Annuloplasty Band Research Articles

Repair of Partial Atrioventricular Septal Defects in Adults: A Single Center Experience

Limited data are available on long-term outcome after repair of partial atrioventricular septal defects (pAVSD) in adults. We sought to review our experience. Between January 1, 1957 and December 31, 2016, 179 adult patients [median age (IQR) 34 (18, 72) years] underwent primary repair of pAVSD. The most common associated defects were secundum atrial septal defect (n = 38) and ventricular septal defect (VSD) (n = 7). Left atrioventricular valve (LAVV) zone of apposition (ZOA) was complete in 47 patients and LAVV regurgitation (≥moderate) was present in 73 patients. Autologous pericardium (n = 79, 45%) and polytetrafluoroethylene felt (n = 56, 32%) were mainly used for pAVSD closure. Repair techniques for LAVV regurgitation included: ZOA suture closure (n = 142), suture annuloplasty (n = 10) and posterior band annuloplasty (n = 9). Six had LAVV replacement. There were 61 deaths over a median follow-up of 21 years (IQR 10, 38), with only 4 early deaths. In a limited subset of patients with 80 paired measurements (n = 40), median right ventricular systolic pressure declined from 43 mm Hg (IQR 35-51) to 33 mm Hg (IQR 30-44) postoperatively (P < 0.001), and this improvement was sustained over long-term follow-up (P = 0.513). A total of 34 patients underwent a reoperation (recurrent LAVV regurgitation, n = 26; left ventricular outflow-tract obstruction, n = 7; LAVV stenosis, n = 4; patch dehiscence, n = 1) with cumulative incidence of 6% and 16% at 10 and 15 years, respectively. Repair of pAVSD in adults can be done safely with low early mortality and good long-term outcomes. Postrepair reduction of pulmonary artery pressure is significant. Despite the low re-operation rates, long-term surveillance remains essential.

Tricuspid three-dimensional ring versus fashioned flexible band annuloplasty in management of functional tricuspid valve regurge: comparative long term study

BackgroundFunctional tricuspid valve regurgitation due to left sided valve lesions remains a common finding. Nowadays, different types of three-dimensional rings and flexible bands are considered to be the gold standard techniques for repair of such functional regurgitation. Our study aimed for long-term comparison of the durability and effectiveness of those techniques.ResultsThe data of 170 adult patients with moderate or more functional tricuspid regurgitation secondary to mitral stenosis or regurgitation receiving tricuspid valve repair using either rigid 3D rings (contour 3D or MC3 ring) or prosthetic fashioned bands (Dacron or PTFE) and mitral valve surgery between March 2013 and September 2018 were collected and analysed. Patients were classified in two matched groups: ring group (group A) consisting of 90 cases and band group (group B) consisting of 80 cases. follow-up period ranged from 55.2 to 78 months (mean 67.2 ± 10.8), during this period New York heart association for dyspnea functional class evaluation and full echocardiographic assessment were done and was scheduled as following: before hospital discharge, after 6 months of surgery and finally, every 2 years. In-hospital mortality was 1(1.1%) and 2 (2.5%) with p value 0.49 after ring or band annuloplasty, respectively. No significant differences in both groups regarding hospital mortality and morbidities. There was statistically significant decrease in NYHA class, degree of TR, and PASP within the 2 groups postoperatively with p value of 0.03, 0.04, and 0.033, respectively, with no statistically significant difference between both groups (p value > 0.05). There was statistically significant difference in the freedom from recurrent TR and need for reoperation during the follow-up period between both groups with lower recurrence and reoperation rates in group A, (p value 0.03 and 0.001, respectively).ConclusionTricuspid valve repair with different annuloplasty rigid three dimensional rings or fashioned flexible bands for functional tricuspid regurgitation offers good long-term outcome. Yet, the rigid rings maintain their benefits on the rate of recurrent TR and the need for reoperation.

