticoagulation.
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Poster Presenter
Panagiotis Tasoudis, University of North Carolina at Chapel Hill
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Chapel Hill, NC
United States
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
Objective
Peripheral arterial cannulation (PAC) facilitates minimally invasive cardiac surgery (MICS) by allowing safe vascular access despite small chest incisions. However, because PAC may result in peripheral vascular complications, and is contraindicated in certain patients and anatomy, we have developed and frequently used a central arterial cannulation (CAC) technique as an alternative. We report a comparison of these two cannulation strategies in a contemporary cohort at our institution.
Methods
All patients who underwent minimally invasive isolated mitral valve surgery at our institution between 2015 and 2020 were included. Data was compiled from a NYS Cardiac Surgery Reporting System query and supplemented by patient chart and surgical record review. Unpaired two-tailed T-tests and Fischer's exact tests were utilized to determine significance.
Results
Over the specified 5-year period, 519 patients underwent MICS at our institution. In order to allow for meaningful comparison of operative times, we chose to study only patients undergoing isolated mitral valve operations (n = 73). All of these operations were performed via right minithoracotomy, and 29 (39.7%) had CAC and 44 (60.3%) had PAC. Baseline demographics and preoperative risk factors were similar in the two groups, except that preoperative BMI was significantly higher in the PAC group (CAC: 24.4 vs PAC: 26.5, p=0.030). CAC was associated with significantly decreased anesthesia time compared to PAC (370.6 vs. 397.6 min, p=0.031), and this was also true for cardiopulmonary bypass time (109.8 vs. 141.2 min, p=0.0001) and aortic cross-clamp time (74.8 vs. 88.5 min, p=0.010). Hospital length of stay was not different between groups (CAC: 5.8 vs. PAC: 6.3 d, p=0.487). There were no deaths in either group. Regardless of arterial cannulation, all patients had some form of peripheral venous cannulation, and in 10 patients (13.7%), peripheral vascular or lymphatic complications occurred.
Conclusions
In a contemporary cohort of isolated minimally invasive mitral operations, CAC was not only safe, but resulted in significantly reduced anesthesia, bypass, and clamp times when compared to PAC. Therefore, when patient size and chest anatomy permit, CAC is an excellent option, especially in patients with contraindications to PAC, such as small or tortuous vessels, or vascular disease.
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Poster Presenter
Riley Sevensky, New York Presbyterian/Columbia
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New York, NY
United States
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
Title: Combined Mitral Valve Repair with David V Valve Sparing Aortic Root Replacement
Authors: Patra Childress, MD1; Sameer Singh, MD1; Hiroo Takayama MD, PhD1.
1. Division of Cardiothoracic Surgery, New York-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
Objective:
Combined aortic root and mitral valve pathology is uncommon but represents a complex pathology. In select patients, valve sparing aortic root replacement with concomitant mitral valve repair may offer a durable solution while avoiding the risks associated with prosthetic valves. Since 2005, 13 cases of combined mitral valve repair with valve sparing aortic root replacement have been performed at our institution. Median patient age was 64 years, with 92% (12/13) of patients being male. Median cardiopulmonary bypass and cross-clamp time were 198 and 170 minutes, respectively. Mitral valve repair techniques included annuloplasty (84%, 11/13), leaflet resection (31%, 4/13), and artificial chords (31%, 4/13). In-hospital mortality was 8% (1/13) and the incidence of postoperative stroke was 8% (1/13).
Case Video Summary:
This video depicts a case of combined mitral valve repair and David V valve sparing aortic root replacement. The patient was a 73-year-old male who presented with new symptoms of heart failure and was found to have severe mitral regurgitation and aortic insufficiency as well as a 5cm aortic root and ascending aneurysm. Standard median sternotomy with bicaval cannulation was performed. The mitral repair consisted of a quadrangular resection of P2, followed by the use of neochords attached to P3, and a partial annuloplasty ring. Aortic root replacement was performed via the David V reimplantation technique. Special considerations for this combined repair technique include avoiding the use of complete mitral annuloplasty ring, as it may interfere with subsequent root replacement, and oversewing the ascending aorta prior to mitral valve saline testing to allow for accurate assessment.
Conclusions:
Combined mitral valve repair and valve sparing aortic root replacement can be performed safely, although this requires surgeon expertise in both complex aortic and mitral valve repair techniques. Long term follow-up is warranted to further assess the durability of this technique.
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Poster Presenter
Patra Childress
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United States
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
Objective: It is unknown whether video aided thoracoscopic mitral valve repair(VATS-MVP) in patients with Rheumatic heart disease(RHD) differs from conventional median sternotomy(MS) approach in terms of preoperative patient selection, intraoperative surgical strategy, perioperative results, and long-term prognosis. The aim of this study was to examine the safety, efficacy and durability of VATS-MVP in RHD.
Methods: A retrospective collection with clinical data, echocardiography results, and follow-up data was used to identify 235 consecutive patients underwent MVP for RHD from January 2007 through June 2022, including 114 patients via MS approach and 121 patients via VATS approach(Table 1). A comparison between the MS group and the VATS group was conducted.
Results: One patient death in hospital was observed in the VATS group. Follow-up was 96.1% complete (range, 0.15-14.8 years). There was a higher percentage of artificial ring implantation in the VATS group, but there was no difference between the two groups(P=0.246). Although the total operation time (227.9±72.8 vs 235.2±63.3 min, P=0.155) between the two groups was not statistical different, the VATS group had longer cardiopulmonary bypass time(159.9±46.3 vs 134.9±48.3min, P=0.000) and aortic clamp time(102.9±32.6 vs. 87.5±34.5 min, P=0.001) . The incidence of lung infection and poor wound healing was high in MS group(P<0.05). Pleural effusion is common in VATS group(P<0.05). No significant difference between the two groups in other adverse perioperative complications(P>0.05). Mechanical ventilation time (P=0.015), ICU time(P=0.153), and postoperative hospitalization time(P=0.230) were all shorter in the VATS group. Two patients in the MS group died during the follow-up period. The 1-year, 5-year and 10-year survival rates of VATS groups were all 99.2%. At 1-year, 5-year, 10-year in the AVTS group, the rate of freedom from moderate or greater(>=2+) mitral regurgitation were 87.6%, 74.3%,and 74.3%, respectively. Compared with MS group, there was no significant difference in the survival rate, recurrence rate of mitral regurgitation, reoperation rate and incidence rate of adverse cardiovascular and cerebrovascular events in VATS group(P＞0.05).
Conclusions: Rheumatic mitral valve disease could be effectively and safely repaired with excellent long-term durability via totally endoscopic minimally invasive approach in selected patients.
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Poster Presenter
Huanlei Huang, Southern Medical University
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Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
Objective:
To present our operative approach to a complex case with high mortality and how we minimize pump time and clamp time.
Case Video Summary:
We present a concomitant aortic valve replacement, mitral valve replacement, and tricuspid valve replacement in a 69 year old female with severe mitral regurgitation, severe tricuspid regurgitation, and moderate aortic insufficiency. We begin the case with a median sternotomy and bicaval venous cannulation. We then cross clamp, give antegrade, place an LV vent, and divide the aorta while giving retrograde cardioplegia. We excise the native aortic valve then give handheld antegrade cardioplegia. We then proceed to the mitral valve replacement. The chords of the anterior leaflet were too short and thickened to preserve, but we did preserve the posterior leaflet. We then replace the aortic valve, close the aorta, and remove the cross clamp. We then perform a tricuspid valve replacement beating heart. We close the right atrium, wean from bypass, and decannulate.
Conclusions:
In a case of this magnitude with high mortality, minimizing cross clamp time is critical and we believe this approach minimizes both bypass time and clamp time while providing optimal cardiac protection.
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Poster Presenter
Philip Coffey, MEDICAL COLLEGE OF GEORGIA
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Augusta, GA
United States
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
Title
Concomitant thoracic aorta replacement and mitral valve surgery outcomes and mortality predictors – a national level analysis
Objective
Recent studies demonstrate that a small but important minority of patients are presenting with both aortic pathology and concomitant mitral valve diseases, but the results are confined to select centers spanning from different non-representative time eras. Concomitant aorta and aortic valve surgery have been studied considerably, but the mitral valve is less so. This study was undertaken to examine the national outcomes of mortality and morbidity in patients who required combined thoracic aortic replacement with mitral valve surgery (MVR+Ao) from 2017-2020.
Methods:
We studied the outcomes of adults (18+ years) who received MVR+Ao using the National Inpatient Sample (2017-2020). For comparison, we used isolated Aortic surgery (Ao) and isolated mitral valve (MVR) patients from the same period. We compared the outcomes and analyzed factors associated with mortality with a multivariable analysis, adjusted by age, sex, surgery year, bicuspid aortic valve, mitral replacement, primary insurance, teaching hospital status, and the number of comorbidities.
Results
From 2017 to 2020, 565 patients underwent MVR+Ao. When compared to Ao and MVR patients, MVR+Ao patients group had fewer females (33%) and a higher Elixhauser comorbidity score. The mortality rate was 1.8%. There was no difference in mortality, wound, or valve complications between the groups. However, MVR+Ao patients had higher complication rates including bleeding (61%, p=0.005), acute renal failure (20%, p=0.039), pneumothorax, and respiratory failure. Additionally, the length of stay (8.7 days) and hospitalization cost ($55,469 per patient) were higher than other groups. Factors associated with higher mortality include females (OR: 1.32, CI: 1.01-1.73), mitral replacement (OR: 3.47, CI: 2.43-4.96), and higher Elixhauser score (OR: 1.12, CI: 1.10-1.14).
Conclusions
In patients with both the thoracic aorta and mitral pathology, the incidence of concomitant aortic and mitral surgery has remained relatively stable over the past few years. Consideration of mitral repair over mitral replacement may be pertinent when concomitant surgery is necessary. Future studies may consider investigating the reason for the significantly increased female disparities in this cohort.
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Poster Presenter
Ahmed Alnajar, University of Miami Hospital
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Miami, FL
United States
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
Objective: Tricuspid valve regurgitation (TR) is common in patients with severe mitral valve disease and operative management of moderate TR is contentious. The decision as to whether to perform concomitant tricuspid valve ring annuloplasty for patients with moderate TR or less-than-moderate TR with a dilated TV annulus at the time of mitral valve surgery remains a contentious topic. A meta-analysis was performed to assess the clinical outcomes of concomitant tricuspid valve ring annuloplasty during mitral valve surgery.
Methods: A meta-analysis of comparative studies including mitral valve ( MV) surgery only versus MV surgery and concomitant TV ring annuloplasty (TVA). Primary outcome included in-hospital mortality, TR progression, and PPM implantation rate. Secondary outcome included re-operation for TR (at longest follow up available). Fixed-effect analysis was performed using pooled odd ratios (OR) via RevMan in accordance to Cochrane protocol and PRISMA guidelines.
Results: 8 studies met the eligibility criteria (2 RCTs, 6 cohort studies) with 1941 patients included in the final analysis (1090 patients in MV + TVA, 851 in MV only). The in-hospital mortality was comparable between the two groups ( 3.0% vs. 3.7%, OR=0.79, p=0.38). MV and concomitant TVA is associated with fewer moderate/severe TR progression (3.0% vs. 9.6% OR=0.29 ( 95% CI 0.15-0.55) p=0.0001). The rate of PPM implantation is higher in MV +TVA group although this did not reach statistical significance. (7.6% vs 5.3% OR=1.30 (95% CI 0.85-1.98) p=0.23). No significant difference in rate of re-operation between the two groups was detected.
Conclusions: Concomitant tricuspid valve ring annuloplasty during mitral valve surgery can be safely performed without increasing mortality and morbidity risks. There is a tendency for increased rate of PPM implantation in concomitant TVA although this did not reach statistical significance. Concomitant TVA is associated with a significantly lower incidence of post-operative moderate/severe TR progression. Further prospective and RCT studies are needed to evaluate the impact of concomitant TVA on right ventricular function and long term clinical benefits.
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Poster Presenter
Shi Sum Poon
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United Kingdom
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
Objective: It is well established that patients with coronary heart disease can develop ischemic chronic secondary mitral regurgitation (MR) due to the effect of left ventricular remodelling on mitral valve (MV) function. In patients who for coronary artery bypass grafting (CABG) and who also have a degree of MR, it is conceivable that revascularisation alone may improve myocardial blood supply, recruit hibernating myocardium and reduce the severity of MR, without the need for surgical intervention on the valve per se. The amount of MR that is acceptable to leave without surgical correction is a topic of debate. The 2020 ACC/AHA guidelines provide a level 2a recommendation that MV surgery is reasonable in patients with severe ischemic MR undergoing CABG. These guidelines do not make a recommendation for those patients with moderate MR. Our objective was to assess the incidence of early and late recurrence of regurgitation in patients with moderate MR undergoing concurrent CABG and MV surgery.
Methods: A database of all patients operated on by a senior mitral surgeon from 2015 – 2022 was retrospectively searched to identify patients who had simultaneous CABG and MV surgery. Patients were screened to identify those patients who had ischemic secondary MR that had been graded as 'moderate' in severity. Data on severity of MR, mean transmitral gradient and left ventricular ejection fraction (LVEF) were collected at baseline, 1 year follow-up and latest follow-up. Recurrence was defined as more than mild MR at follow-up.
Results: Twelve patients were included in our analysis with a mean age of 68 years (range 58 – 80). All underwent CABG and concurrent MV repair (n = 9) or MV replacement (n = 3). There was no statistically significant difference between LVEF (%) at baseline (43.6 +/- 8.5) and follow-up (46.9 +/- 10.2, p = 0.30). At 1 year, all 12 patients were alive and no patients (n = 0) had recurrence of MR. Late follow-up data was available for 8 patients. At a mean of 1287 days (3.5 years) post-op, 1 patient had developed mild-moderate recurrence and 1 patient had died (non-cardiac cause of death).
Conclusions: In this highly selected cohort of patients, our experience demonstrates that moderate ischemic secondary MR can be treated surgically at the same time as CABG with low risk of recurrence at early and late follow-up. The majority can be treated successfully with a downsize annuloplasty, but a small group will warrant replacement.
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Poster Presenter
Luke Holland, Barts Heart Centre, St Bartholomew's Hospital
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London, NA
United Kingdom
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
Objective: High body mass index (BMI) correlates with increased morbidity and mortality after cardiac surgery. We aimed to elucidate if any differences in outcomes existed in patients with high BMI undergoing mitral valve repair (MVr) with different minimally invasive approaches.
Methods: We performed a retrospective, cohort study of patients undergoing minimally invasive MVr at a quaternary academic center between 04/2011–04/2022. Information on demographics, comorbidities, intraoperative variables, and postoperative outcomes were retrieved. Patients were stratified by surgical approach: anterolateral mini-thoracotomy (n=62) versus totally endoscopic, robotic-assisted MVr (n=200). Emphasis was given to data on renown obesity-related complications (i.e., need for blood products, postoperative reintubation, prolonged ventilation, surgical site infection, acute kidney injury). A sub-analysis was performed in patients with BMI≥25 to probe if any outcomes differences existed between the two minimally invasive approaches in overweight and obese patients.
Results: We found no difference in median BMI values between the two groups (p=0.766), with 54.8% of patients in the mini-thoracotomy group and 47.0% of patients in the robotic group having a BMI≥25 (p=0.31). In the whole population, patients undergoing robotic versus mini-thoracotomy MVr had significantly shorter aortic cross-clamp times (79 vs. 97 minutes, p<0.001) and postoperative length of stay (4 vs. 5 days, p<0.001); these differences persisted in the sub-analysis of patients with high BMI (p=0.04 and p<0.001, respectively). Patients with high BMI undergoing either approach had remarkably low and not significantly different rates of surgical site infection (p=0.462), need for blood products (p=0.381), and acute kidney injury (p=1). Results are further detailed in Table 1. Interestingly, patients with high BMI who underwent robotic MVr had similar rates of pulmonary-related complications, regardless of a higher proportion of patients with chronic lung disease (17.0% versus 2.9%, p=0.04) and despite higher rate of extubation in the operating room (58.5% versus 8.8%, p<0.001) when compared to patients with high BMI in the mini-thoracotomy group, with no difference in reintubation rates (3.2% versus 2.9%, p=1).
Conclusions: The benefits of totally endoscopic, robotic-assisted MVr persist even in patients with high BMI, with lower aortic cross-clamp times and shorter postoperative length of stay.
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Poster Presenter
Andrea Amabile, University of Pittsburgh Medical Center
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PITTSBURGH, PA
United States
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
Objective: To assess the early outcomes and midterm survival, recurrent mitral regurgitation (MR) and reoperation of robotic MV repair.
Methods: After a systematic literature search up to 2/5/2023, 11 studies with >100 patients and late follow-up (FU) data were pooled in a random-effects meta-analysis model. All results are expressed as mean (95% confidence interval [CI]) or % (95% CI) unless otherwise stated.
Results: Of 4705 patients (men, 68.1% [62.7-73.3%]) (Table), mean age was 55.8y (53-58.6), 87.2% (70.5-97.7%) had severe MR, 18.3% (12.2-25.4%) had atrial arrhythmia, and 29.8% (20.2-40.3%) were in NYHA Class 3/4. Etiology was degenerative in 78.9% (50.7-97%) and rheumatic in 5.9% (4.8-7.2%). Posterior leaflet prolapse (LP) was seen in 64.6% (55.1-73.5%), anterior LP in 15.9% (8.5-25%) and bileaflet LP 13% (7.4-19.7%). Left atrial size was 4.7cm (4.4-4.9) and LVEDD was 5.6cm (5.1-6).
Leaflet resection was used in 52.2% (27.5-76.4%), neochords in 40% (23.3-58%), cleft closure in 19.6% (6.1-38.2%) and commissural plication in 10.8% (4.8-18.9%). Annuloplasty was used in 98.2% (95.8-99.6%) and 15.2% (10.2-21%) had ablation for atrial fibrillation (AF). Mean CPB and clamp times were 133min (115-151) and 93min (79-107). A 2nd CPB run occurred in 4.4% (2.2-7.2%), 1.5% (0.4-3.3%) were converted to open repair, and 5.4% (0.8-13.4%) had ≥2+ MR post-CPB.
