Significant Aortic Insufficiency Research Articles

Successful Percutaneous Balloon Dilatation of Membranous Sub-aortic Stenosis in a 22 Year Old Pregnant Patient

Congenital obstruction of the left ventricular outflow tract comprises a heterogeneous group of disorders, with obstruction potentially occurring below, above, or at the level of the aortic valve. Subvalvular stenosis is the second most common type of left ventricular outflow tract obstruction, of which discrete membranous type is the most common. Although surgical resection of the subaortic membrane is the treatment of choice in discrete membranous subaortic stenosis, in selected patients with isolated membranous subaortic stenosis, without significant aortic insufficiency, percutaneous balloon tearing of the membrane results in reduction in the degree of left ventricular outflow tract obstruction and symptomatic relief. We report a case of 22 year old pregnant patient admitted with NYHA class III breathlessness, found to have discrete membranous subaortic stenosis. Balloon aortic valvuloplasty was performed in the patient with good result. Patient underwent normal vaginal delivery at 38 weeks. Both mother and newborn were asymptomatic. Patient is asymptomatic on subsequent follow-ups.

Imaging characteristics of acute type A aortic dissection and candidacy for repair with ascending aortic endografts

BackgroundAcute type A aortic dissection (ATAD) remains associated with substantial short-term mortality, and despite increasing rates of surgical repair, as many as 10% to 20% of patients do not undergo surgery because of comorbidities and dissection-related complications. For patients unable to undergo open repair, previous attempts at endovascular treatment of ATAD used devices originally designed for deployment in the descending thoracic aorta. Industry has begun to support early investigational devices meant specifically for placement within the ascending aorta. We evaluated relevant aortic parameters to examine which patients may be candidates for repair with an ascending aortic endograft. MethodsWe reviewed 100 consecutive patients in our institutional ATAD database with contrast-enhanced computed tomography imaging on an Aquarius iNtuition workstation (TeraRecon, San Mateo, Calif), using curved planar reformatting (vessel tracking) and orthogonal views for measurements. We compared relevant aortic measurements against proposed criteria for future ascending endografts, including various landing zone diameters and intimal tear distances from the distal coronary ostium. ResultsOf the 100 patients examined, 39% had proximal intimal tears located outside the tubular ascending aorta. In all, 30% were excluded on the basis of either the presence of a prosthetic aortic valve or significant aortic insufficiency, and 6% were excluded on the basis of the presence of patent coronary artery bypass grafts from the ascending aorta. Many patients had multiple exclusion criteria, and based on various proposed criteria, overall candidacy ranged from 2% to 23%. If a maximum landing zone diameter of 42 mm and intimal tears as little as 20 mm distal to the distalmost coronary were considered treatable, only 8% of patients would have been candidates compared with 20% candidacy if aortic diameters up to 46 mm and intimal tears as little as 10 mm distal to the distalmost coronary were considered treatable. The most frequent single cause for exclusion was inadequacy of the proximal landing zone. Iliofemoral vascular access was also assessed and deemed adequate in >90% of cases. ConclusionsA minority of patients suffering ATAD would currently qualify for ascending aortic endografting on the basis of anatomic criteria alone. Future device designs should take into account these common anatomic exclusion criteria so that more versatile devices may be developed and commercially available to treat a larger number of patients.

Reported outcomes after aortic valve resuspension for acute type A aortic dissection: a systematic review and meta-analysis.