Surgical Repair versus Conservative Treatment for Moderate Functional Tricuspid Regurgitation in Concomitant with Mitral Valve Surgery

Background: Management of moderate functional tricuspid regurgitation (FTR) secondary to left-sided valve lesion is controversial. The objective of this study was to compare the short-term results of surgical repair versus conservative treatment for moderate functional tricuspid regurgitation in concomitant with mitral valve surgery.&#x0D; Methods: Our study included 60 patients with mitral valve lesion and moderate functional tricuspid regurgitation. Patients were divided into 2 groups; group A included 30 patients whose tricuspid valve disease were managed conservatively, and group B included 30 patients who had tricuspid valve band annuloplasty.&#x0D; Results: Preoperative clinical and echocardiographic data were comparable between groups. There was no difference regarding mechanical ventilation time (6 .13 ± 3.02 vs. 7.01 ± 4.14 hours; p= 0.291), or intensive care unit stay (51.42 ± 12.1 vs. 52.31 ± 15.32 hours; p=0.614) in group A and B respectively. There was a significant improvement in the degree of tricuspid valve regurgitation in group B early postoperative (moderate tricuspid regurgitation reported in 22 (73.3%) vs. 4 (13.3%); p&lt;0.001) and at 3 months (moderate tricuspid regurgitation 11 (36.7%) vs. 2 (6.7%); p&lt;0.001) and 6 months follow up (moderate tricuspid regurgitation 10 (30%) vs. 2 (6.7%); p&lt;0.001) in group A and B respectively. After 6-months, 20 (66.7%) patients in group A had dyspnea grade I compared to 26 (86.7%) patients in group B; p=0.021.&#x0D; Conclusion: Although the correction of the left-sided lesion improved the degree of TR in some patients, concomitant repair of the tricuspid valve could produce better improvement in the clinical outcome when compared to the conservative approach.

P1714 When the mechanism of mitral regurgitation is unclear, 3D Trans-esophageal echocardiography is the solution

Abstract Introduction Assessment of mitral regurgitation (MR) mechanism is not always easy and may require advanced imaging techniques. A 28-year-old male presented with significant MR three years following surgical mitral valve repair for severe MR due to mitral valve prolapse. During surgery, he underwent artificial chordal implantation on A2 scallop and Gore-Tex posterior band annuloplasty. Early post-operative transthoracic echocardiography (TTE) showed mild to moderate eccentric, posteriorly directed MR of unknown mechanism. Since the patient was asymptomatic, only regular follow-up was advised. He missed his follow-up for three years after which presented complaining of exertional dyspnea NYHA class II. TTE showed dilated left ventricular dimensions with moderate to severe MR of unknown mechanism. 2D trans-esophageal echocardiography (TEE) (figure 1, panel A&amp; B) showed severe, posteriorly directed mitral regurgitation, with a mass (arrow head) at the level of the mitral annulus. 3D TEE (figure 1,panel C, 3D zoom mode and panel D, true view mode) showed dehiscence (arrow head) of the annuloplasty band from the posterior mitral annulus with a wide gap measuring 83 mm² in 3D planimetred area. The patient was referred for re-do surgery. Conclusion 3D TEE has a great added value in elucidating the mechanism of MR in obscure cases and guiding the proper management strategy. Abstract P1714 Figure 1

P6489Preoperative determination of artificial chordae length by transesophageal echocardiography

Abstract The use of artificial chordae is one of the main techniques used in mitral valve repair to treat prolapsing leaflets, especially in anterior and bileaflet prolapse. With the use of PTFE sutures to replace elongated or ruptured chords mitral valve repair rates have significantly improved. The main difficulty with this technique is to determine the optimal length of the artificial chordae. Intraoperative transoesophageal echocardiography (TOE) is mandatory in mitral valve repair in order to determine the type of lesion of the mitral valve but also to evaluate the quality of the repair. We examined the accuracy of preoperative prediction of artificial chordae length by the preoperativeTOE. Patients and methods Twenty-one consecutive patients (7 females) underwent mitral valve repair with artificial chordae for significant mitral valve prolapse in our department during the last year. The median age of the patients was 62 y. (range 25 - 87) and the mean EuroSCORE II 3,36% (SD 4,61%). During the prep TOE we determined the predicted length of the required replacement chordae for the repair using mainly the 4 chamber view to calculate the distance between the tip of the papillary muscle and the coaptation point of the two leaflets and we subtracted 5mm which is the minimum of the desired coaptation length (top right part of the Figure). All the patients underwent totally endoscopic mitral repair through a 3 cm right periareolar incision. 14,3% of the patients had anterior leaflet (AML) prolapse, 23,8% bileaflet and 61,9% posterior (PML). The appropriate length of the required chordae was measured intraoperatively. Results We used on average 3 loops of artificial chordae size 23,3 mm (SD 1,15mm) to treat the AML prolapse, 5 loops size 23,2 mm (SD 2,28mm) to treat the bileaflet prolapse and 2,23 loops size 18mm (SD 2mm) to treat the PML prolapse (bottom part of the figure). The predicted size of the artificial chordae had a positive correlation to the length used (Pearson correlation, p&lt;0,001) as demonstrated in the top left part of the Figure. An annuloplasty band was implanted to all the patients. All the patients had no mitral regurgitation in the postoperative TOE. The mean valve area was 3,54cm2 (SD 0,57) and the mean peak gradient 5,6 mmHg (SD 1,82). There was no mortality. Chordae length predicted by echo Conclusion The length of artificial chordae can be predetermined with great accuracy with the use of TOE, making TOE an important tool not only for the determination of the mitral lesion and quality of the repair but also for the planning of the operation.