Operative mortality was 0.2% (0.1-0.4%). Rate of stroke was 0.7% (0.3-1.3%), new-onset AF 17.2% (12.6-22.4%) and pacemaker insertion 1.2% (0.6-1.9%). Early reoperation on MV was done in 0.5% (0.1-1.3%) and for bleeding in 2.1% (1.2-3.3%). Mean intubation time was 7.5h (6.7-8.2) and >24h in 1.9% (0.8-3.5%). Mean ICU and hospital lengths of stay were 1d (0.7-1.3) and 5.2d (4.1-6.3).
Clinical FU was complete in 97.4% (94-99.5%) at mean 3.3y (2.2-4.4) and echocardiography FU in 87.5% (80.3-93.3%) at mean 2.1y (1.3-2.9). Late death was 2.4% (1.6-3.2%) and reoperation 2.5% (1.7-3.4%), done in 103 patients at mean 1.2y (0.5-1.9), for recurrent MR in 60.2% (62/103). Moderate MR recurred in 5.4% (3.5-7.7%) and severe MR in 2% (1.1-3.1%). At 5 years, weighted mean rates (n, range) of survival, and freedom from moderate MR and reoperation were 95.5% (n=4141, 87.6-98.2%), 88.4% (n=4481, 77-97.6%) and 96.7% (n=2681, 94.5-98.1%), respectively.
Conclusions: Robotic MV repair is safe and provides durable midterm results. Data from large series of longer duration are needed to evaluate its long-term outcomes.
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Poster Presenter
Wei-Guo Ma, Yale School of Medicine
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New Haven, CT
United States
Thursday, May 4, 2023: 6:30 PM - 6:35 PM
Objectives: The NeoChord DS1000 system is an innovative device that implants neochords transapically, through a left mini-thoracotomy to treat mitral valve regurgitation (MR) without cardiopulmonary bypass. NeoChord implantation and length adjustment is performed under transesophageal echocardiographic guidance and beating heart conditions. We describe our experience with the Neochord system in moderate to high risk patients with degenerative MR using an "over-tensioning" strategy to account for LV reverse remodeling over time.
Methods: In this prospective series, all study patients had degenerative MR and were considered for conventional mitral valve surgery but were moderate to high-risk. Eligibility for NeoChord was based on echocardiographic criteria, including isolated posterior leaflet prolapse, leaflet to annulus index greater than 1.2, and coaptation length index greater than 5mm. Patients with multi-leaflet pathology, mitral annular calcification, and ischemic MR were excluded.
Results: Ten patients underwent the procedure; 6 male and 4 female with mean age of 76 years. All patients had severe chronic MR. Two of ten patients had prior MV repair with annuloplasty. NeoChord was successfully implanted transapically in 9 of 10 patients. One patient required conversion to an open procedure due to leaflet injury. The average number of NeoChord sets was 3 (+/- 1.49). Immediate post-procedure degree of MR on echocardiography ranged from trivial to mild, and on postoperative day 1 from trivial to moderate (N=2). Average length of coaptation was 0.85±0.21cm and average depth of coaptation was 0.72±0.15cm. Post-operative MR on echocardiography was least in those with prior annuloplasty with (trace-mild) compared to those without (mild-moderate). One month follow up of MR ranged from trivial to moderate and left ventricular inner diameter dimensions decreased from an average of 5.3 cm to 4.5 cm. No patients with successful NeoChord implantation required blood products. Half or 50% of patients were discharged in less than 3 days. There was 1 perioperative stroke with no residual deficits. At 30-days post-procedure no patients were readmitted or had died.
Conclusions: We report the first Canadian experience with NeoChord DS1000 for off-pump, transapical, beating heart mitral valve repair, through a left mini-thoracotomy. Based on our initial results Neochord is safe and effective, and may be best for patients with recurrent MR and prior annuloplasty.
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Thursday, May 4, 2023: 6:30 PM - Friday, May 5, 2023: 6:30 AM
OBJECTIVE: To analyze echocardiographic outcomes after transcatheter edge-to-edge repair (TEER) with mitral valve clip device (MitraClipTM) for mitral valve regurgitation (MR).
METHODS: All consecutive patients undergoing TEER between 03/2017-10/2021 were included in the study. Primary outcome was long-term incidence of all-cause death and major adverse cardiovascular and cerebrovascular events (MACCE).
RESULTS: The cohort consisted of 171 consecutive patients. Mean age was 79-years (± 8.9), 85 (49.7%) were women, STS-PROM score was 7.2% (± 8.2%), and 156 (91.2%) patients presented with heart failure (91 diastolic, 31 systolic, and 34 combined). In addition, 36 (21.5%) patients had functional MR, 123 (72%) had degenerative MR and 12 (6.5%) patients had mixed MR etiology. Mean EF was 42.2% (± 16.8%), mean mitral transvalvular gradient (MTG) was 3.4 (± 3.3) mmHg, mean mitral valve area (MVA) 3.8 (± 0.8) cm², mean stroke volume 59.96 (±19.3) ml, left ventricular end-diastolic volume (LVEDV) 199.8 (±72.4) ml, left ventricular end-systolic volume (LVESV) 62.5 (±51.1) ml, left ventricular end-systolic diameter 4.56 (LVESd) (±1.7), left ventricular end-diastolic diameter (LVEDd) 5.96 (±1.35) ml, regurgitation fraction 34 (± 31.1) ml, regurgitation volume 56 (±26.9) ml, left atrial end-systolic volume (LAESV) 91.8 (±27.7) ml, left atrial area (LAE) 6.58 (±5.69) cm², right ventricular systolic pressure (RVSP) 42.2 (±16.2) mmHg, moderate/severe tricuspid valve regurgitation (TR)=80 (46.8%). Intraoperatively, mean transvalvular gradient was 3.59 (±1.76) mmHg, mean EF=48% (±14.8), 92 received 1clip, 67-2 clips, 10-3 clips, 1-4 clips. Postoperatively, mean postprocedural mitral valve gradient was 3.6 mmHg (± 1.7) and 71 (41.5%) patients had none or mild MR. Mean EF was 42.2% (± 16.8%), mean MTG 3.4 (± 3.3) mmHg, mean stroke volume 60.8 (±27.4), LVEDV 104.5 (±50) ml, LVESV was 50.1 (±34.4) ml, LVEDd was 6 (±1.5) cm, LVESd was 4.6 (±1.7), LAESV 91.35 (±4.2) ml, RVSP 38.4 (±9.2) mmHg, moderate/severe TR was 74 (43.2%). Mean LOS was 4.4 (± 7.4) days. At discharge, 75 (43.8%) patients had mild MR, 82 (47.9%) moderate MR, and 14 (8.3%) severe MR.
At 5-years follow-up, mean EF=50.8% (± 14.5) mmHg, mean MTG 5 (±3) mmHg, mean stroke volume 59.5 (±23.9) ml, LVEDD 5.7 (±1.4) cm, LVESD 4.2 (±1.8) cm.
CONCLUSIONS
Echocardiographic outcomes showed an increased EF and decreased MTG.
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Poster Presenter
Aleksander Dokollari
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Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
Objective: The Edge-to-Edge repair (EE), achieved by suturing of anterior to posterior leaflet segments, is often used to improve mitral leaflet apposition during mitral valve repair (MVr) for degenerative mitral regurgitation (DMR). Because EE creates a double-orifice valve, it introduces a theoretical risk of mitral stenosis (MS). In our unit, EE is primarily used as an adjunct to other more complex repair techniques, and only if there is sufficient available mitral orifice area. We examined the impact of EE repair on postoperative mitral valve gradient (MVG).
Methods: Data was retrospectively collected from 567 consecutive adult patients undergoing MVr for mitral insufficiency at our institution between 2015 and 2020. Of these, 249 operations were MVr with annuloplasty in patients with DMR, no history of MV surgery, VAD implantation, or heart transplant. Outcomes stratified by EE usage were evaluated in propensity score matching. The primary outcome was MVG. Secondary outcomes included postoperative
complications, re-hospitalization, and re-operation.
Results: Our cohort consisted of 46 (18%) patients who received EE and 203 (82%) who did not. Propensity score matching compared 40 patients who received EE repair and 40 patients who did not. There were no differences in MVG (median 3.2 vs 4.0, p = 0.06); no differences in post-operative complications such as atrial fibrillation (p = 0.822), AKI or CKD (p = 1.00), stroke (p = 1.00), or mortality (p = 1.00); and no differences in re-operation (p = 0.239) or re-hospitalization (p = 0.35). Among the unadjusted (overall) patient cohort who received EE, there was one death and one case of high postoperative MVG (> 10 mmHg).
Conclusions: Our data suggests that EE as a supplemental MVr technique increases the technical options for successful mitral repair. EE resulted in rates of repair success comparable to non-EE techniques, without significant increases in postoperative mitral gradients, demonstrating the safety and efficacy of this technique. One case of a high mitral gradient on post-discharge testing illustrates the importance of assessing the post-repair mitral gradient by TEE in the operating room.
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Poster Presenter
Connor Barrett, NewYork- Presbyterian/Columbia University Medical Center
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New York, NY
United States
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
Objective:
Active infective endocarditis caused by MRSA usually requires emergency surgery because of the rapid extension of infection.
Case Video Summary:
We demonstrated a 28-year-old lady who transferred to our hospital due to bacteremia caused by methicillin-resistant Staphylococcus aureus (MRSA) and dyspnea. Transthoracic echocardiogram demonstrated mitral regurgitation with big fragile vegetations and dissection of the posterior left atrial wall and pericardial effusion. Brain CT demonstrated cerebral infarction. At emergency surgery, pericardiotomy revealed purulent pericarditis. Infection extended the posterior mitral valve (P2) widely, posterior mitral annulus, and dissecting space of the left atrial wall. After resection and removing the infected tissues, reconstruction of the left atrial wall, mitral annulus, and posterior leaflet repair using several pieces of xenopericardium were achieved step by step (as demonstrated in the first half of the video). IntraopTEE demonstrated no MR. After additional antibiotic therapy for 3 weeks, she was discharged from the hospital. She complained fever again, and TTE showed vegetation at the anterior leaflet 3 months after surgery, necessitating a redo surgery. Redo surgery revealed vegetation at the anterior mitral leaflet, persistent infection at the reconstructed mitral annulus and posterior left atrial wall at initial surgery (as demonstrated in the latter half of the video). After removal of infected tissue, reconstruction of the left atrial wall and mitral annulus with pieces of xenopericardium was achieved again without leaving infected tissue or space. Then, mitral valve was replaced with a mechanical valve considering her age. She survived 15 years after surgery enjoying dancing and playing golf. Latest TTE showed no perivalvular leakage of mitral mechanical valve and good left ventricular function (LVEF of 67 %).
Conclusions:
Active infective endocarditis caused by MRSA usually requires emergency surgery because of the rapid extension of infection. And the reconstruction of mitral annulus and left atrial wall associated with purulent pericarditis is quite rare.
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Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
Objective:
To evaluate various management options in patients with dense calcification of left atrium and interatrial septum. Surgical challenges encountered in gaining access to the mitral valve.
Method:
A 48 year old female presented with shortness of breath, NYHA class four. She required mechanical ventilation and supportive therapy. Her X-ray chest revealed calcified left atrium. Echocardiography demonstrated critical mitral stenosis, severe tricuspid insufficiency, pulmonary artery systolic pressures of 55mmHg, dense calcification of entire left atrial wall and interatrial septum and specks of calcium in the mitral annulus.The patient was in atrial fibrillation with a large calcified thrombus. Her computed tomography of the chest also confirmed the findings. Repeat echocardiography of the patient revealed the appearance of fresh clots in the left atrium. Hence other alternatives of management were ruled out. After combined discussion surgery was considered as the best possible option. As no soft area could be negotiated through the septum so it was opened with a number 11 knife with great difficulty. The calcified thrombus was dissected and peeled out. There was no visibility to the mitral valve at all after thrombectomy. Hence the entire left atrium along with the septum were decalcified to gain access to the mitral area. Mitral valve was then replaced with a mechanical valve and the tricuspid valve was repaired. Post operative echocardiography revealed good prosthetic mitral valve function and tricuspid repair. She improved gradually and was discharged on twelfth post operative day.
Results:
In this patient, complete endoatriectomy of the left atrium and inter atrial septum was performed to reach the mitral orifice. The calcified thrombus was removed and the mitral valve was replaced with a mechanical valve along with tricuspid valve repair. Patient tolerated the surgery well.
Conclusion:
Porcelain left atrium is a known entity in rheumatic heart disease in which the inter atrial septum is mostly spared. In this patient the septum was also densely calcified prohibiting the access to the mitral valve. As there was calcified thrombus with fresh clots in left atrium so the only option left was to decalcify the septum and perform endoatriectomy of the left atrium to reach the mitral apparatus. Patient behaved well in the postoperative course.
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Poster Presenter
Sandeep Shrivastava
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Indore
India
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
Objective: Isolated tricuspid valve surgical repair can be associated with a high risk of perioperative morbidity and mortality. The use of a beating heart approach has been described in order to potentially mitigate peri-operative right ventricular (RV) dysfunction. Furthermore, a re-operative setting can present significant challenges in achieving control of both vena cavae. We present a case of a minimally invasive, beating heart tricuspid valve surgical repair with use of Tri-Ad ring and percutaneous bicaval endovascular occlusion with CODA balloon catheters.
Case Video Summary: A 72 years old patient with previous CABG surgery was admitted due to severe tricuspid regurgitation (TR). Past medical history included : long-standing persistent atrial fibrillation, permanent pacemaker in 2017 for tachy-brady syndrome, obstructive sleep apnea. Pre-operative TEE showed severe TR mostly due to annular dilatation (6.1 cm) with no evidence of RV lead impingement, moderate RV dysfunction, dilated RV ventricle, RVSP = 55 mmHg, LVEF = 45-50%.
A minimally invasive procedure was planned via a right mini-thoracotomy: following cannulation of the SVC and IVC, CPB was instituted and both venae cavae were occluded by using a CODA balloon advanced beyond each respective cannulae. Under beating heart conditions, the right atrium was opened, excellent exposure of the TV was achieved: a Tri-AD ring size 32 was implanted. Post-repair TEE confirmed excellent result of the TV repair with no residual regurgitation and a mean gradient around 1 mmHg.
Conclusions: A minimally invasive, beating-heart strategy can represent a useful option for TV repair especially in the setting of a redo procedure: in particular, the use of a percutaneous venae cavae occlusion can minimize potential manipulation and avoid unneccesary risks during snaring. The Tri-Ad ring allowed for an effective TV annular remodeling even in presence of a significantly large annular dilatation (> 6 cm).
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Poster Presenter
Gianluigi Bisleri, St. Michael’s Hospital
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Toronto, ON
Canada
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
Objectives: There is no current guidelines for cardiogenic shock associated with mitral valve endocarditis that dictate surgical candidacy, timing of the operation, and peri-operative management strategy. Herein, we present an endocarditis case of acute severe mitral regurgitation complicated by multi-organ failure required peri-operative mechanical circulatory support as bridge to surgery.
Methods: 39-year-old male with no significant past medical history presented to an outside hospital with sepsis. Echocardiogram showed ejection fraction 50% and severe mitral regurgitation with 2.4 cm vegetation on the anterior leaflet. Blood cultures were positive for Streptococcus. He was started on antibiotics and hemodialysis for acute renal failure. Additionally, he developed coagulopathy and ischemia of fingers and toes. A week later, patient was transferred to our center on modest dosage of inotropes and pressors, yet with decompensated cardiogenic shock. Patient was placed on peripheral veno-arterial ECMO along with intra-aortic balloon pump. Coagulopathy and shocked liver started to improve however with persistent pulmonary edema. He was taken to surgery within 48 hour.
Results: Intraoperatively the anterior mitral valve leaflet was completely destroyed by endocarditis (Figure). After adequate debridement, patient underwent mitral valve replacement with a bio-prosthesis (size#33). Upon separation from cardiopulmonary bypass, left ventricular function was severely depressed, thus configuration was switched to veno-arterial-venous ECMO. Patient had accelerated recovery of end-organ function, weaned off mechanical circulatory support on day 4 after surgery, then off dialysis and extubated on day 5. He was transferred to regular floor soon after to start physical therapy. Post-operative echocardiogram showed ejection fraction 35% with well seated bio-prosthetic mitral valve. Patient is being prepared to discharge to rehabilitation facility to continue recovery. Patient will still require vascular procedures to address fingers and toes ischemia.
Conclusions: There is no consensus regarding the optimal timing for the management of acute mitral valve endocarditis associated with cardiogenic shock. Our case demonstrates that a narrow window of time may exist for early surgery with peri-operative mechanical circulatory support before irreversible end-organ damage succumbs the patient to fatal outcome
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Poster Presenter
Karolis Bauza, Cleveland Clinic
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Cleveland, OH
United States
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
Objectives
Robotic mitral valve repair has been shown to be safe and equally efficacious when compared to open mitral valve repair. The potential benefits include small incisions and quicker recovery. While qualitive outcome of robotic mitral surgery has been widely published, the data on functional outcomes of robotic mitral valve repair is sparse. Our study aims to quantify the functional benefit of robotic mitral valve repair.
Methods
We performed a single institution, retrospective analysis of prospectively collected survey data to evaluate our objective. 203 patients who had undergone robotic mitral valvuloplasty between March 1, 2010 and September 31, 2020 were assessed. Among these patients, 63 patients responded to an online survey regarding postoperative functional outcomes using the modified KCCQ-12 survey. We performed a paired non-parametric Wilcoxon and one sample t-test to assess statistical significance in measured outcomes.
Results
We found that respondents had a statistically significant improvement in functional outcomes with respect to physical limitation (PL), symptom frequency (SF), quality of life (QL), social limitation (SL), and composite scores. The composite score difference using the one sample t-test was 17.16 out of 100 points, which was statistically significant. Similarly, paired non-parametric Wilcoxon test also showed statistical significance when comparing patient scores before and after the surgery.
Conclusions
There is limited data to support the functional improvement of patients who undergo robotic mitral valve repair. Our study found that patients who underwent robotic mitral valvuloplasty showed statistically significant improvement in heart failure symptoms as measured by modified KCCQ-12 survey.
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Poster Presenter
Suk Hong
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United States
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
OBJECTIVE: To identify risk predictors that interact with prohormone B-type natriuretic peptide (proBNP), and analyze their impact on long-term outcomes in patients undergoing transcatheter edge-to-edge repair (TEER) for mitral valve regurgitation (MR).