In the majority of patients presenting with acute type A aortic dissection (AAD) complicated by aortic valve insufficiency, the aortic valve (AV) can be preserved by AV resuspension. A meta-analysis was performed to investigate the outcomes following AV resuspension for AAD. A systematic literature search for publications reporting outcomes after AV resuspension in AAD published between January 1998 and June 2018 was conducted. Early outcome events and linearized occurrence rates for late outcome events were derived. The retrieval process yielded 18 unique studies involving 3295 patients with a total of 17532 patient-years (pt-yrs). Pooled early mortality was 15.5% [95% confidence interval (95% CI) 11.5-19.4%, I2 = 91.9%], and the linearized late mortality rate was 3.21%/pt-yrs (95% CI 2.49-3.77, I2 = 29%). The linearized occurrence rates for aortic root reintervention was 1.4%/pt-yrs (95% CI 0.88-1.79, I2 = 48%); for recurrent significant aortic valve insufficiency (>2+), it was 1.12%/pt-yrs (95% CI 0.79-1.45, I2 = 68%); and for endocarditis, it was 0.01%/pt-yrs (95% CI 0-0.04, I2 = 7%). The composite rate of thromboembolism and bleeding was 1.41%/pt-yrs (95% CI 0.18-2.63, I2 = 82%). A more recent surgical period was associated with a decreased hazard of reoperation on the aortic root (P < 0.001). Requirement of AV resuspension alone in AAD is a risk factor for mortality. The long-term durability of AV resuspension is excellent, with low rates of endocarditis and thromboembolism and bleeding. Root reoperation hazard has become acceptable in recent years. Preoperative aortic valve insufficiency grade exceeding 2+ is a predictor for root reoperation.

Novel Left Heart Catheterization Ramp Protocol to Guide Hemodynamic Optimization in Patients Supported With Left Ventricular Assist Device Therapy.

BackgroundLeft ventricular (LV) hemodynamic assessment has been sparsely performed in patients supported on continuous‐flow LV assist devices (cfLVADs). Insight into dynamic changes of left heart parameters during ramp studies may improve LV assist device optimization and evaluate pathology.Methods and ResultsTo complement right heart catheterization, a novel technique for left heart catheterization in patients with a cfLVAD was developed. Patients implanted with cfLVADs underwent hemodynamic ramp left heart catheterization and right heart catheterization with transthoracic echocardiography. Continuous aortic and LV pressures were measured along with right atrial, pulmonary artery, and pulmonary capillary wedge pressures. A novel index, the transaortic gradient (TAG) was established. Thirty eight patients with cfLVADs were evaluated at a median of 446 days (interquartile range, 183–742) after device implant. During left heart catheterization performed for hemodynamic optimization, drop‐in LV end‐diastolic pressure and pulmonary capillary wedge pressure were associated with a rise in TAG. A range was identified for TAG (20–40 mm Hg) as providing the most optimal level of hemodynamic offloading. Pathologic states deviated from normal responses to ramp. LV assist device thrombosis was associated with an inability to increase in TAG during speed ramp. Significant aortic insufficiency was associated with a marked increase in LV end‐diastolic pressure despite a concomitant decrease in pulmonary capillary wedge pressure with increasing LV assist device speeds.ConclusionsInclusion of left heart catheterization to a typical right heart catheterization LV assist device ramp protocol imparted unique insights to optimize cfLVAD speeds in different clinical scenarios. A novel index, the TAG was defined and provided additional resolution to optimized offloading.

Clinical Case: Place of Cardiac Stimulation in Asymptomatic Significant Chronic Aortic Insufficiency Associated with Sinus Dysfunction

The association between aortic insufficiency and sinus dysfunction is rare. We reported a case of significant chronic degenerative aortic insufficiency associated with sinus dysfunction. This was a 66-year-old patient on follow-up for asymptomatic chronic aortic insufficiency who was referred to us for a preoperative invasive hemodynamic assessment. The indication for surgery was based on the left ventricular dilation criteria. The echocardiography and cardiac catheterization showed a disappearance between the aortic insufficiency and the left ventricular repercussion. Upon discovery of the sinus bradycardia, the patient received a single chamber pacemaker set at a base rate of 70 seconds in AAIR at first and then the patient was measured remotely. At five months, cardiac pacing resulted in a significant reduction in the left ventricular diameter and volume on the echocardiography and magnetic resonance imaging; therefore surgery was postponed.

Left ventricular assist device implantation and concomitant aortic valve replacement

Introduction. The implantable device for mechanical support of the left ventricular circulation (LVAD) is widely applied as a therapeutic option for survival and improvement of the quality of life in patients with the end-stage heart failure. The objective of our paper was to present the implantation of the aforementioned device together with the aortic valve replacement in the same procedure. Case outline. The patient was admitted to the hospital during his terminal stage of heart failure, with ejection fraction of 18%. The ergospirometry test showed that the maximum VO2 was 10.1 ml/kg/min. Because the medicament therapy hadn?t provided adequate results, the LVAD device was implanted as a bridge until transplantation. Due to severe aortic insufficiency, the aortic valve was concomitantly replaced with bioprosthesis in order to prevent the negative effect of this valvular disease on pump work and clinical outcome. Conclusion. This case report confirms that LVAD implantation with the correction of a significant aortic insufficiency is a procedure with satisfactory short-term and long-term results.