Ring, Band or Suture in Tricuspid Annuloplasty for Functional Tricuspid Regurgitation; Which is Better and More Durable?

In this study, we evaluate different annuloplasty modalities to repair functional tricuspid regurgitation. Between January 2011 and January 2017, 200 patients with moderate or greater functional tricuspid regurgitation received tricuspid valve repair as part of primary surgeries on the left side of their cardiac valves. Of these, 39 patients received rings (Group A), 84 patients received bands (Group B), and 77 patients received suture annuloplasty (Group C). Two patients from Group C were operated on again, during the primary hospital stay due to severe symptomatic tricuspid regurgitation. The degrees of early postoperative tricuspid regurgitation - mean vena contracta and mean jet area - significantly were higher in Group C. During a mean follow-up period of 26 ± 12.6 months, 5 patients within Group C (6.85%) and one patient in Group B (1.3%) were operated on again with tricuspid valve replacement due to severe symptomatic tricuspid incompetence. Also during follow up, mean degrees of tricuspid regurgitation, mean vena contracta, and mean jet areas significantly were higher in Group C. Patients who received rings followed by band annuloplasty had better early and late results with lower recurrence rates than those who received suture annuloplasty.

Penetration cardiac wound associated with anterior mitral leaflet perforation: a case report and review of the literature

The paper presents a rare case of successful correction of an anterior mitral leaflet perforation. A 28-years old patient was referred with progressive heart failure symptoms at 18 weeks after he had a penetrating stab wound of the right ventricle. Massive pericardial effusion with cardiac tamponade risk and severe mitral valve insufficiency were found at examination. By the time of referral, spontaneous closure of the ventricular septal defect, which is an inevitable component of the “unhappy triad”, had happened. Accurate topical ultrasound diagnosis of the intracardial lesion that resulted from the penetrating wound of the left ventricular outflow allowed for a successful urgent mitral valve reconstruction with a xenopericardial patch and the insertion of a 28 mm MedEng annuloplasty band. To prevent any future pericardial constriction, subtotal pericardectomy by Cooley was performed.Conclusion: Perioperative echocardiography and subsequent follow up by cardiologist are obligatory in all cases of precordial wounds after discharge from hospital. Timely surgery for traumatic mitral leaflet perforation allows for a successful valvuloplasty.

Adjusting the neochords height for better leaflets coaptation following mitral valve repair.

Often times, in mitral valve repair techniques, the height of the newly placed Gore-Tex sutures needs correction to achieve better mitral valve leaflet coaptation or to correct systolic anterior motion (SAM). Herein, a less challenging "Hornet" technique to accurately adjust artificial chordal length is described. This technique describes a way to adjust/shorten the Gore-Tex chords, should they need revision. Ideally, this should not be needed, however due to the circumstances for mitral valve repair, this is sometimes necessary. With the annuloplasty band already in place, it is somewhat harder to reinsert new chords and hence, this technique may be beneficial.

Modified band annuloplasty technique for functional tricuspid regurgitation repair in patients with grossly dilated annuli: The three-suture junctional continuous suture band annuloplasty technique.

Functional tricuspid regurgitation (FTR) is the most common of all tricuspid dysfunctions. Ring annuloplasty is an effective treatment strategy for FTR. Currently, the most commonly used suture method for tricuspid ring annuloplasty is the interrupted U-shaped suture method. However, when tricuspid annuli are grossly dilated (septal segments > 60 mm), interrupted sutures are insufficient in avoiding the folding over of the annulus or the tearing of sutures. Therefore, we recommend a new band suture technique; namely, the three-suture junctional continuous suture band annuloplasty technique.