METHODS: All consecutive patients undergoing TEER between March 2017 and October 2021 were included in the study. Patients with proBNP ≤ 500 and ˃ 500 were compared for baseline demographics. A propensity-adjusted analysis was used to compare the two groups. Primary outcome was long-term incidence of all-cause death and major adverse cardiovascular and cerebrovascular events (MACCE). A Multivariable Cox proportional hazards regression analysis was performed to identify independent predictors for long-term all-cause mortality.
RESULTS: A total of 171 patients who underwent TEER were included in the study. After propensity-adjusted analysis, 90 patients were included in the proBNP ≤ 500 (low) cohort and 76 patients in the proBNP ˃ 500 cohort. Preoperatively, mean age was 79.4 vs 78.4-year-old in the low proBNP and high proBNP cohorts, respectively. Cardiogenic shock incidence was 3 (3.33%) vs 8 (10.53%) in the low and high proBNP cohorts, respectively. Intraoperatively there were no differences. Postoperatively there was a higher incidence of total ICU length of stay in the high proBNP vs low proBNP cohort (54.5 vs 18.6 hours, respectively; p˂0.0001), total LOS (6.45 vs 2.7 days, respectively; p=0.003), creatinine level (1.7 vs 1.2, respectively; p=0.0001), and warfarin use upon hospital discharge (19 (25%) vs 8 (8.9%) patients, respectively; p=0.022). Mean follow-up time was 2.2 years. All-cause death (HR 1.9 [1,2; 3,0]; p=0.009), MACCE (HR 1,8 [1,2; 2,8]; p=0.006), and cardiac mortality (HR 2,2 [1,1;4,4]; p=0.026) were higher in the proBNP ˃ 500 compared to the proBNP ≤ 500 proBNP cohort. Cardiac readmission included 30 (33.3%) patients in the low proBNP cohort and 29 (38%) patients in the high proBNP cohort. Risk predictors for all-cause mortality were pre-operative grade of MR, EF ˂50%, functional MR, and NYHA class IV.
CONCLUSIONS
Patients with a proBNP level ˃ 500 had a higher incidence of all-cause mortality, MACCE and cardiac mortality when compared to patients with a proBNP ≤ 500. Risk predictors for all-cause mortality included functional MR etiology. The study outcomes suggest that prior optimization of proBNP levels in TEER by the heart-team is crucial for good outcomes.
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Poster Presenter
Aleksander Dokollari
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Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
Introduction: Current literature investigating the role of pre-operative clinical depression on the outcomes of cardiac surgery is often limited to small, single-center studies over a short timeframe, or is isolated to one cardiac surgery approach. This national study examined the outcomes of all cardiac surgery patients over 17 years to better understand the effect of pre-existing depression.
Methods: This study is a retrospective National Inpatient Sample analysis (2001-2018). Patients were included if they were adults (age>18 years) and underwent coronary artery bypass graft (CABG), aortic valve repair (AVR), mitral valve repair (MVR), tricuspid valve repair, and/or ascending aorta repair. Propensity matching for depression based on patient age, sex, and surgery type was performed. Primary outcomes included in-hospital mortality. Secondary outcomes included major adverse cardiac events, and length of stay (LOS).
Results: We matched 302,572 patients with depression to 5,161,521 patients who underwent cardiac surgery and found 298,058 matched patients without depression. Patients with depression had a lower Elixhauser co-morbidity score compared to non-depressed patients. All cardiac patients with depression had less mortality, stroke, and myocardial infarctions, but more complications in the form of bleeding and heart block. Those who underwent CABG had no significant difference in heart block or pacemaker requirements but were more likely to be transferred to other facilities. MVR patients with depression had higher valve complications, heart block, pacemakers, and LOS>2 weeks, but lower mortality and perioperative MI (p<0.05). After adjusting for important factors, MVR has a higher mortality likelihood than isolated CABG (by 63% for isolated MVR, 145% for MVR+CABG, and 166% for MVR+AVR). Depression decreased the likelihood of mortality by 45% (OR: 0.55 [95%CI: 0.48 – 0.62]; p<0.001); however, the interactions of depression with anxiety, obesity, and smoking were significantly associated with an increased likelihood of mortality (Table).
Conclusion: Patients with pre-existing depression had decreased mortality rates, potentially due to established care and awareness of their mental and physical health before admission for cardiac surgery. Surgeons should work with patients and their social support mechanisms to encourage behaviors that promote positive mental and physical health, especially when considering isolated or concomitant MVR.
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Poster Presenter
Ahmed Alnajar, University of Miami Hospital
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Miami, FL
United States
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
Objective: search for arrhythmias trigger and mechanism of myocardial fibrosis (MyF) in malignant mitral prolapse (MMVP).
Method: A 30 y.o. woman with negative T waves in D2, D3, recurrent prelipotymic crises and known trivial mitral regurgitation (tMR) is presented. In a fibroelastic deficiency MV, transthoracic echocardiography (TTE) reveals - Fig1: bileaflet prolapse (BiP), tMR, mitral annular disjunction (MAD of 9mm) and curling. Between the posterior mitral leaflet (PML) and inferior left ventricle wall (iLVW) a >90° angle was seen. TDI echo shows the pickelhaube helmet sign (PHS). ECG Holter shows complex ventricular arrhythmias (VA): a run of polymorphic ventricular tachycardia, premature ventricular complex (PVC) 25%, with bi and trigeminal beats. Exercise ECG test showed paired, bi, trigeminal PVC. Late Gadolinium Enhancement (LGE) was seen on the basal portion of the iLVW at CMR. In Heart Team the patient was judged to be MMVP at high risk of sudden death and surgery was proposed.
Results: In right minithoracotomy approach a thin MV was seen with BiP, more evident on P2. Surgery: P2 limited triangular resection + restoring of coaptation plan from left atrium inside of LV + PTFE chordae to stabilize P2 area + a complete prosthetic ring. TTE showed tMR, long coaptation (9mm), rebuilding of the coaptation triangle (CoT), loss of MAD, curling and of PHS.
CONCLUSIONS: MMVP can occur even in tMR uninfluenced by the degree of MR, if MyF is present and the key to analysis is the PML motion. Abnormal PML motion angle (>90°) releases kinetic energy to the MV hinge area creating cell damage, apoptosis and MyF. Since in a normal MV a sharp angle occurs between the PML and iLVW - creating a 3rd degree lever of forces, while in MMVP, due to the BiP, this angle increases >90° and so a lever of 1st degree rises. Loss of MAD, curling and PHS after surgery confirms that the PML jerk effect has been eliminated by rebuilding of a normal MV geometry. In fact, at 4y F-UP ECG is normal, the patient is asymptomatic with just 1,7% VA at Holter, prelipotyms disappeared and the ECG stress test showed only occasional bigeminal PVC. The only great difference from pre-Op and post-Op MV geometry at TTE was the restoring of CoT, initially absent, to a near normal one. Bringing back of the MV coaptation plane into the LV removes the mechanical triggers of PML in this arrhythmogenic prolapse. Further studies are needed for a better understanding of this life-threateni
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Poster Presenter
Gheorghe CERIN, Cardioteam Foundation
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Torino, Piemonte
Italy
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
Objective: Concomitant repair of the tricuspid valve during surgery for degenerative mitral regurgitation remains contentious. Current guidelines recommend intervention when at least moderate regurgitation or excessive annular dilation is present. A recent CTSNet trial did not demonstrate a mortality benefit or improvement in quality of life following concomitant repair but did demonstrate significantly higher permanent pacemaker placement. We sought to quantify the rate of tricuspid repair in eligible patients following publication of these trial results.
Methods: Utilizing a regional collaborative, we identified all patients from 2017 until present with degenerative mitral regurgitation undergoing mitral valve repair or replacement. We included only those patients with moderate tricuspid regurgitation or annular diameter greater than 40 millimeters. Those with endocarditis, primary tricuspid regurgitation, severe tricuspid regurgitation, or undocumented degree of tricuspid disease were excluded. Our time event was February 22, 2022 when the trial results were published. A 1-month washout period before and after time of publication was employed to account for change in surgeon practice.
Results: We identified 164 patients who met inclusion criteria with 17 (10.4%) patients undergoing surgery in the post-trial period. The rate of tricuspid annuloplasty in the pre-trial group was 45.6% as compared to 35.3% in the post-trial group (p=0.42). Baseline demographics and comorbidities between the groups were similar. All postoperative outcomes including mortality were similar between the groups (p>0.05) aside from a higher rate of reoperation for valve dysfunction in the post-trial group (5.88% vs. 0.00%, p=0.003).
Conclusion: Despite similar degrees of indication for tricuspid intervention, there appears to be a slow downtrend, although non-significant, in the rate of tricuspid annuloplasty during mitral surgery following trial publication. Longer term data is necessary to elucidate future trends in concomitant tricuspid annuloplasty.
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Poster Presenter
Alexander Wisniewski
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CHARLOTTESVILLE, VA
United States
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
Objective
Post-cardiotomy Cardiogenic shock [PCCS] following mitral repair for severe mitral regurgitation [MR] is an infrequent complication. Often taking the surgeon by surprise, due to combination of over-estimation of LVEF due to severe MR, and myocardial stunning, we report 3 interesting cases recovered successfully with extracorporeal membrane oxygenator therapy [ECMO] for PCCS, following difficult repair
Methods
Between January 2022 and 2023, 3 patients underwent complex mitral repair, using standard antegrade/retrograde Buckberg cardioplegia.
Results
Patient 1: severe MR due to bileaflet prolapse & posterior commissure [PC] involvement, and interestingly, some restriction in initial portion of P2 due to LAD infarct and LV dilatation, & moderate aortic stenosis. He was diagnosed with Ischemic cardiomyopathy with LVEF 28% 6 years ago, which improved with biventricular pacing and medical therapy to 40%. He underwent bileaflet repair with chordal transfer to A2, neochords to A2, A3, P2, P3, cleft closure P1/2, PC advancement, 40mm complete mitral ring, aortic valve replacement, biatrial maze, & LIMA to LAD
Patient 2: severe MR due to acute posterior leaflet prolapse from multiple ruptured primary cords to P2/3 due to chest trauma, severe pulmonary hypertension, severe functional tricuspid regurgitation [FTR] with dilated RV, and atrial fibrillation [AF]. He presented with ascites and congestive failure, requiring pre-optimization. He underwent mitral repair with neochords to P2, P3, cleft closure P2/3, PC advancement, 36 mm complete mitral ring, a 32mm tricuspid partial ring, & biatrial maze
Patient 3: severe MR due to prolapse of A2, A3, P2, P3, & PC involvement, AF, biventricular dysfunction, severe FTR. She underwent mitral repair with Neochords to A2, A3, P2, 40mm complete mitral ring, 30mm partial tricuspid ring, & biatrial maze.
All 3 patients required perioperative ECMO support, and are alive and well currently
Conclusions
These cases highlight the difficulty in estimating preoperative LV dysfunction in patients with complex mitral pathology. Preoperative right heart catheter studies remain paramount for prognosis and risk stratification in these patients, as LVEF grossly over-estimated function and is therefore inadequate [Table-1]. ECMO provides a very elegant way of managing PCCS in these patients, allowing recovery of biventricular function without end-organ dysfunction seen with high-inotropic support alone
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Poster Presenter
♦Balakrishnan Mahesh, Penn State Health Milton S. Hershey Medical Center
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HERSHEY, PA
United States
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
Objective: Rheumatic heart disease (RHD) is the leading cause of mitral valve disease in the developing world. Most of these rheumatic heart disease patients also have concomitant atrial fibrillation. Mitral repair is feasible for patients with degenerative or ischemic heart disease, however, the appropriateness of repair for rheumatic heart disease remains controversial. Its results in the rheumatic valve are not as successful as that for degenerative repair. Also the efficacy of atrial fibrillation ablation in rheumatic mitral valve disease has been regarded inferior to that in nonrheumatic diseases. Our approach has been to repair rheumatic mitral valves concomitant atrial fibrillation ablation, and we aimed by this study to present our immediate and midterm follow-ups of our cohort of rheumatic valve repair patients concomitant atrial fibrillation ablation.
Methods: From September 2019 to December 2022, 38 consecutive rheumatic mitral valve patients with persistent atrial fibrillation underwent mitral valve repair concomitant atrial fibrillation ablation. The mitral valve repair was done with the 4-step commisuroplasty SCORe procedure. The ablation line was done with the Cox procedure.
Results: These patients mean age was 45.92±11.81 years. The study population was 81.6% female. Twenty-nine patients were in New York Heart Association functional class III or IV. The repair techniques were performed in 4 steps in general and mainly based on commissuroplasty; tricuspid repair with Carpentier-Edwards Classic tricuspid annuloplasty ring in 36 (94.7%) patients, the Cox procedure with Medtronic ablation clamp in all 38 patients. There was no operative mortality. They were followed up for a median of 23.5 months (Average 25.2±11.5 months). Mitral valve orifice area (MVOA) was less than 1.5 cm2, and mean (SD) MVOA for the whole cohort was 1.20 (0.34) cm2 preoperative. The mobility of the anterior leaflet was improved (P < .001) during the cardiac cycle postsurgery, but that of the posterior leaflet was not (P = .591). The mean (SD) coaptation length was increased significantly from 6.69 (1.32) mm to 7.92 (1.24) mm (P < .001) postoperatively. M
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Poster Presenter
Zhiwei Xu, Nanjng Medical University
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Huaian, Jiangsu
China
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
Objective: The aim of the study was to assess outcomes of combined aortic root replacement and mitral valve surgery.
Methods: From 2005 to 2019, 36 patients (age 53.6 ± 12.7 years) underwent aortic root surgery (David procedure, n=14 or Bentall procedure, n=22) concomitant with mitral valve repair (isolated ring implantation, n=29 or complex valve repair, n=7). Preoperatively, in 4 patients were identified chronic aortic dissection and in 3 cases were pulmonary autograft failure after previous Ross procedure. All patients had moderate or severe mitral regurgitation in 21 (58.3%) and 15 (41.7%) patients, respectively. The aortic valve was bicuspid in 10 (27.8%) of patients.
Results: Cardiopulmonary bypass and cross-clamping periods were 224.5±54.0 and 177.2 ±55.3 minutes, respectively. There were 2 (5.6%) cases of in hospital deaths (myocardial infarction – 1; bleeding – 1). No perioperative strokes were registered. At discharge, all patients had trivial or mild mitral insufficiency. Among aortic root sparing patients no one had ≥2 aortic insufficiency, 9 patient had trivial or mild and 5 had zero grade. The mean follow-up was 5.1 ± 4.3 years. One patient died, however no cardiac-related deaths occurred and all patients were free from aortic root or mitral valve re-intervention.
Conclusions: Concomitant aortic root surgery and mitral valve repair is associated with acceptable in-hospital mortality and high freedom from death and valves reinterventions.
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Poster Presenter
Anastasiia Karadzha, Mayo Clinic (Rochester, MN)
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Rochester, MN
United States
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
MINIMALLY INVASIVE MITRAL VALVE REPAIR USING ARTIFICIAL CHORDAE VIA RIGHT MINI‐THORACOTOMY: A SINGLE-CENTER EXPERIENCE
Objective: Minimally invasive mitral valve repair is known for its safety and efficacy, but the use of artificial chordae presents its own challenges, including technical difficulty, outcome variation, and the absence of standardized protocols. This study aims to analyze the mid-term outcomes of mitral valve repair using artificial chordae via right mini-thoracotomy.
Methods: The study analyzed all consecutive patients who underwent minimally invasive mitral valve repair using artificial chordae via right mini-thoracotomy at a single center in Vietnam between April 2016 and April 2022. The mitral valve repairs were divided into two groups based on a previously validated complexity score: simple repair (Group 1) and intermediate and complex repair (Group 2). Demographic information, comorbidities, surgical characteristics, surgical outcomes, and mid-term survival were analyzed. The primary endpoints were survival, freedom from reoperation, and recurrent mitral regurgitation.
Results: A total of 90 patients were analyzed, including 41 simple repairs and 49 intermediate-to-complex repairs. The mean patient age was 50.5 ± 12.9 years, with 77 (77.7%) being male. The mean annular mitral diameter was 39.2 ± 4.4 mm, and the vena contracta was 8.0 ± 1.6 mm. Myxomatous Barlow disease was present in 16 (17.8%) valves. The left ventricular dimensions slightly decreased after the repair. The mean follow-up time was 26.2 ± 16.1 months, with two (2.2%) deaths. All patients underwent ring annuloplasty, and the additional Alfieri edge-to-edge technique was applied in 6 (6.7%) cases, mostly in Group 2. Kaplan-Meier survival estimates at 12 and 24 months for both groups were 97% (92-100%) and 100% (P=.85), respectively. The recurrent mitral regurgitation estimates were 97% (92-100%) and 92% (84-100%) (P=.279), and 97% (92-100%) and 88% (79-99%) (P=.279), respectively. No reoperations occurred during the follow-up period.
Conclusion: Minimally invasive mitral valve repair using artificial chordae via right mini-thoracotomy is feasible, safe, and effective in a resource-limited country for patients with mitral regurgitation, regardless of the complexity of the valve repair. Further studies are needed to determine the long-term outcomes.
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Poster Presenter
Dinh Hoang Nguyen, University Medical Center Ho Chi Minh City
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Ho Chi Minh, NA
Viet Nam
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
Introduction:Valvular preservation will always be a challenge when it's done on patients with congenial cardiopathies. For adults cardiac surgeons, it's even harder to take the decision on how and when to treat these patients during their reinterventions. In this case, we would like to share our focus on CCTGA with right atrio-ventricular valve endocarditis as a consequence of an infected endocardial pacemaker.Case:A 16-year-old male patient with CCTGA and congenital atrioventricular blockage. Treated with an univentricular epicardial pacemaker implantation during his childhood and recently endocardial univentricular pacemaker implantation via endovascular approach. Facing complications with bacterial endocarditis (staphylococcus epidermidis) in the right atrio-ventricular valve consequence of pocket infection after the implantation.The patient received multiple cycles of parenteral antibiotics without evidence of clinical improvement. On his echocardiographic control there's evidence of the presence of multiple vegetations with emboligenic potential in the non-systemic valve (figure1). Surgical exploration is decided and in the same operative act the placement of a resynchronizer (CRT-P).Procedure:Firstly, it was decided to remove the pacemaker electrode in the hemodynamics room and later go into surgery to perform a resternotomy, starting with the ECC with peripheral vascular access.Atrioventricular and aortopulmonary double discordance was found. Severe insufficient mitral valve (figure 2) with destructuring of the posterior leaflet with multiple vegetations (figure 3). Initially, resynchronizer electrodes were placed in both ventricles. Afterwards, the reparation of the mitral valve was made (Removal of the infected quadrant together with its subvalvular apparatus). The reconstruction was completed Closure of the defect in the posterior leaflet with and placement of artificial cords in its free edge with PTFE.The control during his 3-year follow-up of his control echocardiogram showed improvement of his function(figure 4).Summary:Pacemaker infection and endocarditis can be an undesirable complication. Management of such complication deserve early and specialized treatment.In this particularly case with CCTGA and atrioventricular block requiring open heart surgery for mitral valve repair due to infective endocarditis and implant de CRT-P seems to be a better choice than standard AV dual pacing in order to avoid failure in long term (figure 5).