Percutaneous balloon dilatation for congenital aortic stenosis during infancy: A 15-years single-center experience

Introduction The aim of this study was to identify factors predictive of reintervention following balloon aortic valvuloplasty (BAV) for congenital aortic stenosis (AS) during infancy. Methodology Retrospectively, patients with congenital AS who required BAV in the first year of life between 2001 and 2016 were included. Patients who required direct surgical intervention were excluded. Echocardiography (echo) and cardiac catheterization (cath) data were analyzed. Response ratio (RR) was defined as the ratio between the drop in aortic valve (AV) peak gradient to the baseline peak gradient. Follow-ups and the need for reintervention were documented. Results A total of 60 infants were included. Sixteen patients (27%) were newborns. The average peak-to-peak gradient from the left ventricle to the ascending aorta was 64 ± 27 mmHg, which was reduced to an average of 27 ± 13 mmHg. Average response ratio was 53 ± 24%. None of the patients had a significant aortic insufficiency (AI) before procedure, while 6 (10%) had significant AI immediately after BAV. Fourteen patients (23%) required an additional BAV. They had low cath-RR of 39 ± 27 and echo-RR of 15 ± 33 versus those who had BAV once with ratios of 60 ± 17 (cath; p = 0.002) and 36 ± 28 (echo; p = 0.025) during the initial intervention. Eight patients (13.3%) required surgical interventions following BAV. They had small AV to pulmonary valve (PV) ratios (p = 0.029) and higher residual AV gradients (p Conclusion Balloon valvuloplasty in infancy resulted in a high rate of reintervention and mortality. The response ratios were useful for predicting the future need of an additional BAV, and the AV/PV ratio and AV residual gradient were more predictive of the need for surgical intervention.

Pericardial Patch Augmentation Is Associated With a Higher Risk of Recurrent Aortic Insufficiency

This study assessed early and late clinical outcomes in patients who underwent aortic valve repair or an aortic valve-sparing operation and investigated predictors for failure. Of 227 consecutive patients who underwent aortic valve repair or a valve-sparing operation in our department between 2004 and 2016, 81 (36%) underwent aortic root replacement with or without cusp repair, 97 (42%) ascending aorta replacement with or without cusp repair, and 49 (22%) isolated aortic valve repair. Clinical and echocardiographic follow-up was complete. One patient (0.4%) died in-hospital. Mean clinical and echocardiographic follow-up was 69 ± 40 months (range, 1 to 147 months) and 53 ± 40 months (range, 1 to 147 months), respectively. Fifteen patients (6.6%) died during follow-up, with an overall 5-year survival rate of 94.4%. Recurrent significant (≥3) aortic insufficiency developed in 20 patients (8.8%), 17 of whom underwent reoperation, with a 5-year freedom from reoperation rate of 88%. Predictors for recurrent significant aortic insufficiency or reoperation were greater preoperative aortic insufficiency (grade III to IV vs I to II; relative risk [RR], 1.97; p= 0.023), cusp repair (RR, 2.92; p= 0.001), higher European System for Cardiac Operative Risk Evaluation score (RR, 1.16; p= 0.006), and valve repair with pericardial patch augmentation (RR, 2.34; p=0.032). Aortic valve repair and valve-sparing operations can be performed with good early and late clinical outcomes. In our experience, however, the rate of recurrent aortic insufficiency was significant, especially in patients who underwent cusp augmentation with glutaraldehyde-treated autologous pericardial patch.

Natural History of Mild Aortic Insufficiency at the Time of Left Ventricular Assist Device Implantation for Heartmate II and HVAD

Significant aortic insufficiency (AI) after continuous flow left ventricular assist device (CF-LVAD) implantation complicates the patient management. The progression of AI during CF-LVAD support is not well studied. We analyzed our single-cer experience with CF-LVADs to determine if mild aortic insufficiency (AI) at the time of LVAD implantation progresses to severe AI requiring surgical intervention.