EP19 INFERIOR REVERSED J SHAPED MINI STERNOTOMY FOR MITRAL VALVE SURGERY

Abstract Background and Aim: To reduce the morbidity of mitral valve surgery, we present our mininvasive approach. Methods: From January 2017 to April 2018, 35 patients underwent mitral valve surgery using a partial lower sternotomy through a 9–12 cm longitudinal median skin incision and a left reversed “J-shaped” ministernotomy from the second intercostal space to the xiphoid. Mitral valve replacement was performed in 8 patients (22.8%), while mitral valve repair (using quadrangular resection, sliding plasty or butterfly technique in addition to intertrigonal annuloplasty band) in 27 patients (77.2%). Results: One patient (4.4%) required conversion to full sternotomy. Twenty-four patients (68.5%) were extubated within 6 hours of surgery, and 75% of patients spent less than 24 hours in the intensive care unit (ICU). Mean hospital length of stay was 7.2 +/- 3.4 days. Eighty percent of patients received no blood products. We did not register any operative mortality or re-exploration for bleeding. Morbidity included respiratory insufficiency in 3 patients (6.6%) and wound infection in 1 patients (2.2%). Conclusions: We chose the lower mini-sternotomy because the mitral valve exposure is very similar to that of the full sternotomy and enables repair with the same degree of success as the full sternotomy does. Furthermore, ease conversion to conventional surgery when needed make this technique preferable to the right minithoracothomy approach. The mininvasive approach, in addition to its cosmetic benefits, reduce the sternal trauma, avoid excessive rib traction, reduces the postoperative pain and allows early extubation, mobilization and discharge from the ICU.

Clinical Outcomes of Mitral Annuloplasty with Flexible Bands in Ischemic Mitral Regurgitation.

In this study, we present the outcomes of 53 patients with concomitant coronary artery disease and ischemic mitral regurgitation (IMR)who underwent coronary bypass grafting (CABG) plus mitral repair (flexible posterior band annuloplasty). A total of 53 patients with concomitant ischemic mitral regurgitation and coronary artery disease underwent CABG plus posterior mitral band annuloplasty between June 2008 and June 2015. Flexible Duran AnCore® annuloplasty band (Medtronic) was used in all patients. Transesophageal echocardiography (TEE) was intraoperatively performed in all patients. A transthoracic (TTE) follow-up examination was performed at postoperative months 1, 3, 6, and 12. The average cross-clamp and cardiopulmonary bypass times were 85.11 ± 5.79 and 105.98 ± 6.14 minutes, respectively. Postoperatively, there was an improvement in the grade of mitral regurgitation from 3.8 to 0.7 and in the NYHA class from 3.1 ± 0.5 to 0.5 ± 0.6 (both P < .001). In addition, statistically significant reductions in LVEDD, LVESD, and PAP were observed (P < .001). Ejection fraction rose from 39 ± 10% to 45 ± 8% (P < .01). Early mortality rate was 7.5% (n = 4). Mean follow-up was at 16 months. Late mortality occurred in one patient. During the follow-up period, reoperation was required in 2 patients. Only 2 parameters, redo surgery (P = .030) and IABP use (P = .021), were found related to mortality (P < .001). Cox regression analysis showed that redo surgery and postoperative bleeding increased mortality by 14.731 times (odds ratio: 14.731; 95% confidence interval [CI]: 1.530-141.852) and 23.839 times (odds ratio: 23.839; 95% CI: 1.478-348.641). In patients with IMR, mitral band annuloplasty performed in conjunction with CABG was associated with an increase in functional capacity and ejection fraction as well as a reduction in LVEDD and LVESD. This approach represents a feasible alternative with low mortality and prevents future development of mitral regurgitation and the need for redo surgery.

Automated Titanium Fasteners Versus Hand-Tied Knots: A Randomized Controlled Trial