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Poster Presenter
Orlando Moreno, Centro Medico Docente la Trinidad
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caracas, DF
Venezuela, Bolivarian Republic of
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
Objective. The clinical benefits of mitral valve repair over replacement in the setting of mitral infective endocarditis remain not clearly established. We aim to review the clinical experience in mitral valve surgery for infective endocarditis looking at mid-term survival.
Methods. Prospectively collected data of patients who underwent cardiac surgery for infective endocarditis between 2001 and 2021 at two cardiac centres were reviewed. Among them, 282 patients underwent native mitral valve surgery and were included in the study. Nearest-neighbour propensity score matching was performed including fifteen variables to account for differences in patients' profile between the repair and replacement subgroups.
Results. Mitral valve replacement was performed in 186 patients, while in 96 cases patients underwent mitral valve repair.
PM analysis provided 89 well-matched pairs. Mean age was 60±15 years, 75% of the patients were male. Twenty-three patients (13%) had a recent cerebral event. Mitral valve replacement was more commonly performed in patients with involvement of both mitral leaflets, commissure(s) and mitral annulus. Patients with lesion(s) limited to P2 segment underwent in most of the cases mitral valve repair (Figure). There was no difference in terms of microbiological findings. In-hospital mortality was 7% with no difference between the repair (n=7, 7%) and the replacement (n=6, 7%) cohorts, p=0.77. Survival probabilities at 1-, 5- and 10-years were 88%, 72% and 68%, respectively after mitral repair, and 88%, 78% and 63%, respectively after mitral replacement; log-rank p=0.94. Cumulative risk of reoperation at 10-years was 3.5% after mitral valve repair and 5% after mitral valve replacement, Gray's test p=0.71.
Conclusions. Surgery for native mitral valve infective endocarditis is still associated with a non-negligible risk of mortality. Mitral valve repair was more commonly performed in patients with isolated single leaflet involvement and provided good early and mid-term outcomes. Patients with annular disruption, lesion(s) on both leaflets and commissure(s) were successfully served on early and mid-term course by mitral valve replacement.
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Poster Presenter
Pietro Giorgio Malvindi
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Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
Objective: Mitral valve repair is the gold standard for treatment of mitral regurgitation, but the optimal technique remains debated. Utilizing a regional collaborative, we sought to determine the change in repair technique over time, respective outcomes, and predictors of technique usage.
Methods: We identified all patients undergoing mitral valve repair from 2012-2022. Those with endocarditis, undergoing transcatheter repair, or other concomitant procedures including tricuspid intervention or atrial fibrillation ablation were excluded. Continuous variables were analyzed via two-way t-test and categorical variables via chi-square testing. Multiple regression was used to determine outcome predictors.
Results: We identified 1658 patients that underwent isolated mitral valve repair with 948 (57.2%) undergoing a leaflet sparing repair. Over the last decade, there was no significant trend in the proportion of repair techniques across the region via logistic regression (p=0.85). Those undergoing leaflet sparing repairs were more likely to be female (44.0% vs. 34.7%, p<0.001), African American (13.2% vs. 8.3%, p=0.002), redos (6.4% vs. 2.1%, p<0.001), undergo minimally invasive approaches (51.6% vs. 24.1%, p<0.001), and have higher predicted risk of morbidity or mortality (median 8.5% vs. 7.8%, p=0.004). Intraoperatively, leaflet sparing repairs were associated with both longer bypass (138 ± 43 vs. 127 ± 48 minutes, p<0.001) and cross clamp times (96 ± 32 vs. 90 ± 36 minutes, p<0.001) compared to leaflet resection repairs. Operative mortality was similar between both groups (0.95% vs. 0.99%, p=0.94) as were other postoperative outcomes aside from a lower rate of reoperation for valve dysfunction in the leaflet sparing group (0.11% vs. 0.70%, p = 0.04). Anterior leaflet prolapse (OR=7.0, p<0.001) and minimally invasive approach (OR=5.3, p<0.001) were most predictive of leaflet sparing repair.
Conclusion: Despite minor differences in operative times, statewide over the past decade there remains a diverse mix of both classical "resect" and newer "respect" strategies with comparable short-term outcomes and no major timewise trends. These data may suggest that the approaches are either viewed as complementary rather than dichotomous or perhaps are decided on a case-by-case.
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Poster Presenter
Alexander Wisniewski
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CHARLOTTESVILLE, VA
United States
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
Introduction: ALCAPA is a rare coronary alteration that can present itself in a unique clinical sense (0.25%)with a high mortality rate during the first year of life. Surgical correction is the best treatment to manage this condition. In this case report, we'll present a patient that during his first year of life, went through a correction and throughout his adolescence, started suffering congestive heart failure thanks to mitral valve regurgitation.Case Report: A 20-year-old male patient was treated that while he was 11 months old was intervened .On this opportunity, he underwent a corrective surgery using the Takeuchi procedure (figure 1). 20 years later he found himself getting diagnosed with cardiomegaly at the expense of the left chambers after a global cardiac insufficiency (class IV/NYHA) was detected. On an echocardiogram, a dilatation of every single left chamber was discovered, with a severe mitral regurgitation and global hypokinesia predominantly in the anterior wall of the left ventricle (figure 2). Through a coronary angiography it was later on revealed that the transpulmonary patch was dehiscent and was causing the left coronary flow to direct itself to the pulmonary artery with a valve regurgitation, producing an important pulmonary hypertension (figure 3).Procedure: The reintervention was done through a sternotomy and central cannulation, using cold blood cardioplegia. The pulmonary opening was made and the total dehiscence of the pulmonary patch was verified (figure 4). Subsequently, a neoduct with pericardium and the suspension of the cuspids of the pulmonary artery took place until a coadaptation was achieved (figure 5). Next up, an exploration of the of the mitral valve through the left atrium was made and dilatation annulus was found. It was repaired with the placement of a semi-rigid mitral ring (Carpentier N° 32) (figure 6). The patient was leaves with an echocardiogram with a correct dynamic and normal functioning (figure 7) For the 14 years to come, the patient has maintained himself asymptomatic with a normal cardiac function with no evidence of any sort of ventricular dysfunction and repair without mitral valve regurgitation. Summary:ALCAPA it's a rare congenital anomaly that it ought to be corrected surgically immediately. In this case, heart failure due to mitral valve dysfunction. The choosing of the correct surgical technique along with the experience with these types of cases in adults is to obtain satisfying results.
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Poster Presenter
Orlando Moreno, Centro Medico Docente la Trinidad
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caracas, DF
Venezuela, Bolivarian Republic of
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
Objective: This study aimed to evaluate the outcomes of isolated and elective mitral valve (MV) repair versus MV replacement at Heart Institute - University of São Paulo Medical School during COVID-19 era.
Methods: We retrospectively searched our dedicated in-hospital database for patients referred to our institution for MV surgery during COVID-19 era between March 2020 and December 2022. Among 456 patients who underwent MV surgery, we identified 245 eligible patients for analysis. Redo surgery, urgent operative procedure and patients with other valve pathology or with coronary artery disease were excluded. Mitral valve repair was performed in most cases by "Double Teflon" technique which consists of a quadrangular resection of the posterior leaflet, annulus plication with pledgetted stitches, and leaflet suture. The procedures were performed by the same surgical team in a standard approach by median sternotomy with central cannulation, mild hypothermia and cold blood cardioplegia. Statistical analysis was performed with Fisher's Exact Test.
Results: A total of 243 patients underwent primary isolated elective MV surgery during COVID-19 pandemic period in our institution. A total of 61 patients (25.1%) underwent MV repair. The mean age of the entire cohort was 57.7 years (53.3 years for MV replacement vs 61.5 years for MV repair) and 67.5% were female. The mean Society of Thoracic Surgeons (STS) score was 1.48%. Overall in-hospital mortality for the entire cohort was 3.7% (9/243). In-hospital mortality for MV replacement was 5.2% (9/172) and there was no operative mortality for MV repair (5.2% versus 0%; p = 0.11).
Conclusion: This study indicates that primary elective MV surgery had low operative mortality during COVID-19 era. Although there was no significant difference in early survival between groups, MV repair showed a trend of lower operative mortality compared with replacement during COVID-19 pandemic period.
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Poster Presenter
Fabrício Dinato
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Brazil
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
AIM. To determine significance of patient-prosthesis mismatch (PPM) (indexed effective orifice area < 1,2 cm²/m²) after isolated mitral valve replacement(MVR) in pts with small cavity of left ventricle (SCLV) (end-diastolic volume (EDV) ≤ 75 ml) during hospital period.
MATERIALS. 1811 adult patients (pts) with isolated mitral valve disease MVR were operated in Institute from 01.01.2000 till 01.01.2007. There were 127 (7,0%) pts with SCLV (only mitral stenoses). There were 48(37,8%) males and 79(62,2%) females. Average age was 53,2+ 7,1. 110 (86,6%) pts belonged to IV NYHA class of heart failure, 17 (13,4%) – to III class. Previous closed mitral comissurotomy was performed in 31 (24,4%) pts, to 7 pts – twice (closed recomissirotomy by closed method). Thromboses of left atrium was marked at 13 (10,2 %) pts, including massive in 3 pts. All operations were performed with cardiopulmonary bypass and moderate hypothermia with crystalloid cardioplegia. Average BSA was 1,87±0,32 m². Following prostheses were implanted: bileaflet (Saint Jude, Carbomedics, On-X, ATS) (n=88) and monodisc as Alcarbon`s type (MIKS, LIKS) (n=39). Following prosthesis sizes were used: 23 mm (n=1), 25 mm (n=74), 26 mm (n=3), 27 mm (n=49).
RESULTS. Hospital mortality (HM) was 5,5% (n=7). It was higher in cases with 27 mm size of implanted prosthesis - 8,2% (n=4/49), than other group - 3,8% (n=3/78) (p <0,01). PPM were marked in 21 (16,5%) pts with BSA >1,75 m² and size of prothesis 25 mm but theren`t influence on HM. Heart failure and PPM were marked in 5 (3,9%) pts with BSA>1,75 m², size of prothesis 25 mm and cavity of LV (EDV≤50 ml). Risk-factors for PPM SCLV`s group of pts on hospital stage were: very small cavity of LV (EDV≤50 ml) especially in pts with BSA>1,75 m², previous operation, pulmonary hypertension (> 90mm Hg), mitral valve calcification 3+, duration of rheumatic disease ≥ 25 years. At the remote period (average 15,3± 1,2 yy) 115(95,8%) pts were followed–up. Survival at 15 year follow- up – 85,1%. EDV was increased at 35,4%. PPM wasn`t marked at remote period.
CONCLUSION. Pts with SCLV are in group of higher risk for operation and increasing risk of PPM. In these cases implantation of 25 mm prosthesis is expedient, but for pts with EDV EDV≤50 ml BSA>1,75 m² it may lead for significant PPM and heart failure.
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Poster Presenter
Volodymyr Popov, National Institute of cardio-vascular surgery named after Amosov
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Kiev, Kiev
Ukraine
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
Objective: Rapid deployment valve prostheses (RDV) have been used more and more frequently in aortic valve surgery in recent years due to the simplicity and speed of implantation. It is still unclear whether technical problems such as leaks occur in combination with operations on the mitral valve and whether advantages can be achieved in the combined operations when using RDV in the aortic position.
Methods: From 2019 to 2022 we performed 105 combination surgeries of mitral - and aortic valve surgery. The STS score in all patients was calculated to a mean of 3.9 +/- 1.7. We implanted a RDV in 42 cases in the aortic position (group A). Sixty-three patients received mitral valve surgery in combination with a conventional aortic valve replacement (group B). All patients underwent intraoperative control echocardiography (TEE). In addition, a transthoracic echocardiography was performed before discharge and after 1 year postoperatively. Propensity score matching resulted in 41 matching pairs, which were analyzed.
Results: In group A the intraoperative mortality was 2.4% and in group B 4.9% (p>0.05). One patient of group A, suffered from a significant paravalvular leak at the aortic prosthesis intraoperatively, so we revised the implantation with a conventional valve prosthesis. The operating time (255 +/- 45 min vs. 283 +/- 51 min) and the cross clamp time (91 +/- 21 min vs. 115 +/- 35 min) were significantly lower in group A than in group B. In group A, the transvalvular mean pressure gradient with 9.0 +/- 5.1 of the aortic prosthesis was significantly lower than in group B with 16.5+/- 6.7mmHg. The time spent in the intensive care unit and the time spent in hospital did not differ between the two groups. After 1 year, survival rates were in group A 92.6% and in group B 89.9%. We noticed no differences in either group with regard to mitral valve function. There were no paravalvular leaks from the prosthetic mitral valves or a higher failure rate of the reconstructed mitral valves.
Conclusions: Technically, there is no problem using an RDV in mitral valve operations where the aortic valve also needs to be replaced. The operative and early postoperative results are comparable. It is noticeable that the RDV show a lower pressure gradient. Long-term courses must show whether there is also a clinical advantage for the patient. With regard to the function of the mitral valve, there are no problems when inserting the RDV in combined mitral surgery.
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Poster Presenter
Harald Dr.Hausmann, MediClin Heart Center Coswig
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Coswig, Saxony-Anhalt
Germany
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
Objective: For a reproducible mitral valve repair, multiple neo-chordal creations are accepted as a major repair technique even for posterior leaflet pathology. Although the loop technique has been a standard way for this purpose, the decision of the length of the loop set was difficult. To resolve drawbacks in the original loop technique, a modified loop technique called the Loop-in-Loop technique was applied. It uses a premade loop set (4 loops and 8mm in length) as an anchor on the papillary muscle and the efficient length of a neo-chord is adjusted by a second loop that connects the anchor to the mitral leaflet.
Methods: In the current study, one-year results of the consequent 34 cases (Age 60.6±13.2 (31-84), Female 13) from 2019 to 2022 using the modified loop technique were verified retrospectively. Follow up date was 182.6±179.1 (4-618).
Results: An endoscopic-assisted small right mini-thoracotomy was applied in 28 cases. A daVinci surgical assist robot was used in two cases. The full-sternotomy approach was used in the remaining four cases. Mitral valve repair was completed in all attempted instances during the study period. Neochords were created for the anterior leaflet (4), the posterior leaflet (22), and both leaflets (8). The average number of neo chords was 3.6±1.5. Although plication of commissure or indentation was added in 15 cases, any leaflet resection was not added in the whole series. Ring annuloplasty was added with Medtronic CG Future Band (11), Edwards Physio Flex Ring (5), and Medtronic SimuPlus Band (18). The average size was 31.4±2.5. Tricuspid annuloplasty with a Medtronic Tri-Ad ring was added in four cases. Although all cases were discharged with equal to or less than mild mitral regurgitation, a recurrence of regurgitation was detected in a case 482 days after the surgery. The mean mitral valve pressure gradient was 3.0±1.2.
Conclusions: The modified loop technique was a reliable repair way for all kinds of mitral valve leaflet prolapse. It was reproducible in complicated mitral valve repair and realized a stable one-year result.
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Poster Presenter
Kazuma Okamoto, Kindai University Hospital
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Kobe, Hyogo
Japan
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
OBJECTIVE: To analyze the outcomes of dual antiplatelet (DAPT) therapy with aspirin (ASA) and clopidogrel after mitral valve repair (MVR) with transcatheter edge-to-edge repair (TEER).
METHODS: All consecutive patients undergoing TEER between March 2017 and October 2021 were included in the study. DAPT vs. non-DAPT cohorts were compared for baseline demographics and pre-operative characteristics. A propensity-adjusted analysis was used to compare the two groups. Matched samples were compared with McNemar's test and marginal homogeneity tests for categorical variables and matched paired t-tests and signed rank tests for continuous variables. Primary outcomes were long-term incidence of cardiac death and all-cause death. To illustrate the effect of DAPT therapy on long-term prognosis, Kaplan–Meier cumulative survival curves were constructed. After propensity adjustment, all baseline characteristics (including oral anticoagulant usage, age, risk etc.) were similar between the two groups.
RESULTS: A total of 171 patients were included in the study. After propensity-adjusted analysis 65 patients were included in the DAPT cohort and 104 patients were included in the non-DAPT cohort. Preoperatively, the DAPT cohort had a lower STS-PROM score (5% [±6%] vs 8% [±9%]; p=0.005), a lower proBNP level (562 [±844] vs 831 [±892]; p=0.02), a lower incidence of atrial fibrillation (19 [±29.2%] vs 97 [±93.3%]; p<0.0001), and a higher mean ejection fraction (56.2% [±16.1%] vs 50.6% [±15.3%]; p=0.02) compared to the non-DAPT cohort. Intraoperatively, there were no differences among groups. Postoperatively, DAPT cohort had a lower use of oral anticoagulants including warfarin (2 [3.1%] vs 27 [25.9%]; p<0.0001), apixaban (2 [3.1%] vs 47 [45.2%]; p<0.0001), rivaroxaban (1 [1.54%] vs 20 [19.2%]; p=0.0004). Mean follow-up was 2.2 years. At 5-years follow-up, cardiac mortality was significantly higher in the non-DAPT cohort (HR 0.4 [0.2, 1.1]; p=0.018). All other outcomes including all-cause death (p=0.139), myocardial infarction (p=0.13), stroke (p=0.4), MACCE (p=0.1), repeat intervention (p=0.43), and new pacemaker implantation (p=0.5) did not differ among groups.
CONCLUSIONS. DAPT therapy had a lower incidence of cardiac death. Secondary prevention with DAPT in patients undergoing TEER for MR may play a role in reducing the incidence of cardiac mortality and warrants prospective randomized controlled trial evaluation.
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Poster Presenter
Aleksander Dokollari
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Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
Objective: To compare early and mid-term outcomes of robotic vs non-robotic approaches to concomitant mitral valve (MV) and tricuspid valve (TV) repair.