Percutaneous balloon dilatation for congenital aortic stenosis during infancy: A 15-year single-center experience.

Background:Congenital aortic stenosis (AS) is a rare disease. Treatment options for newborns are challenging. Newborns may have higher reintervention rate and mortality.Objectives:The study aimed to identify the factors predictive of reintervention following balloon aortic valvuloplasty (BAV) for AS during infancy.Methods:Retrospectively, between 2001 and 2016, echocardiography (echo) and cardiac catheterization data for infants with AS were analyzed, including follow-ups and reinterventions. Percentage reduction was defined as the ratio between the drop of aortic valve (AV) peak gradient and the baseline peak gradient.Results:Sixty infants were included and 48 were followed up. Sixteen (27%) patients were neonates. Peak-to-peak gradient at AV was 64 ± 27 mmHg, which was reduced to 27 ± 13 mmHg. Percentage reduction was 53% ±24%. Forty-nine (82%) patients had adequate results (residual AV gradient <35 mmHg). There was no significant aortic insufficiency (AI) before procedure, while 6 (10%) patients had increased AI immediately after BAV. Of 48 patients, 14 (29%) required an additional BAV. Of 48 patients, 8 (17%) required surgical interventions following BAV. Reintervention was associated more with small left ventricular outflow tract (LVOT), high residual AV, and low percentage reduction. Mortality was 8.3%.Conclusions:BAV in infancy has a reasonable success rate (82%) with high rate of reintervention. Patent ductus arteriosus-dependent neonates carried the highest risk of mortality. Small LVOT, high AV residual gradient, and low percentage reduction resulted in more reinterventions.

Open repair of chronic thoracic and thoracoabdominal aortic dissection using deep hypothermia and circulatory arrest

BackgroundChronic dissection of the thoracic and thoracoabdominal aorta as sequela of a prior type A or B dissection is a challenging problem that requires close radiographic surveillance and prompt operative intervention in the presence of symptoms or aneurysm formation. Open repair of chronic thoracic and thoracoabdominal aortic dissection using deep hypothermia has been our preferred method to treat this complex pathology. The advantages of this technique include organ and spinal cord protection, the flexibility to extend the repair proximally into the arch, and the ability to limit ischemia to all vascular beds. MethodsOpen repair of arch by left thoracotomy and descending thoracic and thoracoabdominal aortic pathology using deep hypothermia was performed in 664 patients from 1995 to 2015. A subset of this cohort had chronic thoracoabdominal aortic dissection (n = 196). All nonemergency cases received coronary angiography and echocardiography preoperatively. Significant coronary artery disease or severe aortic insufficiency was addressed before repair of the chronic dissection. In recent years, lumbar drains were placed preoperatively in the most extensive repairs (extents II and III). Important intercostal arteries from T8 to L1 were revascularized with smaller-diameter looped grafts. Multibranched grafts for the visceral segment have been preferred in recent years. ResultsMean age of patients was 58 ± 14 years. Men comprised 74% of the cohort. Aortopathy was confirmed in 18% of the cohort. Prior thoracic aortic repair occurred in 57% of patients, and prior abdominal aortic repair occurred in 14% of patients. Prior type A aortic dissection occurred in 44% of patients, and prior type B occurred in 56% of patients. Operative mortality was 3.6%, permanent spinal cord ischemia occurred in 2.6% of patients, permanent hemodialysis occurred in 0% of patients, and permanent stroke occurred in 1% of patients. Reexploration for bleeding was 5.1%, and respiratory failure requiring tracheostomy occurred in 2.6%. Postoperative length of stay was 11.9 ± 9.7 days. Reintervention for pseudoaneurysm or growth of a distal aneurysm was 6.9%. The 1-, 5-, and 10-year survivals were 93%, 79%, and 57%, respectively. ConclusionsOpen repair of chronic thoracic and thoracoabdominal aortic dissection using deep hypothermia and circulatory arrest has low morbidity and mortality. The need for reintervention is low, and long-term survival is excellent. We believe that open repair continues to be the gold standard in patients who are suitable candidates for surgery.