The relative benefits of automated titanium fasteners (LSI Solutions, Victor, NY) have not been examined in patients undergoing sternotomy. The aim of this study was to assess the time and cost required for suture fixation with the automated device versus conventional hand tying in sternotomy for mitral or tricuspid ring annuloplasty. Fifty patients scheduled to undergo primary mitral or tricuspid, or both, ring annuloplasty-based valve repair operation by a single surgeon were randomly assigned to receive either conventional hand-tied knots or automated titanium fasteners, with 25 patients in each group. The primary outcome variable was the time required to affix the annuloplasty device to the valve annulus. The times taken to affix a mitral annuloplasty band or ring were 6.1 ± 0.9 min for manual tying versus 3.1± 0.4 min for automated fasteners (p < 0.0001); when calculated per annuloplasty stitch, the values were 22 ± 2 s versus 12 ± 1.1 s, respectively (p < 0.0001). The corresponding values for tricuspid annuloplasty were 4.2 ± 1.2 min (hand tying) versus 2.2 ± 0.3 min (automated fasteners) (p= 0.0005), and the times for each suture were 20 ± 2.1 s versus 13 ± 2 s, respectively (p= 0.0004). The use of the automated fastener had no significant impact on aortic cross-clamp time or cardiopulmonary bypass duration. Total cost associated with annuloplasty fixation with automated titanium fasteners (device cost in addition to operating room time cost) was significantly higher than with hand tying ($1,190 ± 374 vs $164 ± 60; p < 0.0001). Using the automated fastener to facilitate annuloplasty fixation through a sternotomy resulted in a small procedural time savings (average of 10 s/stitch) that had no overall impact on cardiopulmonary bypass or cross-clamp times but added an average cost of $1,026 to the operation.

Long-term results of suture annuloplasty for degenerative mitral valve disease: a propensity-matched analysis.

Ring annuloplasty is the gold standard of surgical repair in degenerative mitral valve disease. However, prosthetic annuloplasty has some drawbacks and potential hazards. Suture annuloplasty theoretically is able to preserve annular leaflet dynamics and left ventricular performance, but experience is limited. The aim of the study was to review the early and long-term outcome of the posterior double-suture annuloplasty (DSA) technique for degenerative mitral valve repair. From January 2002 to December 2008, 400 patients underwent primary mitral valve repair for degenerative disease either with posterior DSA [n = 147 (37%)] or with flexible posterior annuloplasty band [n = 253 (63%)]. Differences in patient characteristics were addressed by propensity-score matching (132 pairs). A composite end-point of mitral valve failure (MVF) was calculated as the incidence of mitral valve regurgitation greater than 2+ or need for mitral valve replacement at follow-up. After propensity-score matching, the distribution of preoperative variables among matched pairs was, on average, equal. Isolated annuloplasty and leaflet repair techniques were similarly performed in both groups (P = 0.20). In-hospital mortality was comparable between the two study groups (P = 0.48). Predischarge echocardiography showed excellent results regarding valve hemodynamics (P = 0.71). At a mean follow-up of 11 ± 3 years, all-cause mortality (P = 0.12), need for mitral valve replacement (P = 0.49), and cardiac re-hospitalization rate (P = 0.57) resulted comparable between the two groups. Ten-year survival (75 vs. 71%, P = 0.51) and freedom from MVF (92 vs. 84%, P = 0.39) were similar between posterior annuloplasty band and DSA groups. Suture annuloplasty demonstrated comparable results with posterior flexible band repair and could be a viable option for mitral valve surgery in selected patients, such as in the minimally invasive approach, in endocarditis, and in developing countries.

Improving Results of Surgery for Ebstein Anomaly: Where Are We After 235 Cone Repairs?

Ebstein anomaly has heterogeneous anatomy and numerous operative techniques are described. Cone repair provides a near anatomic tricuspid valve repair. The purpose of this study was to examine our experience with cone repair. Cone repair was performed in 235 consecutive patients with Ebstein anomaly, 134 children (57%) and 101 adults (43%), from June 2007 to October 2015. Median age was 15.6 years (range, 6 months to 73 years). Cone repair was the first operation in 192 patients (82%), the second in 41 (17%), and the third in 2 (1%). Previous tricuspid valve repair had been performed in 27 (12%). Echocardiograms were obtained preoperatively and at hospital dismissal for all patients and for a subgroup of patients at least 6 months after cone repair (n= 81). Leaflet augmentation was done in 67 patients (28%), Sebening stitch in 57 (24.2%), neochordae in 49 (21%), and annuloplasty band in 158 (67%). Bidirectional cavopulmonary shunt was performed in 46 patients (20%). There was 1 early death (0.4%). Early reoperation was required in 14 patients (5.9%); re-repair was possible in 7 (50%). The majority of early reoperations (11 of 14; 79%) occurred in the first third of the series. Mean follow-up was 3.5 ± 2.5 years. There was sustained reduction in tricuspid regurgitation (p < 0.0001), a progressive decline in right ventricle size (p < 0.0001), and late increase in right ventricle fractional area change after initial decline (p < 0.0001). Freedom from late reoperation was 97.9% at 6 years. Cone repair is safe, and the learning curve is significant. Sustained reduction in tricuspid regurgitation and favorable changes in the right ventricle at follow-up suggest that cone repair has an advantageous impact on right ventricular remodeling.