Methods: Data were analyzed for 69 adults (age 70±11.5 years; 36 men, 52.2%) with concomitant MV and TV repair from 2014-22 for primary mitral regurgitation (MR) (52), secondary MR (15), and infective endocarditis (2). Concomitant CABG or aortic valve replacement was excluded.
Results: There were 33 robotic-assisted and 36 non-robotic cases (26 sternotomy, 10 thoracotomy). The two groups were otherwise comparable at baseline (Table 1), except that robotic patients were significantly older (73.1±8.8 vs 66.7±12.9, P=.021).
MV and TV annuloplasty were performed in 95.7% and 100%, respectively. Maze ablation was done in 51.5% of robotic and 43.5% of non-robotic patients (P=.197). Cardiopulmonary bypass (CPB) time was significantly longer in the robotic group (168±40 vs 136±31 min, P<.001), while cross-clamp time was not (103±28 vs 106±26, P=.567). More robotic patients were extubated in operating room (OR) (27.3% vs 2.8%; P=.005).
There was no significant difference in early mortality or major morbidity as well as requirement for permanent pacemaker implantation (PPI) between the robotic and non-robotic groups. Median lengths of ICU stay (2.0 vs 4.2 days; interquartile range [IQR] 1.3-3.7 vs 2.1-5.1, P=.012) and hospital stay (6 vs 10.6 days; IQR 4-7 vs 5.3-12.0; P=.008) were significantly shorter in the robotic group.
During follow-up (100% complete) at mean 3.4±2.2 years, none required reoperation. Survival was 84.5±5.6% at 5 years and did not differ significantly by approach (P=.950). Age at surgery (year) predicted all-cause death (hazard ratio [HR] 1.09; P=.036), and Maze ablation predicted PPI (HR 4.32; P=.028).
Echocardiographic results were available in 100% of cases with mean follow-up of 2.7±2.4 years. Most recent echocardiogram indicated ≤ mild MV regurgitation in 93.9% of robotic and 86.1% of non-robotic patients (P=.431) and ≤ mild TV regurgitation in 84.8% of robotic and 91.7% of non-robotic patients (P=.466).
Conclusions: Compared to non-robotic approach, robotic MV and TV repair showed advantages in OR extubation, and shorter lengths of ICU and hospital stay. Robotic-assisted approach allows for excellent results with modest but significantly longer CPB times without longer cross-clamp times in concomitant left- and right-sided cardiac operations.
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Poster Presenter
Alyssa Morrison, Yale
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New Haven, CT
United States
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
Objective: Recent studies suggest that permanent pacemaker (PPM) implantation after concomitant tricuspid valve repair (TVr) and mitral valve surgery is higher than previously thought. Our aim was to assess permanent pacemaker implantation (PPI) rate and risk factors after isolated and concomitant tricuspid valve repair surgery.
Methods: We performed a retrospective analysis of all TVr at a single tertiary academic center performed from 2014-2022. Patients with pre-existing PPM or implantable cardiac defibrillators (ICD) and those with implantation during index procedure were excluded. Survival was assessed using Kaplan-Meier survival analysis.
Results: Tricuspid valve repair was performed in 231 patients, with isolated TVr in 22. Concomitant procedures included mitral valve (MV) repair (81), MV replacement (109), aortic valve replacement (AVR) (41), coronary artery bypass grafting (30), and Maze procedure (57).
Within 30 days of TVr, 23/231 (9.96%) of patients underwent PPI. PPI occurred at median 6 days (IQR 5-7) with a range of 2-14. The indications for the 23 PPM were atrioventricular (AV) node block in 16/23 and sinoatrial (SA) node dysfunction in 6/23. There was no significant difference between the rates of Maze procedure amongst patients with early PPI (9/29) vs without (48/208), P=.123.
In assessing differences between patients with early PPI and those without early PPI, there were no significant differences between the groups regarding baseline demographic characteristics or comorbidities such as age, sex, history of myocardial infarction, and history of prior cardiac surgery (Table 1). There were also no differences in operative characteristics such as rates of concomitant procedures such as AVR or MV surgery, or in annuloplasty/valve size.
Median follow-up was 2.76 years (IQR 1.18-4.78). Late PPI occured in 15 patients, median 1.23 years (IQR 0.64-4.6) after TVr. Indications for late PPI include AV node dysfunction (4), SA node dysfunction (10), and unknown (1). There was no significant difference in the long-term survival based on early PPI status (P=0.305).
Conclusions: The rate of PPM implantation following TVr within 30 days postoperatively in our cohort was 9.96%, suggesting PPM implantation is not an uncommon occurrence in the perioperative period for tricuspid valve repair surgery, and typically occurs within the first 10 days. AV block accounts for the majority of early PPI, followed by SA node dysfunction.
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Poster Presenter
Alyssa Morrison, Yale
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New Haven, CT
United States
Objective: Postoperative atrial fibrillation (POAF) is common after cardiac surgery with an incidence of 20-40%. POAF is often regarded to be "benign," however recent data suggest worse long-term outcomes with POAF. Furthermore, there are no guidelines for the amount of POAF that triggers anticoagulation. Therefore, we examined the rate of POAF, incidence of subsequent neurologic events, and mortality in patients undergoing isolated mitral valve surgery at a Mitral Foundation reference center.
Methods: Adult patients from 2011-2022 with no history of AF, SVT, or heart block undergoing isolated mitral valve surgery (88% were repaired) at a Mitral Foundation reference center were included. Primary outcomes were incidence of POAF (STS definition within 30 days), neurologic event rate, development of new/recurrent AF after the postoperative period, and long-term survival. Perioperative strokes (<72 hrs) were censored. The majority of patients were discharged on aspirin and anticoagulation. Bivariable analyses and multivariable logistic regression were used to compare and analyze independent associations between patient and operative characteristics, POAF, and primary outcomes. Kaplan-Meier and the Cox proportional-hazards model were used to characterize long-term survival.
Results: The incidence of POAF was 37% (350/943). Median follow-up was 5 months (IQR 1-42 months). As expected, valve replacement (OR 2.9, p=0.004 95% CI 1.4-5.8) and increased age (OR 1.1, p<0.001 95% CI 1.0-1.1) were independently associated with POAF, whereas worsening heart failure was not (OR 1.2, p=0.4 95% 95% CI 0.8-1.6). Neurologic events occurred in 6% (21/350) of POAF, significantly higher than the 3% (18/593) in no-POAF (p=0.03). Although POAF itself did not impart a mortality risk, POAF was an independent risk factor for the development of new/recurrent AF after 30 days (OR 3.7, p<0.001 95% 2.5-5.5). Additionally, new/recurrent AF did independently increase risk of long-term mortality (HR 1.3, p=0.002, 95% CI 1.1-1.6). Ultimately, POAF patients had worse long-term survival (p=0.002) (Figure 1).
Conclusions: POAF increases the risk of neurologic events, portends development of new/recurrent AF and is associated with worse long-term survival. POAF is not benign and carries a long-term mortality implication. Further research into the cause, prevention and management of POAF is warranted. Patients should be carefully surveilled for the development of long-term AF.
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Poster Presenter
Whitney Fu
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Ann Arbor, MI
United States
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
Objective: Systolic curling (SC) is defined as a downward and anteriorly directed systolic motion of the posterior mitral annulus (PMA), resulting in a curled appearance of the adjacent myocardium on cardiac imaging. According to previous studies, similarly to mitral annular disjunction, SC has been associated with arrhythmic MV prolapse. We developed and tested a method to measure the SC angle on patients affected by degenerative mitral regurgitation (DMR) who underwent surgical MV repair (MVR).
Methods: All patients treated with isolated surgical MVR for DMR at our Centre between January 1st 2022 and December 1st 2022 were included. Patients with concomitant coronary artery disease or previous ACS were excluded. The MIRA (Mitral valve annulus to Inferobasal wall Rotation Angle) was measured as following. On TTE parasternal long-axis view, end-systole, we measured the MIRA that is included between the line perpendicular to the LV posterior wall long axis (from the endocardium to the epicardium) at the level of the tip of the AML (AB) and the line connecting B and the insertion of the PML onto the mitral annulus (BC), as shown in Figure 1. A frame rate superior to 60% was used. We measured the MIRA in each patient at baseline, before surgery, and after MVR and we compared these values. All measurements were made by the same operator three times and the mean value was selected. An eyeball estimation of the presence of SC was made as well. Paired Student's t-test was used to make the comparison.
Results: Thirty patients were included. All of them underwent MVR, 28 had an annuloplasty ring implanted. Out of the 3 patient with no annuloplasty, 2 underwent transapical off-pump Neochord Implantation while 1 had a high risk of postoperative SAM and the surgeon opted for PML resection and Goretex neochord implantation only. At eyeball estimation, SC was present in 23 (77%) patients while after surgery it was visualized in 2 patients (7%) (p<0.001). Mean baseline MIRA was 55±12°, postoperative MIRA was 80±8°. MIRA angle was significantly higher after MVR (p<0.001) corresponding to less evident SC.
Conclusions: MIRA significantly increase after MVR with annuloplasty suggesting that preoperative SC is resolved by stabilization of the PMA provided by the annuloplasty ring. Resolution of SC might mitigate malignant ventricular arrhythmias in patients affected by arrhythmic DMR. Further studies to define the normal value of the MIRA are needed.
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Poster Presenter
Laura Besola, University of Pisa, Italy
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Pisa
Italy
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
Objective:
Transapical NeoChord mitral valve repair (MVR) is a novel minimal-invasive procedure to treat primary mitral regurgitation (MR) without concomitant annuloplasty. Systematic preoperative calculation of leaflet-to-annulus index (LAI) and coaptation index (CI) using transesophageal echocardiography (TEE) has been identified as a prognostic predictor of outcomes at follow-up. This study aims to correlate the predictive value of preoperative assessment and proctor review with the success of the NeoChord procedure.
Methods:
Patients with prolapse/flail of the posterior mitral leaflet scheduled for NeoChord MVR underwent preoperative TEE analysis. TEE analysis was performed using 3mensio software (3mensio, Pie Medical Imaging, Maastricht, The Netherlands). Different parameters, including predictive indexes like LAI and CI, systolic pulmonary artery pressure, indexed left ventricle end-systolic volume (iLVESV), prolapse/flail width (FW), systolic antero-posterior (AP) annulus diameter, systolic latero-lateral (LL) annulus diameter and presence of calcification were analysed. A proctor predicted the results of the procedure based on the TEE data. Finally, the procedure's predicted result of MR reduction was compared to the actual result for all patients.
Results:
238 consecutive patients were screened and analyzed between 2019 and 2022. 210 patients (88.2 %) met or increased the proctors' expectations regarding the perioperative result. On the other hand, 21 patients (8.8 %) did not meet the prediction. While a proctor supported every procedure, no prediction report was available in 4 cases (1.7%). However, a proctor supported every procedure. Three patients (1.3%) have been converted to classical open-heart surgery.
Conclusions:
A TEE-based prediction model is a helpful tool in clinical decision-making and in identifying patients who may benefit from a ringless MVR using the NeoChord procedure. TEE analysis and proctor evaluation are powerful tools for selecting patients benefiting from the NeoChord procedure.
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Poster Presenter
Ferdinand Vogt, Klinikum Nürnberg, Nuremberg, Germany
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Nuremberg, Bavaria
Germany
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
Objectives
The objective of this paper is to differentiate types of mitral valve masses. Transesophageal echo is the most common modality used to identify intracardiac lesions. TEE is an adequate way of identifying intracardiac tumors but is unable to differentiate a benign myxoma from a malignant intracardiac sarcoma. Greater than 75% of cardiac tumors are benign. Our case, however, presents a mass suggestive of a myxoma in the left atrium, which was found to be a primary intimal sarcoma of the mitral valve. Primary intimal sarcomas are extremely rare, mostly found in the right atrium, infiltrate surrounding tissue, and cause symptoms related to their location.
Methods
A 37 year old woman was transferred to our hospital after 2 weeks of worsening SOB. The patient was intubated in the ED due to hypoxic respiratory failure. A transthoracic echo was performed with findings of severe mitral valve stenosis with a mass, concerning for endocarditis. CT PE protocol showed a large filling defect in the left atrium, pulmonary edema, and bilateral pleural effusions. A TEE showed a mobile mass on the posterior leaflet measuring 3.1 x 3.2 cm. Acoustic contrast showed complete opacification and a small stalk, consistent with a left atrial myxoma.
Results
The patient was taken to the OR and sternotomy was performed with percutaneous bicaval cannulation. An incision was made through Sondergaard's groove with identification of a mitral valve mass that involved the anterior and posterior leaflets with no clear stalk. The mass and mitral valve leaflets were excised and replaced with a 29 mm St. Jude mechanical valve. The final pathology revealed a 4.0 x 2.2 x 1.5 cm tumor composed of many features consistent with primary intimal sarcoma. Her PET scan revealed no residual intracardiac tumor or extracardiac extension.
Conclusions
It is challenging to differentiate a primary intimal sarcoma from a myxoma via TEE. Whether benign or malignant-appearing, tumor removal is essential for tissue sampling and patient management. Usually, less than 50% of tumors can undergo complete surgical resection. Due to the aggressive nature of the tumor, primary intimal sarcomas require prompt surgical resection, postoperative chemotherapy and radiation. These tumors often recur and metastasize. The prognosis is very poor with a 3 month to 1 year survival rate. Our case is an example of what appeared to be a benign myxoma, but was found to be an aggressive primary intimal sarcoma.
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Poster Presenter
Michael Bishop, Rush University Medical Center
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Chicago, IL
United States
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
OBJECTIVE: To analyze access of racial minorities to a high-volume mitral valve transcatheter edge-to-edge repair (TEER) center. In addition, we analyzed five-year outcomes of these patients compared to white patients.
METHODS: This is a retrospective clinical study of prospectively collected patients. All consecutive patients undergoing TEER between March 2017 and October 2021 were included in the study and input on a hospital database. White and non-white race patients were compared for baseline demographics. A propensity-adjusted analysis was used to compare the two groups. Primary outcome was long-term incidence of all-cause death and major adverse cardiovascular and cerebrovascular events (MACCE).
RESULTS: A total of 171 patients were included in the study. After propensity-adjusted analysis 15 patients were included in the non-white race cohort and 155 patients in the white race cohort. Preoperatively, non-whites were younger (72.2 vs 79 years; p=0.01) than white patients. However, non-white presented with a higher incidence of pre-procedural cardiogenic shock (4 [26.7%] vs 8 [5.16%]; p=0.01) compared to white patients. In addition, non-white patients had lower albumin levels (3.15 [0.75] vs 3.73 [1.62]). and proBNP levels reached twice the levels of the ones of white patients (1125.4 vs 685.6; p=0.17), although this difference did not reach statistical significance.
Intraoperatively, there were no differences among groups. Postoperatively, non-white patients had a higher ventilation time (16.1 vs 10 hours; p=0.0007) and total LOS (9.8 vs 3.9 days; p=0.04) compared to white patients. Mean follow-up was 2.1-years. There were no differences among the two groups in term of hospital readmission rates. At 5-years follow-up, there were no differences in term of all-cause death (HR 1.4 [0.7, 2.8]; p=0.33), MACCE (HR 1.3 [0.4, 3.5]; p=0.67), stroke (HR 0.8 [0.1, 6.0]; p=0.81), repeat intervention (HR 0.8 [0.1, 6.4]), and pacemaker implantation (HR 0.7 [0.1, 5.5]; p=0.74) among the two groups.
CONCLUSIONS. Racial disparities persist in a high-volume center. Despite their younger age, racial minorities have higher incidence of cardiogenic shock, lower albumin levels and higher proBNP levels, indicating more advanced disease and heart failure compared to white patients, at time of hospitalization for TEER procedure. Further research is needed to better understand racial disparities in utilization and outcomes of TEER.
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Poster Presenter
Aleksander Dokollari
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Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
OBJECTIVE. To determined possibillities of correction of the left parts of the heart by preservation of MV`s apparatus and concomitant reduction of left atrium (LA) during correction of combined mitral-aortic valve diseases (CMAVD).
METHODS. During 01.01.2006-01.01.2020 yy. 201 adult patients (pts) were operated with CMAVD, giant diameter of LA (diameter 60 mm and more) and concomitant left ventriculomegaly (left ventricle`s end-diastolic volume 300 ml and more) at Institute. Average age was 57,2± 10,6 yy. 171 (85,1%) pts were in IY NYHA class and 30 (14,9%) in III class. All material divided at 2 groups: group A (n= 82): AVR + LA`s plasty (all pts) + MVR with preservation of posterior leaflet (all pts) and additionally translocation of anterior leaflet`s papillary muscles (n=54); group B (control group) (n= 119): only MAVR without preservation of MV`s structure and without LA`s plasty. In both groups concomitant procedures were occured on reconstruction of the annuli of narrow ostium of aorta (n =5), tricuspid valve`s plasty (n = 47), CABG (n =21).
RESULTS. There were 3 deaths at the hospital period (hospital mortality (HM) - 3,6%) (group A). At the remote period (average was 9,3± 1,8 yy) 75 pts were followed –up. Sinus rhythm was preserved at 11 (14,7%) pts and there were 3 deaths . Unsatisfactive results were marked: myocardial infarction (n=2), thromboembolic event (n=1).
Data of echo for group A: end-systolic volume index (ESVI) (ml/m.sq.) - preoperative 78,8 ± 13,5, postoperative (6 -11 dd) - 59,8 ± 9,1 and at the remote period 49,6 ± 7,2 and diameter of LA (mm) preoperative - 63,4 ± 5,2, postoperative - 49,4 ±4,2, remote period - 51,8 ± 3,3.
There were 6 deaths at the hospital period (HM - 5,0%) (group B). At the remote period (average was 8,1± 1,5 yy) 99 pts were followed –up. Data of echo for group B: ESVI - preoperative 81,8 ± 12,2, postoperative (6 -11 dd) - 70,6 ± 13,4 and remote period 61,4 ± 9,2 and diameter of LA (mm) preoperative - 64,5 ± 5,2, postoperative - 62,4 ± 6,7, remote period – 74,1 ± 5,6. Sinus rhythm wasn`t marked in any pts and there were 13 deaths. Unsatisfactive results were marked: progressive heart failure(n=8), thromboembolic events (n=4).