Hybrid Treatment of Multilevel Aortic Disease in an Adolescent :A Case Report

Bicuspid aortic valve is a common congenital defect associated with several other pathological processes. We describe a complex case in a 13-year-old boy where there was significant aortic valve insufficiency and a severely dilated ascending aorta. In addition, there was complex coarctation of the aorta in which both subclavian arteries arose from the coarctation site. A hybrid bilateral carotid-subclavian bypass grafting with coarctation stenting procedure was performed followed by a modified Bentall procedure. This case illustrates a successful two-stage, hybrid technique in a late-diagnosed paediatric patient.

Mitral Valve Regurgitation in the LVAD-Assisted Heart Studied in a Mock Circulatory Loop.

Permanent closure of the aortic valve (AVC) is sometimes performed In LVAD patients, usually when a mechanical valve prosthesis or significant aortic insufficiency is present. Mitral valve regurgitation (MVR) present at the time of LVAD implantation can remain unresolved, representing a limitation for exercise tolerance and a potential predictor of mortality. To investigate the effect of MVR on hemodynamics of the LVAD-supported heart following AVC, studies were performed using a mock circulatory loop. Pressure and flow measured for a range of cardiac function, LVAD speed, and MVR show that cardiac contraction augments aortic pressure by 10-27% over nonpulsatile conditions when the mitral valve functions normally, but decreases with MVR until it reaches the nonpulsatile level. Aortic flow displays a similar trend, demonstrating a 25% decrease from fully functioning to open at 7krpm, a 5% decrease at 9krpm, and no observable effect at 11krpm. Pulsatility decreases with increased LVAD speed and MVR. The data indicate that a modest level of cardiac output (1.5-2 L/min) can be maintained by the native heart through the LVAD when the LVAD is off. These results demonstrate that MVR decreases the augmentation of forward flow by improved cardiac function at lower LVAD speeds. While some level of MVR can be tolerated in LVAD recipients, this condition represents a risk, particularly in those patients that undergo AVC closure, and may warrant repair at the time of surgery.

IMPACTS OF THE SYSTEMIC RIGHT VENTRICULAR TRABECULAE AND PAPILLARY MUSCLES ON VOLUMES AND FUNCTION ASSESSED BY NOVEL MAGNETIC RESONANCE ALGORITHM

BACKGROUND: Procedural rapid ventricular pacing (RVP) and transoesophageal echocardiography (TOE) guidance have been well established in the transcatheter aortic valve replacement field. However, scarce data exist on the use of these techniques for transcatheter treatment of congenital aortic stenosis. METHODS: Charts of all patients undergoing balloon aortic valvuloplasty from January 1995 to January 2015 at the Centre Hospitalier de l’Universite Laval in Quebec City were reviewed. Statistical analyses between groups were done by univariate studies. Cox regression analysis was used to evaluate factors influencing freedom from surgery. RESULTS: Sixty-one patients (37 males; 24 females) with a mean age of 7.2 11.5 years and a mean gradient of 58 21 mmhg underwent 71 balloon aortic valvuloplasty. The mean follow-up period is 4.9 4.9 years. Fourteen balloon valvuloplasty (19.7%) were done on patients <1 month and 22 (31%) on patients between 1 month and 1 year of age. Twenty-six procedures (37%) were on patients with associated left sided lesions, fibroelastosis or pulmonary stenosis (2 patients). Three patients had an aortic valve Z-score h -2. At last follow-up, 20 (32%) patients have required surgery: 8 for aortic insufficiency, 9 for residual stenosis and 2 for a mixed lesion. Since August 2006, rapid pacing has been used in 20 procedures, which represents 28% of the overall cohort and 82% of the procedures done after 08-2006. The use of rapid pacing was associated with a shorter procedure time (112 11 vs 79 5 min p1⁄40.008), and a tendency towards requiring less surgical intervention on follow-up (p1⁄40.08). Since January 2004, determination of balloon diameter has relied on valve annulus measurement done per procedure by TOE (40/51 procedures; 78%). The use of TOE was associated with less complications (7 vs 32% p1⁄40.01). Significant aortic insufficiency, on early follow up transthoracic echocardiogram, was the only predictor of the need of a surgical aortic procedure at median term follow-up (p1⁄40.002). CONCLUSION: The use of TOE guidance and RVP improved the results of balloon aortic valvuloplasty in congenital patients. This may have a major impact on the need for surgical procedures in these patients. Larger studies with a longer follow-up are needed to confirm these results. 059 IMPACTS OF THE SYSTEMIC RIGHT VENTRICULAR TRABECULAE AND PAPILLARY MUSCLES ON VOLUMES AND FUNCTION ASSESSED BY NOVEL MAGNETIC RESONANCE ALGORITHM