Annuloplasty band implantation in adults with partial atrioventricular septal defect: a propensity-matched study.

The incidence of recurrent left atrioventricular valve (LAVV) regurgitation is generally high after repair of partial atrioventricular septal defect (AVSD). This study aimed to evaluate the effect of implanting an additional annuloplasty band into the LAVV during partial AVSD repair and to assess the late outcomes of recurrent LAVV regurgitation. This study enrolled 133 patients who underwent repair of partial AVSD at our institution from January 2005 to December 2015. All patients underwent repair of the ostium primum atrial septal defect and closure of the LAVV cleft; 37 patients underwent additional annuloplasty band implantation. To minimize differences in preoperative data, propensity score matching was used to identify 33 well-matched patient pairs. Cardiopulmonary bypass time and aorta cross-clamp time were significantly longer in the band implantation group (P < 0.05). The 2 groups had similar durations of intensive care and hospital stay (P > 0.05). There was 1 in-hospital death in the band implantation group. During follow-up, conduction block occurred in 6 patients in each group. After follow-up of more than 10 years, freedom from late recurrent LAVV regurgitation was 91% in the band implantation group and 57% in the isolated cleft closure group (P < 0.05). In patients with preoperative severe regurgitation and moderate/mild regurgitation, the rates of freedom from recurrent LAVV regurgitation were 85% and 37%, respectively (P < 0.05). In patients with moderate/severe LAVV regurgitation or severe annular dilation, additional band implantation significantly reduces the incidence of recurrent regurgitation and improves long-term outcomes.

Intentional Percutaneous Laceration of the Anterior Mitral Leaflet to Prevent Outflow Obstruction During Transcatheter Mitral Valve Replacement: First-in-Human Experience

ObjectivesThis study sought to use a new catheter technique to split the anterior mitral valve leaflet (AML) and prevent iatrogenic left ventricular outflow tract (LVOT) obstruction immediately before transcatheter mitral valve replacement (TMVR). BackgroundLVOT obstruction is a life-threatening complication of TMVR, caused by septal displacement of the AML. MethodsThe procedure was used in patients with severe mitral valve disease and prohibitive surgical risk. Patients either had prior surgical mitral valve ring (n = 3) or band annuloplasty (n = 1) or mitral annular calcification with stenosis (n = 1). Iatrogenic LVOT obstruction or transcatheter heart valve dysfunction was predicted in all based on echocardiography and computed tomography. Transfemoral coronary guiding catheters directed an electrified guidewire across the center and base of the AML toward a snare in the left atrium. The externalized guidewire loop was then electrified to lacerate the AML along the centerline from base to tip, sparing chordae, immediately before transseptal TMVR. ResultsFive patients with prohibitive risk of LVOT obstruction or transcatheter heart valve dysfunction from TMVR successfully underwent LAMPOON, with longitudinal splitting of the A2 scallop of the AML, before valve implantation. Multiplane computed tomography modeling predicted hemodynamic collapse from TMVR assuming an intact AML. However, critical LVOT gradients were not seen following LAMPOON and TMVR. Doppler blood flow was seen across transcatheter heart valve struts that encroached the LVOT, because the AML was split. Transcatheter heart valve function was unimpeded. ConclusionsThis novel catheter technique, which resembles surgical chord-sparing AML resection, may enable TMVR in patients with prohibitive risk of LVOT obstruction or transcatheter heart valve dysfunction.