CONCLUSION. Reconstruction of the left part of the heart for CAMVD by preservation of MV and LA`s plasty during MAVR was allowing to improve indixes of LV`s and LA`s morphometry, contractility during early and at the remote period comparing with gro
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Poster Presenter
Volodymyr Popov, National Institute of cardio-vascular surgery named after Amosov
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Kiev, Kiev
Ukraine
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
INTRODUCTION
We report a case of severe bioprosthetic carcinoid tricuspid valve regurgitation(TR), rapid degeneration of a pericardial tricuspid valve prosthesis performed robotically and rereplacement via sternotomy with a mechanical valve. Bioprosthetic tricuspid valve destruction may occur with persistent carcinoid disease. With combined cardiac and hepatic disease, addressing the cardiac component is favored first. Severe TR is an indication for tricuspid valve replacement(TVR).
With combined cardiac and hepatic disease, addressing the cardiac component is favored. The choice of prosthetic TVR remains controversial with some groups favoring mechanical, others biological. Mechanical valve may obviate risk of bioprosthetic valve deterioration if persistent hepatic carcinoid disease is present. Tissue valve options include bioprosthesis or percutaneous choices.
We report a case of rapid degeneration by carcinoid of a pericardial tricuspid valve prosthesis performed robotically and rereplacement with a mechanical valve via sternotomy.
METHODS
A 45-year-old man with primary terminal ileal carcinoid tumor, hepatic metastases, elevated chromogranin levels, previously treated with chemotherapy presented with dyspnea, a pansystolic murmur, jugular venous distention, hepatomegaly, ascites, and peripheral edema. Original preoperative TEE seen by the cardiothoracic surgery attending of the initial native stenotic and regurgitant tricuspid valve secondary to carcinoid disease showed massive TR with leaflet sclerosis and tethered, retracted chords (Figure 1). The patient did not desire a mechanical prosthesis initially with concern for possible hepatic reintervention.
RESULTS
He initially underwent a right thoracic robot-assisted #29 Magna Ease bovine pericardial TVR. Nine months later he developed severe tricuspid bioprosthesis insufficiency.
At median sternotomy reoperation, fibrotic tissues surrounded the tricuspid annulus.
The thickened, immobile and retracted pericardial bioprosthesis was difficult to extirpate and was replaced via median sternotomy with a 27-mm St. Jude mechanical prosthesis.He is well postoperatively.
CONCLUSION
We illustrate a case of bovine pericardial bioprosthesis destruction with carcinoid.
Options for subsequent bioprosthesis degeneration from persistent carcinoid have not been thoroughly
Historically, the morbidity and mortality of TVR have been higher in carcinoid.
Percutaneous options should be considered.
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Poster Presenter
Barbara Robinson, Mayo
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Lake Barrington, IL
United States
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
Objective: The degree of both mitral and tricuspid valve regurgitation correlates with mortality, based on a vicious cycle of increasing regurgitation and decreasing ventricular function. Restoration of valve competence should therefore break this vicious cycle and improve life expectancy. However, complete restoration of valve competence is still considered potentially detrimental by some for its elimination of a "pop-off" mechanism into the low-pressure atrium presumably avoiding pump failure. We reasoned that such a mechanism should offset the preoperative relationship between mortality and valve regurgitation after an invasive procedure.
Methods: We performed a comprehensive literature search to identify contemporary studies reporting long-term outcomes between populations, who were categorized by different degrees of mitral/tricuspid valve regurgitation (none-mild/moderate/severe). MEDLINE delivered 11,601 studies, 110 studies showed direct comparison between the degree of valve regurgitation and survival rates. These studies were included in the distribution plots.
Results: The figure shows that without any invasive procedure increasing degrees of mitral and tricuspid valve regurgitation are associated with worse long-term mortality. Data for structural mitral valve regurgitation without intervention are too sparse to display but individual studies find the same relationship. After invasive procedures (surgery or intervention), the relationship remained the same. It was present in both mitral and tricuspid regurgitation, independent of the regurgitation mechanism and unaffected by differences in invasive procedures performed to treat regurgitation.
Conclusions: The same relationship between the degree of regurgitation and mortality before and after an invasive valve procedure argues against the existence of a pop-off mechanism. In contrast, the results suggest that complete and durable elimination of valve regurgitation interrupts the described vicious cycle and is associated with the longest life expectancy.
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Poster Presenter
Tulio Caldonazo, Department of Cardiothoracic Surgery, Friedrich-Schiller-University Jena, Germany
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Jena, Thuringia
Germany
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
Repairing complex rheumatic mitral valve: Current advances
Taweesak Chotivatanapong, MD , Piyawat Lerdsomboon,MD
Central Chest Institute of Thailand, Nonthaburi,
*Vejthani Hospital, Bangkok,
THAILAND.
Abstract:
Rheumatic heart disease remains a big challenge for many part of the world globally. Although valve repair for rheumatic mitral valve has been successfully done with encouraging results. However, in late stage of rheumatic disease , mitral valve often is severely affected and badly changed. A truly challenging situation for repair.
Current approach for repairing this group of valve is aimed for virtual repair of the valve. Valve analysis is the crucial step for planning and choice of surgical techniques. The goals are to restore normal systolic and diastolic dynamics. Type I mobility of valve leaflets is a MUST. Both quantity and quality of valve tissues especially anterior leaflet is of paramount concern. Pliability of mitral valve leaflets and subvalvular structure are very important for normal mitral dynamics. Leaflet peeling is an integral part of rheumatic valve repair in current era. Fenestration along with papillotomy are effective to improve collateral flow as well as pliability of subvalvular structure. Chordal repair usually can be done successfully by either chordal transfer or neochordal implantation. Tissue repair can be accomplished by autologous or bovine pericardium or synthetic material depends on surgeon preference. Calcified mitral valve poses a real challenge for valve repair. Current understanding and improvement of techniques allows surgeon to successfully tacked this problem. Choice of valve ring is last but not least step for good outcome.
Conclusion: With better understanding of mitral complex and dynamics plus improvement of surgical techniques, complex rheumatic mitral valve repair can be fixed more with encouraging results.
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Poster Presenter
*Taweesak Chotivatanapong, Chest Disease Institute
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Meung, Nonthaburi
Thailand
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
Objective: To compare the long-term outcomes of two main techniques used in mitral valve repair (MVr) for mitral regurgitation (MR): (a) chordal replacement ("respect approach"), whereby artificial neochordae are used to resuspend prolapsed segments of the affected leaflet and (b) leaflet resection ("resect approach"), whereby diseased leaflet segment is resected, and the remaining segments are sutured together.
Methods: PubMed/MEDLINE, EMBASE and Google Scholar were searched for studies comparing the two techniques and which reported rates of all-cause mortality/survival and/or MR recurrence and/or reoperation accompanied by at least one Kaplan-Meier curve for any of these outcomes. We adopted a 2-stage approach to reconstruct individual patient data based on the published Kaplan-Meier graphs
Results: Fourteen studies with Kaplan-Meier curves met our eligibility criteria. In comparison with patients who underwent MVr with the resect approach, patients who underwent MVr with the respect approach presented better 10-year survival (HR:0.73, 95%CI 0.56-0.96, P=0.024) and no statistically significant difference in the rates of MR recurrence (HR:1.39, 95%CI 0.92-2.08, P=0.116) and reoperation (HR:0.92, 95%CI 0.62-1.35, P=0.663) at 10 years. When considering only the propensity-score matched studies, we observed no statistically significant differences in terms of 10-year survival (HR:1.0, 95%CI 0.55-1.82, P=0.991) and MR recurrence (HR:1.62, 95%CI 0.76-3.47, P=0.211) over time.
Conclusions: The respect approach seems to outperform the resect approach in terms of overall survival, but this result is not consistent in populations with similar baseline characteristics. Despite any possible advantages of one technique over the other, which approach is best for each patient must be decided on a case-by-case basis and more studies with long-term follow-up data are warranted.
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Poster Presenter
Tulio Caldonazo, Department of Cardiothoracic Surgery, Friedrich-Schiller-University Jena, Germany
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Jena, Thuringia
Germany
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
[Objective] With the increasing popularity of minimally invasive cardiac surgery (MICS), its indications are expanding to include not only isolated mitral valve repair but all types of mitral valve disease cases. MICS approach for patients with a history of open heart surgery is routinely used at our institution. Herein, we present a case of perivalvular leakage that developed after aortic root replacement and mitral valve replacement (MVR) performed for a patient with a history of three open heart surgery procedures.
[Case video presentation] A 76-year-old man who underwent MVR and root replacement (Freestyle valve) for infective endocarditis 20 years prior, re-MVR (mechanical valve) for a prosthetic valve infection 19 years prior, and redo Bentall surgery (mechanical valve) due to aortic root prosthesis infection 17 years prior came to our department complaining of worsening anemia and dyspnea on effort. Transesophageal echocardiography revealed severe perivalvular regurgitation on the lateral side of the mitral mechanical valve. Because of a high LDH level ( 1072 IU/L), anemia (Hb: 7.2 g/dl), and worsening dyspnea, redo surgery was considered. Based on a history of multiple midline incisions and requirement of a surgical procedure for the aortic root to reach the mitral valve with a redo sternotomy approach, a right 4th intercostal MICS approach with use of a thoracoscope was chosen. A cardiopulmonary bypass was established via the right femoral artery and vein, and the adhesion in the thoracic cavity was dissected. Although the left atrial incision line was easy to approach, it was considered that dissection around the aortic root prosthesis would be too severe for aortic cross-clamping, thus we decided to perform an on-pump beating approach without cardiac arrest. The left atrium was opened under rapid pacing and a suction tube inserted into the left ventricle. After confirming a large regurgitation site around the valve on the lateral side, the perivalvular leakage site was directly sutured with 2-0 ethibond sutures with felt used in the area with strong tissue and a bovine pericardium patch in the fragile area of the annulus. No obvious perivalvular leakage was observed.
[Conclusion] MICS approach for mitral valve surgery in a patient with a history of open heart surgery can minimize adhesion dissection and secure the operative site after aortic root replacement, and is considered to be a useful option for redo mitral valve surgery case
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Poster Presenter
Hiroyuki Nishi
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Japan
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
Background
Redo MV surgery represents one of the most challenging and high-risk procedure in cardiac surgery. The presence of dense adhesions, and the high probability of grafts, heart, and great vessels injuries make these operations demanding through a median sternotomy. Conversely, the right mini-thoracotomy (MT) approach is able to offer the surgeon the possibility to minimize the surgical trauma, to avoid re-sternotomy-related injuries, to reduce the need for extensive and time-consuming dissection of adhesions, and to improve the MV exposure.
Aim of this study is to compare the MT with the re-sternotomy approach in terms of short and long-term results in patients undergoing redo MV surgery.
Methods. Data of patients undergoing redo MV surgery from 2006 to 2021 were prospectively collected and retrospectively analyzed. Inclusion criteria were prior operations through median sternotomy, and required MV surgery; associated procedures such as tricuspid surgery and atrial fibrillation ablation were considered suitable for enrollment. To reduce possible differences between groups, a propensity score analysis was performed using greedy nearest neighbor matching without replacement. Kaplan-Meier curves were used to estimate freedom from death and re-operation, and compared using the Log-rank test.
Results. 488 patients were enrolled: 337 underwent surgery via MT and 151 via re-sternotomy. The estimated propensity score analysis based on 16 clinically relevant demographics variable resulted in 138 well-matched patient pairs. No differences were recorded in terms of 30-day mortality, stroke, re-exploration for bleeding and freedom from reoperation at follow-up. Mechanical ventilation time (11.4 vs 14 hours, p=.04), and ICU length-of-stay (1 vs 2 days, p=.02) were shorter in the MT group; pneumonia (14 vs 33%, p=.002), minor neurological events (1 vs 10%, p=.006), and long-term mortality (Figure) were lower in the MT group.
Conclusion. This analysis clearly shows better early and long-term outcome of the MT approach in redo MV surgery patients when compared with the sternotomy approach. A rigorous preoperative screening and experience on different minimally invasive setting of arterial perfusion and aortic clamping is mandatory to reach safe results.
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Poster Presenter
Cristina Barbero, AO Citta' della Salute e della Scienza di Torino
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Torino, Turin
Italy
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
Objective
Robotic cardiac surgery is becoming widespread. According to the report, the number of facilities that perform complex procedures is increasing. It is necessary to examine whether appropriate procedures can be performed with robots for complex lesions.
Case Video Summary
The patient was a woman in her 60s with severe mitral regurgitation with heart failure symptoms. Trans-esophageal echocardiography showed redundant and calcified P2 prolapse of mitral valve. As surgery, valve slicing increased valve mobility, and height reduction was used to treat prolapse and prevent SAM. The treatment was effectively completed.
Conclusion
Even relatively complex mitral valve lesions can be treated with robotic surgery. We would like to expand the indication for robotic surgery further in the future.
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Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
Objective: To demonstrate a robotic assisted redo mitral valve replacement is feasible in a patient with an undersized prosthesis installed via sternotomy due to inadequate debridement of mitral annular calcification (MAC).
Case Video Summary: Patient is a 59-year-old male with HTN, LVH, ESRD on HD, BMI 38 that presented with progressive SOB and fatigue. Workup revealed CAD and severe mitral stenosis with MAC. The patient initially underwent a CABG x2 and MVR with a 21mm mechanical valve via median sternotomy. The initial surgery was complicated by inadequate debridement of MAC, resulting in an undersized valve. The patient also required postoperative LAD stenting one week post operation. Redo MVR was indicated for pulmonary edema and ventilator dependance due to elevated mean MV gradient >10mmHg.
The robotic procedure was performed with general anesthesia, dual lumen ETT intubation, peripheral femoral cardiopulmonary bypass, a 5cm anterolateral 4th intercostal thoracotomy and cardiac arrest. Three robotic instruments were inserted in a triangular fashion. The left atrium was entered via Sondergaard's groove and an atrial retractor was inserted. The prosthesis was explanted, and the remaining MAC was thoroughly debrided. We reconstructed the mitral annulus using bovine pericardium strips circumferentially. A larger 27mm mechanical valve was implanted with good leaflet movement. The patient was weaned off cardiopulmonary bypass without difficulty. TEE showed good prosthesis function without perivalvular leak and mean MV gradient of 3mmHg.
A 30-degree robotic camera with enhanced 3D imaging provided deep ventricular view of mitral annular calcium deposits and visualization of the mitral annulus junction with the myocardium. This allowed more thorough debridement while maintaining mitral annular integrity. With seven degrees of freedom, the fine instruments allowed accurate suture placement into the mitral annulus particularly at the aorto-mitral junction; a common location for perivalvular leakage. Intra-atrial perpendicular view of the prosthetic sewing cuff ensured optimal prosthesis position and securement. Finally, limited incision via robotic access allowed prompt surgery despite recent anticoagulation and anti-platelet therapy.
Conclusions: With optimal visualization, robotic-assisted MVR was superior to a redo sternotomy approach in this obese patient with a deep chest cavity, hypertrophied heart and poor exposure of the mitral valve.
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Poster Presenter
Alin Cheran
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Houston, TX
United States
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
Objective: Variants of Shone's Complex are often unrecognized when presenting in adults, and many cardiac surgeons are unfamiliar with the complexities of surgical correction. Repair of a parachute MV with dysplastic tissue and severe stenosis is challenging and often not feasible, resulting in the need for a more complex double valve replacement with a Konno-Rastan aortoventriculoplasty. The purpose of this report was to increase surgeon awareness of this condition and to demonstrate the feasibility of complex MVr in these patients. A 38 year old woman presented with a parachute MV, with dysplastic and restrictive tissue, and severe tunnel-like mitral stenosis (PG = 27mmHg), a severely stenotic unicuspid aortic valve and a small aortic annulus (18 mm). This video demonstrates the operative techniques used for complex MVr, AVR and posterior aortic root enlargement in this patient.
Case Video Summary: The video shows a dysplastic and restrictive parachute MV with two papillary muscles (PM), restricted leaflet movement and funnel-like stenosis. The PMs are noted to be fused directly to the anterior and posterior MV leaflet edges, and to the left ventricular wall. The posterior leaflet has dysplastic tissue along the free edge with fan-like fusion to the subvalvular apparatus. An initial attempt at splitting the PMs to the ventricular apex and cutting restrictive attachments did not produce adequate leaflet mobility. Therefore, the anterior PM and posterior branch of the posterior PM were transected, and the dysplastic tissue along the free edge of the leaflet was cut, followed by placement of PTFE neochordae for bi-leaflet repair. The unicuspid aortic valve was excised and the aortic annulus enlarged, extending the transannular patch onto the anterior MV leaflet, allowing AVR with a #21 mechanical valve.
Conclusions: Repair of adults with variants of Shone's Complex is complicated, and the pathology may be underappreciate by many adult cardiac surgeons. This video demonstrates a unique approach for complex repair of a parachute MV with dysplastic subvalvular tissue, combined with AVR-aortic root enlargement. This is one of the first reports of repair of a dysplastic parachute MV with restrictive papillary muscle-leaflet fusion in an adult with Shone's complex by PM division and neochordae repair. This approach was an effective option and should be considered for parachute MVs when splitting the fused papillary muscle alone is not adequate.
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Poster Presenter
Katherine Phillips
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New York, NY
United States
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
OBJECTIVE: Ischaemic Mitral Regurgitation (IMR) is a significant source of morbidity and mortality. its optimal treatment has eluded clinicians for decades. The customised ischaemic Mitral Ring (IMR) annuloplasty has emerged as a promising innovative intervention to improve outcomes. we report the early outcomes of our experience with this intervention.
METHODS: Retrospective data analysis of consecutive patients with at least moderate ischaemic mitral regurgitation (vena contracta width 3 to less than 7mm) treated with the IMR annuloplasty in a single centre over a 3year period. All patients had complete concomitant surgical myocardial revascularisation and implantation of customised IMR annuloplasty ring. Outcome measured were survival, freedom from >moderate mitral regurgitation at 1 year and reverse ventricular remodelling using Left ventricular Ejection Fraction (LVEF) and left ventricular internal diastolic Dimension (LVIDD) as surrogate marker. data presented as median interquartile range.