Aortic valve repair for insufficiency in older children offers unpredictable durability that may not be advantageous over a primary Ross operation†.

To evaluate the durability of aortic valve (AoV) repair relative to other strategies for children with significant aortic insufficiency (AI). From 2001 to 2012, 90 children with greater than or equal to moderate AI underwent surgery. Resulting procedures were classified according to final operative outcome: AoV repair (repair; n = 46, 51%), Ross procedure (Ross; n = 21, 23%) or replacement with mechanical or tissue prosthesis [aortic valve replacement (AVR); n = 23, 26%]. Repeated measures (n = 1081 echocardiograms) mixed-model analysis and parametric multiphase risk-adjusted hazard analysis were used to evaluate haemodynamic parameters and durability of operations. Mean age at operation was similar for repair and Ross groups, but slightly higher for the AVR group (10.6, 11 and 13.2, respectively; P = 0.04). Baseline annular dimensions were similar among groups. Of 46 repairs, 85% involved pericardial leaflet extensions (commonly with leaflet shaving and/or commisuroplasty). The remaining repairs were commissuroplasties. On multivariable analysis, repair was associated with increased early (∼1-2 years) AI and increased outflow tract peak pressure gradients relative to Ross and AVR procedures. On univariate analysis, repairs tended to have a larger annulus size compared with Ross or AVR; however, this was not significant on multivariable analysis. There were 25 reinterventions (surgical reoperation = 16; transcatheter intervention = 9) for 22 children. Freedom from surgical reoperation was 64, 100 and 51% at 6 years for repairs, Ross and AVR, respectively (P = 0.05); however, three of five reoperations after AVR were for failed bioprosthetic devices. The freedom from reintervention was not significantly influenced by the type of AoV operation (P = 0.43). Durability of aortic valve repair for children is limited by recurrence of AI and/or stenosis, often within the first few years. After repair, reoperation should be anticipated within ∼7 years.

Meandering pulmonary veins mimicking arteriovenous malformation

We report a case of preoperative incidental finding in a 34-year-old man with a significant aortic insufficiency. Preoperative chest x-ray was suspicious for arteriovenous malformation in the right lung. Chest CT angiography discovered an anomalous course of the left superior pulmonary vein crossing the mediastinum to the contralateral hemithorax, joining the right superior pulmonary vein before entering the right inferior pulmonary vein and forming a common trunk of right inferior pulmonary vein.

Comment on: Alternate description of waveform: Pulsus bisferiens

Dear Sir, We read the article written by Kassem et al.[1] in January with great interest. It described the path to diagnosing significant aortic insufficiency starting with abnormal ocular pulse amplitude (OPA) obtained with a dynamic contour tonometer. The OPA waveform obtained showed two peaks instead of one. The abnormal waveform described in this paper shows great resemblance to an arterial waveform described as “pulsus bisferiens.” This potential correlation was not mentioned by the authors. The term “pulsus bisferiens” was described in the context of aortic valve disease by Broadbent and Broadbent in 1900.[2] Fleming described the mechanism of pulsus bisferiens in 1957 in patients with combined aortic stenosis and insufficiency. More recently, Mark published depictions of pulsus bisferiens in his atlas of monitoring.[3] As an anesthesiologist frequently using invasive blood pressure monitoring, it is not uncommon to observe “pulsus bisferiens” displayed when taking care of patients with significant aortic insufficiency. We attached two figures demonstrating “pulsus bisferiens” in patients with aortic insufficiency, showing waveform variations. [Figs. ​[Figs.11 and ​and22]. Figure 1 Example 1 - Arterial waveform with pulsus bisferiens Figure 2 Example 2 - Arterial waveform with pulsus bisferiens If intraocular pressure closely relates to the arterial pressure, it comes as no surprise that the waveform would resemble an arterial waveform. As the authors are that suggesting OPAs might be used as a screening tool for other diseases, we would suggest thinking of “pulsus bisferiens” when noticing a waveform with two peaks, and direct a further workup toward aortic valve disease. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Use of del Nido Cardioplegia for Adult Cardiac Surgery at the Cleveland Clinic: Perfusion Implications