A case of mitral annuloplasty band dehiscence

A case of mitral annuloplasty band dehiscence

Incomplete Atrioventricular Septal Defect in a Patient with New Onset Atrial Fibrillation

A 60-year-old female presented with palpitations associated presyncope and increased shortness of breath on exertion (NYHA II) following a recent viral illness. Physical examination revealed heart rate 122 bpm with blood pressure 97/65 mmHg. ECG confirmed atrial fibrillation with rapid ventricular response and intermittent ventricular ectopics. Her past medical history included spontaneous pneumothorax 30 years prior, recurrent migraines and pernicious anaemia. She had two uncompleted pregnancies. Transthoracic and transoesophageal echocardiography (Fig. 1) showed incomplete atrioventricular (AV) septal defect with ostium primum atrial septal defect (ASD). There was a cleft anterior mitral valve leaflet with grade 2/4 mitral regurgitation. Coronary angiogram confirmed normal coronary arteries and significant left to right shunt. Brain MRI did not demonstrate evidence of previous cerebral emboli. The patient underwent elective repair of the AV canal defect and mitral valve repair. The cleft mitral valve leaflet was opposed to create a single leaflet and 34 mm Cosgrove annuloplasty band was placed. The ASD was closed with a bovine pericardial patch sutured along the anterior mitral valve annulus and secured to the interatrial septum. Atrial fibrillation cryoablation was performed together with left atrial appendectomy. Postoperatively, she remained pacemaker dependent and subsequently underwent dual chamber pacemaker implantation 4 days later. Late presentation congenital heart disease often occurs following the development of arrhythmia and heart failure symptoms. This case demonstrates the importance of evaluation for structural heart disease in patients with new onset atrial fibrillation.

Robotic trans-atrial and trans-mitral ventricular septal resection.

Localized ventricular septal hypertrophy, also known as idiopathic hypertrophic subaortic stenosis or idiopathic hypertrophic subaortic septal obstruction (IHSS), can create severe ventricular outflow obstruction. This often results in a high sub-aortic pressure gradient with potentially lethal symptoms. In 1960, Braunwald described the hemodynamic characteristics of IHSS, and thereafter, Morrow developed a trans-aortic approach to resect a large part of the ventricular septum, enlarging the outflow tract. The Morrow operation has remained the gold standard for surgically treating this pathology. However, in patients with a small aortic annulus, a severely hypertrophied septum, and a long anterior mitral leaflet, the trans-aortic approach may be more difficult, resulting in an inadequate resection and/or systolic anterior leaflet motion. The latter usually increases the obstruction and can cause mitral regurgitation. Herein, we describe a minimally invasive trans-left atrial robotic approach to treat IHSS. First, the anterior mitral leaflet is incised radially to reveal the aortic outflow tract and ventricular septum, which are located posteriorly. Thereafter, a deep "block" of septum is excised, beginning at the right valve cusp nadir and continued counterclockwise toward the left fibrous trigone. This excision is extended to the anterior papillary muscle base, where any septal connections must be divided. Subsequently, the anterior leaflet is re-suspended and the repair is completed with a flexible annuloplasty band. If necessary, the anterior leaflet can be augmented with a pericardial patch. The "wristed" robotic instruments and magnified 3-D vision definitely facilitate an adequate septal resection and anterior papillary muscle mobilization. Moreover, it is possible that this fine control helps to reduce complications, such as heart block or a ventricular septal defect.

Comparison of outcomes of tricuspid annuloplasty with 3D-rigid versus flexible prosthetic ring for functional tricuspid regurgitation secondary to rheumatic mitral valve disease.

Annuloplasty bands and rings are widely used for repairing functional tricuspid regurgitation (FTR). However, the question regarding which is the ideal annuloplasty device remains unclear. The aim of this study was to compare the efficacy and mid-term durability of tricuspid ring annuloplasty for FTR secondary to rheumatic mitral valve disease using flexible Cosgrove-Edwards band and the rigid Edwards MC3 ring (Edwards Lifesciences, LLC, Irvine, CA, USA). We retrospectively collected the clinical data of those who underwent mitral valve replacement (MVR) in concomitant with tricuspid ring annuloplasty from 2009 to 2013. The flexible band was used in 46 patients (flexible group), and the 3D rigid ring was used in 60 patients (rigid group). Echocardiographic evaluation of tricuspid function was performed preoperatively and postoperatively. The grade of TR was significantly improved compared to preoperative values in two groups. There was no significant difference regarding postoperative TR grade between the two groups at 1 week and 2-3 months but there was statistical significant difference at postoperative 6-12 months, and 2-3 years. During the follow up period, 25 of 46 patients (54.3%) in flexible group and 22 of 60 patients (30.3%) in rigid group developed recurrent TR. Freedom from recurrent TR in flexible group is significant lower than rigid group in each postoperative follow up period. These findings suggest that 3D rigid ring annuloplasty might be more effective for tricuspid ring annuloplasty in FTR in mid-term postoperative periods when compared to flexible band.