RESULTS: 13 patients were included, Age 74(65-83) years, preoperative LVEF 40(20-55) %, Preop LVIDD 55(45-66) mm, post operative LVEF at 1yr 50(30-60)%, post operative LVIDD at 1yr 45(44-61) mm, Freedom from at least moderate MR at 1 year 12/13(92%), Mortality 2/13(15%), mortality was associated with poor ventricle LVEF < 25% and advance age >75 years
CONCLUSIONS: Use of the customised IMR ring annuloplasty and complete revascularisation is associated with reverse ventricular remodelling and freedom from mitral regurgitation at 1 year. this strategy in suitable patients would lead to improve outcomes. Severely impaired left ventricle with preoperative LVEF < 25% and age >75 years are associated with adverse outcome
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Poster Presenter
Philemon Gukop, St George's university Hospital NHS Foundtion Trust London
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London, OH
United Kingdom
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
Objective: Learning robotic cardiac surgery is difficult, and the optimal pathways to do so are not well-defined. The objectives of this study were to (1) describe a process for quickly and successfully learning robotic mitral valve surgery and (2) share critical learning points acquired during the first series of operations, to ultimately help other surgeons who are interested in learning robotic mitral valve surgery.
Methods: The required Intuitive training courses were completed, and two cases performed by the mentor were observed. The mentor was present for 8 of the first 10 cases performed by the primary surgeon; thereafter, mentorship continued virtually on an as-needed basis (Table 1). STS data on all robotic mitral valve surgeries performed by a single surgeon between 10/2020-12/2022 was retrospectively reviewed.
Results: Of 46 robotic cardiac operations performed during the study period, 20 were mitral valve repairs and 4 were planned mitral valve replacements. There were no operative or late mortalities, strokes, renal failures, reoperations for bleeding, or prolonged ventilations. One patient required conversion to sternotomy and also cauterization of a liver injury. Median length of hospital stay was 4 days. There was one readmission. For the 20 mitral repair patients, 13 had no MR at and 7 had trace MR during follow-up.
Conclusions: In this single-center descriptive report, with close mentorship from an experienced robotic surgeon, learning to perform robotic mitral valve surgery independently with excellent outcomes can be accomplished in a much shorter timeframe than traditionally considered.
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Poster Presenter
Asad Shah
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United States
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
Mitral repair is considered the gold standard for mitral regurgitation and is recommended by the main guidelines in the management of diseases of the mitral valve apparatus, even in asymptomatic patients.
The aim of this study is to evaluate the risk-benefit ratio of mitral valve repair in patients with severe mitral regurgitation without symptoms or with mild symptoms.
Methods: From June 2010 to January 2021, 266 patients underwent surgery to correct isolated primary mitral regurgitation. Out of the total, 51 patients were in New York Heart Association class I, grade 3-4 isolated mitral regurgitation and comprised our study population.
Results: The mean age was 56.53± 14.44 years. The main causes of mitral insufficiency were degenerative in 48 (94.12%), Barlow in 2 patients (3.92%) and a rheumatic disease (1.96%). Leaflet prolapse was the mechanism responsible for regurgitation in 93% of cases (47/51) and of these, 23 (48%) patients had some chordal rupture. Mitral valve repair was performed in 50 patients and one patient required valve replacement due to repair failure. Mean follow-up was 58.45 ± 36.18 months. There were no deaths in this series of patients. One patient was reoperated 90 months after the first surgery (new repare). We have not presented mortality so far. One patient required permanent pacemaker implantation. The left atrial diameter decreases from 47.2+-5.08mm to 43.46+-6.6mm (p<0.001). The left ventricular end-systolic and end-diastolic diameters decreased from 40.0 ± 6.8 mm and 64.8 ± 7.0 mm to 34.6 ± 6.7 mm (p <0.001) and 52.7 ± 7, 4 mm (p<0.001).
Conclusion: Mitral valve repair for severe mitral regurgitation in patients with mild or no symptoms was performed with low mortality and morbidity, good valve function and preserved left ventricular performance. Early repair may be advocated based on the severity of regurgitation and on the possibility of the valve repair, regardless of symptoms.
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Poster Presenter
Mauro Henrique Batista Camacho, Hcor-SP
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São Paulo, NA
Brazil
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
Surgical Techniques for Four Valve Endocarditis Involving the Aorto-Mitral Fibrous Body:Hemi-Commando Procedure and Pulmonary Valve Homograft
Objective
The endocarditis of 4 valves which involve the aorto-mitral fibrous body, is a condition that expresses severity of disease and for which surgical treatment implies a challenge and poor overall survival.(1) We report the first case successfully treated surgically by developing an hemmicomando procedure and pulmonary valve homograft.
Methods
A 32-year-old female with who was transferred. Currently being treated for infective endocarditis with Vancomycin and Gentamycin. Transthoracic echocardiography showed multiple large AV vegetations (5-25 mm), and mild AS. Blood cultures revealed Streptococcus Species. We performed open heart surgery (Figure 1), Aortic Valve Replacement # 26 Aortic Valve Homograft Hemi-Commando Procedure due to aortic valve endocarditis and aortic root abscess with invasion of the anterior leaflet of the mitral valve, Mitral Valve Repair #30 Annuloplasty Genesee Band, Membranous VSD Repair with Autologous Pericardial Patch, Pulmonary Valve Replacement with #26 Pulmonary Valve Homograft, Tricuspid Valve Repair #28 Annuloplasty MC3 Ring.
Results
As a result of the acute infection, the patient was in her immediate postoperative period with acute respiratory failure hypoxia requiring mechanical ventilation, acute renal failure with electrolyte imbalance. Helicobacter .pylori infection with melena episodes and congestive hepatopathy. Acute on chronic anemia, thrombocytopenia likely secondary to endocarditis and Septic shock. On day 20, a Tracheostomy was performed due to acute post-operative respiratory insufficiency. Postoperatively echocardiogram revealed LVEF 52+-5%, right ventricular systolic function is midly decreased, trace mitral valve regurgitation (Mean gradient 4mmHg), tricuspid valve annuloplasty ring (Mean gradient 2mmHg), homograft aortic valve (trace -+1, peak gradient 5mmHg, mean gradient 3mmHg), pulmonary homograft (peak gradient 16mmHg).
One month after the surgery, the patient is hemodynamically stable with a good recovery with intensive care unit stay, on rehabilitation and without signs of endocarditis or valve insufficiency and still on antibiotics Ertapenem for ESBL Klebsiella pneumoniae and Ceftriaxone for Strep mitis bacteriemia.
Conclusions
Physicians should be aware of this diagnosis which portends an exceedingly complex surgical technique.
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Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
OBJECTIVE . To analyzed main problem in surgery of mitral stenoses (MS) complicated by left atrium`s massive thromboses (LAMT) (thromboses more than 1/3 of left atrium`s volume not including volume of LA`s auriculum).
MATERIALS AND METHODS. 356 adult patients (pts) with MS complicated by LAMT were consequtive operated from 01.01.1984 till 01.01.2022 yy in Institute. Predominant genesis of MS was rheumatism and all pts and all of them were in IV NYHA class. There were male 157 (44,7%) and females 189 (55,3%).The average age was 59,2±5,2 yy. Preoperative thromboembolic episodes were in 59 (17,1%) pts. Calcification of MV was in 197 (57,6%) pts. Previous closed mitral commissurotomy was occurred in 137(5,0%) pts. The following procedures were performed: MVR (n = 314) including plastic procedure on TV by De Vega (n = 75); open mitral commissurotomy (OMC) (n =42) including plastic procedure on TV (n = 7). Only mechanical valves were used. All operations were performed with CPB, moderate hypothermia, ante-retrograde crystalloid cardioplegia (Custadiol). All pts was devided on 2 groups; group A (n =182) maternal thrombotic basement was removal together with all thrombotic masses out of LA, group B (n =174) maternal thrombotic basement in LA wasn`t removal but only thrombotic masses.
RESULTS. The hospital mortality (HM) at the period (01.01.1994-01.01.2022 yy) was 4,1% (n =9/230) for MVR and 0% (n = 0/29) for OMC (p<0,05). The reasons of deaths were in group A - HM – (n = 4/141 ) heart failure (n=2), MOF (n = 1), bleeding (n=1). The reasons of deaths were in group B - HM – (n = 5/89 ) brain damage (thrombemboli) (n=4), MOF (n = 1).
Traumatic rupture of LA`s wall during radical removing of maternal thrombotic basement as specific complication was marked in 2,7% (n=5/182)( group A) and 0% (n=0/174) (group B) (p<0,05).
At all period of experience thromboembolic events were marked: group A – 1,6% (n = 3/172) (lethal = 0), remote period - 3,6% (n = 5/140) (lethal -1,4%), group B – 5,8% (n = 10/174) (lethal- 3,4% ), remote period - 13,3% (n = 19/142) (lethal - 9,2%) (p < 0,05). At all period of experience thromboembolic events were marked: MVR in 4,1 % (n= 12/304), (lethal -1,0%), remote period - 8,9% (n = 22/245) (lethal -5,7%) and during OMC 2,4% (n= 1/42), (lethal -0), remote period - 5,4% (n = 2/37) (lethal -2,7%) (p < 0,05). 292 pts was followed-up at the remote period (average 16,2 ± 7,1 yy).
CONCLUSION. Thromboembolic events at post
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Poster Presenter
Volodymyr Popov, National Institute of cardio-vascular surgery named after Amosov
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Kiev, Kiev
Ukraine
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
Objective: Given the increasing number of elderly patients with primary MR who are candidates for mitral valve surgery, we sought to compare the short- and long-term outcomes of mitral valve repair (MVr) versus mitral valve replacement (MVR) for primary, especially Carpentier type II, MR in elderly patients.
Methods: All patients, age 70 years or greater, with Carpentier type II MR who underwent MVr or MVR between 2012 and 2021 at our institution were retrospectively identified. Short- and long-term outcomes were compared before and after propensity score (PS) matching.
Results: A total of 142 patients were included in the study. The median follow-up was 3.4 years. A total of 115 patients (81.0%) underwent MVr and 27 patients (19.0%) underwent MVR. Apart from age (MVr 76.8±4.3 years vs 78.9±4.3 years MVR, P=.03), preoperative NYHA classification III or IV (MVr 30 (26.1%) vs MVR 14 (51.9%), P=.01), preoperative atrial fibrillation (MVr 55 (47.8%) vs MVR 20 (74.1%), P=.01) and mitral valve complexity score (MVr 2.0±1.3 vs MVR 4.8±2.4, P<.01), there was no significant difference in terms of any other preoperative characteristics between the 2 groups. Postoperatively, patients in the MVR group had significantly longer intubation time (MVr 14 hours vs MVR 20 hours, P<.01) and hospital stay (MVr 16 days vs MVR 25 days, P<.01). The 30-day mortality was significantly higher for the MVR group (MVr 0.0% vs MVR 7.4%, P=.03). Overall survival and freedom from reoperation at 1 and 5 years showed no significant difference between the 2 groups (Survival: MVr vs MVR: 97.2% vs 92.6% at 1 year, 85.9% vs 64.1% at 5 years, P=.08; Freedom from reoperation: MVr vs MVR: 94.4% vs 100.0% at 1 year, 92.8% vs 90.9% at 5 years, P=.65). After PS matching, the 30-day mortality was not significantly higher for the MVR group (MVr 0.0% vs MVR 3.9%, P=1.00). Overall survival and freedom from reoperation at 1 and 5 years still showed no significant difference between the 2 groups (Survival: MVr vs MVR: 96.2% vs 96.2% at 1 year, 76.4% vs 66.6% at 5 years, P=.85; Freedom from reoperation: MVr vs MVR: 91.6% vs 100.0% at 1 year, 91.6% vs 90.9% at 5 years, P=.54).
Conclusions: Regarding mitral valve surgery for primary MR in the elderly, postoperative short- and long-term outcomes were similar between the 2 groups. For elderly patients with primary MR, the comparable prognosis as after MVr would be obtained if MVR is performed in selected cases.
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Poster Presenter
Tsubasa Mikami
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Japan
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
Objective:
Mitral Valve Repairs and our technique of commissural reconstruction in rheumatic mitral stenosis. Restoring the commissural component of mitral apparatus to its normal function helps in abolishing type two pathology and attaining type one with excellent diastolic opening.
Method:
In our centre in Central India, we witness number of patients with rheumatic heart disease (RHD). Rheumatic valve repairs are always a challenge here, as patients often present late. Also, majority of patients are young females who aspire to complete their family. I started the repair program in 2021 when I was inspired after my AATS- WTS (Women in Thoracic Surgery) international travelling fellowship from the United States in 2017. Rheumatic repairs comprised 52% of all our repairs with a majority, 61.5% being females. Age groups between 20-40 years and 40-60 years were 26.9% and 57.69% respectively. Commissural fusion is an obligatory finding in severe mitral stenosis. So addressing this subset also becomes inevitable to attain better valve dynamics post repair. Besides the standard steps, my technique of commissural reconstruction involved bilateral extended commissurotomy, commissural augmentation with a kite shaped pericardium pretreated with 0.6% glutaraldehyde, creating commissural neo chords and a small patch commissurotomy. The newly constructed commissure supports the leaflets and mitigates the stress in mitral complex. The annulus is always supported with a ring especially CG Future ring in mitral stenosis. This reduced the gradients significantly with trivial or no leak post operatively.
Results:
Commissural reconstruction with our technique resulted in excellent mitral valve area with minimal gradients and trivial or no leak on immediate post operative echocardiography.
Conclusion:
RHD contributes to significant number of acquired heart diseases in India. There is a lack of compliance with anticoagulation therapy. Also, young females who wish to plan family are commonly seen with RHD. We introduced mitral valve repair program in central India. We also focused on the commissural component of the mitral apparatus to achieve a normal leaflet motion which can assist in excellent diastolic opening and seamless systolic closure. A good repair with rheumatic prophylaxis in younger age groups is being considered to achieve good long term result. Our immediate results in rheumatic repairs have been encouraging as yet.
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Poster Presenter
Shipra Shrivastava, Medanta Superspeciality Hospital
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Indore
India
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
Objective: We sould like to present our initial experiences with Tendyne system for mitral valve replacement as alternative for some patients who are not suitable candidate for standard surgery.
Metods: Between 9/21 and 1/22 we implanted in 7 patients with sever native mitral insufficiency Tendyne system. System was implanted via left aneteroalateral minithoracotomy in touch of optimal position for implantation. Av age 76,7 (70-85) year. 2 had previous CABG. Risk of periprocedural mortality (STS risk score) for standard mitral valve replacement was 9,8%. All patients had dominant pathology Carpentier I aetiology. All patients were evaluated by specialist from Abbott to confirm technical conditions and probablity of success.
Results: In all patients we system implanted succesfuly and without complications. No conversion or reoperning for bleeding. No wound infection, ICU stay av.2,4 (1-7 days), all stay av.12 (8-20 days). In all patients was mitral insufficiency changed from heavy lto zero. The same result (still zero) we see in early postprocerula follow.. MG on the prostehsis is low, 3,07 torr at discharge.
Conclusions: Tendyne system seems to be very effective catheter based metod of treatment of native mitral insufficiency. Seems to be an alternative in high risk patients. We need more patients and longer follow up for stronger conclusions.
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Poster Presenter
Ales Mokracek, Nemocnice Ceske Budejovice
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Ceske Budejovice, MD
Czech Republic
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
Objectives:
Tricuspid valve surgery is an area of growing interest. Whether operative outcomes differ with the heart arrested or beating during the procedure remains unanswered. We hypothesize that the performance of tricuspid surgery with the heart beating is associated with shorter bypass time, operating room (OR) time and lower mortality.
Methods:
Patients undergoing tricuspid valve surgery at a single center between 2016 and 2021 were included. Patients were stratified by whether the tricuspid portion of the operation was performed with the heart in diastolic arrest. Chi-squared and Wilcoxon Two-Sample tests were performed on continuous and categorical variables, respectively, to determine the effect arrest had on complication rates.
Results:
A total of 255 patients underwent a tricuspid valve surgery during this period, 100 were isolated tricuspid procedures, 155 were performed concomitantly. A total of 199 (78.0%) patients had the heart arrested during the tricuspid portion of the operation. Beating heart tricuspid procedures were not significantly associated with urgency, age, gender, previous valve surgery or STS predicted risk of morbidity or mortality. A higher percentage of beating heart procedures were on patients with ESRD (p=0.003) and beating heart procedure patients had higher MELD scores (p=0.01). Amongst all-comers there was no difference in bypass time (p=0.40), total OR time (p=0.33), operative mortality (p=0.62) or reoperation (p=0.97). Arrested heart tricuspid procedures had a shorter length of stay (14.6 vs. 16.8 days, p=0.03). Amongst concomitant tricuspid procedures, diastolic arrest procedures had decreased bypass time (195 vs. 261 minutes, p<0.01) and OR time (445 vs. 551 minutes, p<0.01). In isolated tricuspid procedures diastolic arrest resulted in shorter ICU length of stay (219 vs. 246 hours, p=0.046).
Conclusions:
Among all-comers, performing tricuspid valve surgery on an arrested heart resulted in a shorter length of stay and no significant differences in bypass time, total OR time, or operative mortality. Patients undergoing isolated beating heart tricuspid procedures had longer ICU length of stay, patients undergoing concomitant beating heart tricuspid surgery had longer bypass time and OR time. These results indicate that the decision to perform tricuspid valve surgery on a beating heart may lengthen operative time and length of stay, however prospective studies are needed to further examine these effects.
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Poster Presenter
Steven Young
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Troy, VA
United States
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
Objective: Robotic technology has improved over the past two decades and robotic surgery has been shown to be largely equivalent and even superior to conventional surgical approaches in many surgical specialties. The adaptation of robotic cardiac surgery has been particularly slow due to mixed outcomes. The purpose of this study was to compare the clinical outcomes of patients who had robotic (Rob) MVR using the most advanced robotic technology (4th generation) with those who had conventional MVR at our institution.
Methods: Average Society of Thoracic Surgeons (STS) risk scores were used to compare the patient groups preoperatively (unpaired samples t-test). STS performance metrics and blood transfusion data were used to compare clinical outcomes (two-sided Fisher's exact test). STS metrics included operative mortality, permanent stroke, reoperation, prolonged ventilation, renal failure, deep sternal wound (DSW) infection, short length of stay (LOS), and composite morbidity and mortality. These metrics were calculated as event rate percentage. Transfusion rates were calculated as average units of red blood cells (RBCs) given per case that required transfusion.
Results: A total of 327 patients underwent MVR from January 2019 to July 2022 (Rob n=154 vs conventional n=173). The two cohorts were comparable in baseline characteristics and risk factors based on STS risk: Rob 2.58±3.56% vs conventional 2.54±4.35%, p=0.88. Patients were further divided into repair (Rob n=92 vs conventional n=58) and replacement (Rob n=62 vs conventional n=115). STS performance metrics for Rob vs conventional repair and replacement are shown in Table 1: the Rob repair group performed significantly better with regard to reoperation, prolonged ventilation, short LOS, composite morbidity and mortality (p<0.05) and the Rob replacement group performed significantly better with regard to short LOS (p<0.05).
Blood transfusion rates were as follows: Rob vs conventional repair 1.8 vs 3.6 and Rob vs conventional replacement 2.9 vs 5.3 units of RBCs per transfused case.
Conclusions: Compared to conventional methods, Rob repair demonstrated significant reductions in reoperation, ventilation time, and composite morbidity and mortality. Also, all robotic cases demonstrated a significant reduction in hospital LOS and the amount of blood required for transfusion by approximately 50%. The value of modern robotic technology in cardiac surgery should be reexamined.
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Poster Presenter
Katherine Nordick
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Houston, TX
United States
Objectives: The Charlson Comorbidity Index (CCI) is widely utilized for risk stratification for non-cardiac surgical patients. CCI scores have not been broadly validated in cardiac surgery patients. We have previously shown that addition of a mitral procedure to aortic procedures does not increase operative mortality in experienced hands. However, predictors of early and late outcomes associated with concomitant mitral valve intervention with aortic aneurysm surgery are lacking. We aim to assess CCI as a predictor of early and late outcomes in this cohort.
Methods: Patients undergoing concomitant mitral valve intervention and aneurysm surgery between 1997 and 2022 were reviewed. Age-adjusted CCI scores were calculated based on clinical status at the time of index operation. Primary endpoint was all cause mortality. Secondary endpoints were a composite of major adverse events (MAE), including operative mortality, dialysis, myocardial infarction and stroke, and incidence of individual major complications. Chi-square test, Logistic and Cox regression analysis, and Kaplan-Meier estimates were used. Maximally selected rank statistics (MSRS) were used to identify the best cutoff of CCI to predict late mortality.
Results: Out of 3853 ascending aneurysm repairs, 186 (4.8%) patients (median age 65 [interquartile range (IQR): 54-76] and 69% males) had concomitant mitral valve intervention. Median CCI was 4 [IQR: 3-6]. MSRS identified a cutoff for CCI of 5, which had the highest significant survival difference. Perioperative MAE was higher in CCI>5 (11.0% vs 2.1%, P=0.017), and postoperative need for tracheostomy and CVA had a trend to be higher in CCI>5 (P=0.055). On multivariable Cox regression analysis, higher CCI (HR= 1.61 [95%CI 1.24;2.10], P=<0.001) was associated with late mortality and recent era (Year 2010 and after (HR= 0.18 [95%CI 0.03;0.95], P=0.0431)) was protective. Logistic regression revealed that higher CCI, as a continuous variable, was associated with higher odds of MAE, postoperative dialysis and need for tracheostomy (Table 1). Five- and ten-year overall survival were 95.9% and 67.1% vs 59.7% and 19.9%, respectively, in CCI≤5 vs CCI>5 (P<0.001).
Conclusions: CCI can be a helpful tool in predicting outcomes of patients undergoing concomitant mitral valve intervention with ascending aortic surgery. A high CCI score is associated with worse operative outcomes and decreased long-term survival.
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Poster Presenter
Mohamed Rahouma, New York Presbyterian Hospital
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New York, NY
United States
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
Objective: To evaluate the causes and outcomes of redo mitral valve (MV) repair.
Methods: All redo MV repair surgeries performed at a single tertiary academic center from 2013-22 were retrospectively analyzed. The final cohort included 14 patients.
Results: The primary MV repair was performed at a different institution in 7 patients (50%). Etiologies at primary operation were degenerative disease in 11 (78.5%), as well as rheumatic disease (1), trauma (1), and infective endocarditis (1) (Table 1). Mean age at primary repair was 55±16 years. Surgery was performed via sternotomy in 8, mini-thoracotomy in 3, and robotic-assisted in 3. Techniques at primary repair included annuloplasty (n=12), neochordoplasty (n=5), cleft closure (n= 4), and leaflet resection (n=4). Mean size of the annuloplasty ring was 34 ± 1.8 mm. No patient showed greater than mild mitral regurgitation (MR) immediately post-CPB.
The median time from primary repair to recurrent symptoms (or >moderate MR) was 2 years (interquartile range [IQR] 0.5-2.6). The median time from primary repair to redo repair was 2.1 years (IQR 0.8-3). Mean age at re-repair was 58.4 ± 14.9 years. Indications for re-repair were failed repair (n=6) and disease progression (n=8). The median time from primary repair to recurrent symptoms within the subset of failed repairs (n=6) was 0.58 years (IQR 0.08-2.09). Re-repair was performed via sternotomy in 10 and robotic-assisted in 4. Mean cardiopulmonary bypass (CPB) time was 131±53 min and cross-clamp time was 91±53 min. Techniques included redo annuloplasty (n=8), neochordoplasty (n=6), leaflet resection (n=3), and cleft closure (n=5). Concomitant procedures included atrial septal defect closure (n=2), patent foramen ovale closure (n=1), tricuspid valve repair (n=1), and pulmonic valve replacement (n=1).
There were no cases of operative mortality. One patient required reexploration for bleeding and two patients experienced prolonged ventilation. No patients experienced stroke, deep sternal wound infection, or new renal failure. No patients have required a second redo cardiac surgery. Follow up echo data, complete in 85.7% postoperatively at 2.4±2.6 years, indicates that no patients have recurrent greater than moderate MR.
Conclusions: The need for redo MV repair typically arises within the first two years after surgery, particularly for failed repairs. Redo MV repair is a viable option for those with failed prior repair and progression of disease.
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Poster Presenter
Alyssa Morrison, Yale
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New Haven, CT
United States
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
Objective: Mitral valve repair (MVR) with annuloplasty is the gold standard treatment for degenerative mitral regurgitation (MR). Three-dimensional saddle-shaped annuloplasty rings have been developed to reproduce the mitral geometry and physiology and increase repair durability. Aim of this study was to report early results after mitral annuloplasty using the MEMO 4D saddle-shaped semirigid ring in totally endoscopic approach.
Methods: All patients undergoing minimally invasive endoscopic MVR using MEMO 4D annuloplasty ring between February 2019 and December 2022 were included. Preoperative characteristics, operative data, in-hospital outcomes and 30-day clinical and echocardiographic follow-up were analyzed. The main outcome was technical success, defined as absence of procedural mortality, successful access, correct positioning of the first intended device and freedom from reintervention related to the device or access procedure. Additional outcomes were in-hospital and 30-day mortality and morbidity and residual mitral regurgitation.
Results: The analysis included 233 patients (mean age 60.4±13.0 years, 145 males, mean EuroScore II 1.79±1.89). The surgical approach was a totally endoscopic technique, through a 3 cm mini right thoracotomy. The type of degenerative MR was Barlow's disease in 51.5% of the cases. MVR was achieved in 100% of cases. Artificial chordae were used in 217 cases (93.1%), 31 on the anterior leaflet, 128 on the posterior leaflet and 57 both. In 16 cases (6.9%) MVR was achieved using only the ring. One or more associated procedure were needed in 82 cases (35.2%). One conversion to full sternotomy was required. In 1 case systolic anterior motion was seen and 5 cases required repeated cross clamp for residual MR, all successfully resolved. In hospital mortality rate was 0.8% (2 cases). No other patients died within the 30-day follow-up. No early failure needing reoperation occurred. Limited number of stroke (0.4%), revisions for bleeding (4.7%), myocardial infarction (0.4%) and low cardiac output (5.2%) occurred during hospitalization. Post-operative echocardiography showed a left ventricular ejection fraction of 56.5±7.1% and mean mitral valve gradient of 3.2±1 mmHg. Mild residual MR was seen in 22 cases (9.4%). No cases of moderate MR were identified.
Conclusions: The MEMO 4D annuloplasty performed in totally endoscopic mitral valve surgery is technically feasible and provides excellent clinical and echocardiographic results.
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Poster Presenter
Giovanni Domenico Cresce, San Bortolo Hospital Vicenza (Itally)
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Vicenza, Italy
Italy
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
Objective: Moderate-to-severe mitral regurgitation (MR) affects approximately 25% of patients with severe aortic stenosis undergoing transcatheter aortic valve replacement (TAVR). Even though MR may improve after TAVR in up to 50% due to left ventricular reverse remodeling, persistent MR is associated with increased morbidity and hospitalization for heart failure. What the best modality is for the treatment of severe MR after TAVR remains debated.
Case Video Summary: We present the case of an acutely decompensated, frail, 86-year-old patient with severe aortic stenosis and moderate-to-severe MR (due to anterolateral commissural prolapse) with multiple comorbidities, who suffered for persistent MR after TAVR. The patient was denied conventional mitral surgery, transcatheter mitral valve replacement, and MitraClip. We offered a totally endoscopic, robotic-assisted approach for mitral valve repair. Port configuration consisted of the working port and camera being placed in the third intercostal space at the left 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 left atrial retractor placed in the fourth intercostal space two centimeters medial to the midclavicular line. Cardiopulmonary bypass was achieved by percutaneous femoral cannulation. Aortic cross-clamp and cardioplegia delivery were provided using the endoaortic balloon occlusion device. After entering the left atrium via the interatrial groove, we exposed the mitral valve while avoiding TAVR valve dislocation via careful manoeuvring of the atrial retractor. The mitral valve had myxomatous degenerative changes, with flailed P1 and anterolateral commissure. We repaired the valve with commissural plication and placement of a 30-mm Physioflex annuloplasty band. Cardiopulmonary bypass and aortic cross-clamp time were 115 minutes and 77 minutes, respectively. Postoperative transesophageal echocardiography revealed trace mitral regurgitation with a mean gradient of 4 mmHg. The patient developed a transient ischemic attack on postoperative day 2, but remained neurologically intact and asymptomatic thereafter.
Conclusions: Using a totally endoscopic, robotic-assisted approach is safe and effective for the treatment of persistent severe MR after TAVR in selected patients.
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Poster Presenter
Andrea Amabile, University of Pittsburgh Medical Center
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PITTSBURGH, PA
United States
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
Objective: This case demonstrates feasibility of a mitral valve replacement in an adult congenital patient with parachute mitral valve using a totally endoscopic robotic-assisted approach.
Case Video Summary: A 33-year-old, 120 kg male presented with severe mitral stenosis and parachute valve. His past medical history was significant for coarctation of the aorta status post repair in infancy. Although he was followed closely with yearly imaging, he recently described decreasing activity levels. Pre-operative transesophageal echo (TEE) demonstrated a parachute mitral valve, with both leaflets attached to the posterior papillary muscle, and severe mitral stenosis with mean gradient 16 mmHg. He was referred for surgery.
The patient was brought into the OR and general anesthesia was induced. Percutaneous access of the femoral vessels was obtained for peripheral cannulation. One camera port, two working robotic arms, and a retractor port were placed into the right intercostal spaces. An endoaortic balloon was placed into the ascending aorta. CPB was initiated. The pericardium was opened. Prompt cardioplegic arrest was accomplished with antegrade cardioplegia. The left atrium was access through the interatrial groove with excellent exposure of the parachute mitral valve. One attempt at mitral valve repair was undertaken with inadequate result. The valve was too deformed to repair. A mechanical mitral valve replacement with 29 mm St. Jude Mechanical Valve was performed. Using pledgeted sutures and Cor-knot device, the sewing ring was secured to the mitral valve annulus. Total bypass time was 203 minutes and cross-clamp time 143 minutes. Post-operative TEE demonstrated a properly functioning valve with no regurgitation and mean gradient 5 mmHg. The patient was extubated in the OR.
Post-operatively, the patient had an unremarkable course. On POD#2 he went into atrial fibrillation with stable hemodynamics. He was treated with ASA, furosemide, and beta-blocker. For anticoagulation, coumadin was started with heparin bridge. He was discharged POD#4 with TTE demonstrating normal biventricular function and properly functioning mechanical valve.
Conclusions: Using a totally endoscopic robotic-assisted approach is feasible and should be considered when treating adult patients with congenital mitral valve disease.
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Poster Presenter
Madonna Lee
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0
United States
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
Objective: The adoption of anterolateral minithoracotomy for mitral valve surgery in elderly patients has proven to be safe and effective. Whether the same benefits persist in octo–nonagenarians undergoing robotic-assisted procedures remains unclear. We aimed to evaluate short-term outcomes of octo–nonagenarians undergoing totally endoscopic, robotic-assisted mitral valve surgery at a quaternary academic institution.
Methods: We performed a retrospective, cohort study including patients who underwent totally endoscopic, robotic-assisted mitral valve surgery between 08/2019 and 08/2022. Demographics, comorbidities, intraoperative, and postoperative data were collected from our Society of Thoracic Surgeons (STS) institutional database.
Results: Twenty-one patients met inclusion criteria. Median age was 82 years (range, 80–91). Demographics and comorbidities are detailed in Table 1. Eighteen patients (85.7%) underwent a variety of robotic-assisted mitral valve repair techniques (7 triangular resections, 1 sliding annuloplasty, 5 clefts closure, 4 commissural plications, 4 anterior neochordoplasty, 4 posterior neochordoplasty, 1 commissural neochordoplasty); all patients underwent concomitant mitral annuloplasty, with a median annuloplasty band size of 30 (28–32) mm. All patients had satisfactory repair. Three patients (14.3%) underwent robotic-assisted mitral valve replacement, with a median prosthesis size of 27 (25–33) mm. Left atrial appendage exclusion was performed in all patients, and tricuspid valve repair in 7 patients (33.3%).
Cardiopulmonary bypass and cross-clamp times were 138±42 and 89±31 minutes, respectively. No intraoperative complications occurred, and 9 patients (42.9%) were extubated in the operating room. Overall, the median STS predicted risk of mortality was 2.7% [1.7%–3.9%], the median predicted risk of morbidity and mortality was 11.2% [9.6–17.0%], the median predicted risk of prolonged ventilation was 6.8% [5.5–11.6%], and the median predicted risk of stroke was 2.3% [1.9–3.0%]. Postoperatively, one patient developed pleural effusion, one patient deep venous thrombosis, and one patient required permanent pacemaker implantation. Neither intraoperative, nor in-hospital, or 30-day deaths occurred.
Conclusion: Results of this study suggest that octogenarians and nonagenarians can safely and effectively undergo totally endoscopic, robotic–assisted mitral valve surgery with satisfactory surgical and short-term outcomes.
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Poster Presenter
Andrea Amabile, University of Pittsburgh Medical Center
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PITTSBURGH, PA
United States
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
Objective: Over the past 20 years, many centers have progressively adopted the use of robotic assistance as part of their mitral valve repair armamentarium. The magnified stereoscopic vision and the enhanced technical dexterity offered by the robotic platform allow for optimal visualization of both the valve and the sub-valvular apparatus. We present the case of a 67-year-old male with severe, symptomatic, bileaflet mitral valve prolapse and history of ventricular tachycardia and prior ablation attempt.
Case Video Summary: Port configuration consisted of the working port and camera being placed in the third intercostal space at the left 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 left atrial retractor placed in the fourth intercostal space two centimeters medial to the midclavicular line. Cardiopulmonary bypass was achieved by percutaneous femoral cannulation. Aortic cross-clamp and cardioplegia delivery were provided using the endoaortic balloon occlusion device. After exposure through the Waterston's groove, the mitral valve was inspected and had myxomatous degenerative changes leading to bileaflet prolapse and severe annular dilatation. We also noted mitral annular disjunction at the base of P1 and P2 scallops. We closed the left atrial appendage and then performed cryo-ablation of the tip of both papillary muscles under magnified direct visualization, with a freezing time of 2 minutes each. We then turned our attention to the mitral valve, which was repaired by a combination of various techniques: we excised the thickened, disjunct basal portion of P1 and P2 with subsequent reattachment to the native annulus, we placed two separate neochords to P2, and we finally completed the repair with a 38-mm annuloplasty band. A small PFO was noted and closed. CPB and AXT were 193 minutes and 148 minutes, respectively. Postoperative transesophageal echocardiography revealed trace mitral regurgitation with a mean gradient of 3 mmHg. The patient had an uneventful postoperative recovery, with no subsequent ventricular arrhythmic events.
Conclusions: Using a totally endoscopic, robotic-assisted approach is safe and effective for the treatment of bileaflet arrhythmic mitral regurgitation.
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Poster Presenter
Andrea Amabile, University of Pittsburgh Medical Center
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PITTSBURGH, PA
United States
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
Objective: It is generally accepted, that the degree of tricuspid valve regurgitation (TR) is related to mortality. The majority of TR is secondary (80%), and surgery consists mainly of annuloplasty repair (TVR). The impact of TVR on mortality is uncertain. Since durability of TVR should be a prerequisite for a lasting treatment effect, we systematically assessed the durability of tricuspid annuloplasty.
Methods: A systematic literature search was performed (MEDLINE, Cochrane Library and Web of Science) assessing long-term results of suture, ring and band TVR annuloplasty techniques. From the qualifying studies, follow-up of respective TVR technique and TR recurrence rate were illustrated in the bubble plot (Figure A). Furthermore, an overall distribution plot was made based on the failure rate of each study weighted by joining the variables population size and follow-up (Figure B), p-value was calculated based on the Kruskal-Wallis-Test.
Results: A total of 3,676 studies were retrieved from the systematic search, of which 43 met the criteria for inclusion in the final analysis. Five studies were randomized clinical trials and 38 were observational cohort studies (13 present adjusted populations). A total of 13,870 patients from 19 different nations were included. The follow-up ranged from 1 to 18 years (mean±SD: 3.9±3.8 years). Mean TR recurrence rate was 14% (Figure B: red line). There was a large heterogeneity of treatment effect with the different types of annuloplasty and the return of TR over time is high. The figure shows that ring annuloplasty was associated with the lowest re-TR rate and suture annuloplasty with the highest. For suture annuloplasty, early re-TR rates have been demonstrated (within the first three years; Figure A). In the combined patient-follow-up analysis, ring annuloplasty had lowest re-TR rates (6.5%), followed by band (16%) and suture annuloplasty (19%).
Conclusions: Long-term durability of tricuspid valve annuloplasty techniques is suboptimal and heterogeneous. Based on these outcomes, it may still be reasonable to expect that a durable elimination of tricuspid regurgitation can deliver a survival advantage to these patients.
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Poster Presenter
Tulio Caldonazo, Department of Cardiothoracic Surgery, Friedrich-Schiller-University Jena, Germany
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Jena, Thuringia
Germany