Cardiac arrest by cardioplegia provides a reproducible and safe method to induce and maintain electromechanical cardiac quiescence. Techniques of intraoperative myocardial protection are constantly evolving. For the past three decades, modified Buckberg cardioplegia solution has been used for adult cardiac surgery at the Cleveland Clinic. This formulation serves as the crystalloid component, which is delivered 4:1 with oxygenated patient’s blood to crystalloid. Meanwhile, our use of the del Nido cardioplegia solution in adult patients, heretofore primarily used in pediatric cardiac surgical centers, has been increasing over the past several years. Single-dose, cold blood del Nido cardioplegia can be delivered antegrade if the duration of the operation will be limited and if there is no significant coronary artery disease or aortic insufficiency that would limit the distribution of cardioplegia. The addition of del Nido cardioplegia to our cardioplegia armamentarium allows us to customize our myocardial protection strategies for different surgical needs. This article aims to provide information on technical aspects of del Nido cardioplegia in adult cardiac surgery and its use at the Cleveland Clinic in the adult surgical population.

Sutureless Aortic Valve Replacement: A Canadian Multicentre Study

BackgroundSutureless aortic valve replacement (AVR) has recently been introduced as an alternative to standard AVR in elderly high-risk surgical patients. The purpose of this study was to report the early Canadian experience with sutureless AVR. MethodsA Canadian multicenter study included 215 consecutive patients from 6 centres who underwent sutureless AVR using the Perceval S bioprosthesis (Sorin Group, Saluggia, Italy) between June 2011 and May 2013. Perioperative clinical and echocardiographic outcomes were assessed in all patients. ResultsMean age was 79 ± 6 years, and 116 patients (54%) were women. Concomitant procedures included coronary artery bypass grafting in 86 patients (40%), multiple valve procedures in 24 (11%) patients, and septal myectomy in 9 (4%) patients. A full sternotomy was used in 173 cases (80%), a minithoracotomy in 23 (11%) cases, and a partial sternotomy in 19 (9%) cases. Nineteen cases (9%) were redo procedures. For isolated AVR, mean aortic cross-clamp time was 41±12 minutes. In-hospital mortality occurred in 9 patients (4%). No postoperative valve migration was reported. A total of 37 patients (17%) underwent postoperative implantation of a permanent pacemaker, including 20 patients (9%) who had complete atrioventricular block. Postoperative stroke occurred in 7 patients (3%). Echocardiographic evaluation demonstrated well-seated valves with no significant (2+) valvular or paravalvular aortic insufficiency and a mean aortic gradient of 13 ± 6 mm Hg. ConclusionsSutureless AVR using the Perceval S prosthesis is safe and reproducible and results in short operative times. Echocardiographic results are encouraging, with low gradients and no paravalvular aortic insufficiency. However, in this series, sutureless AVR was associated with a high risk of permanent pacemaker implantation.

Hybrid balloon valvuloplasty through the ascending aorta via median sternotomy in infants with severe congenital valvular aortic stenosis: feasibility of a new method†

To evaluate a novel hybrid balloon valvuloplasty procedure for severe congenital valvular aortic stenosis in low-weight infants, performed through the ascending aorta via median sternotomy. Eighteen infants (<90 days of age) with severe congenital aortic stenosis were included in this study. Hybrid balloon valvuloplasty procedures were performed in a hybrid operating room. Patients were followed up at 3 months, 6 months, 1 year and then annually following the procedure. The hybrid balloon valvuloplasty procedure was successful in all patients. Eight patients were successfully rescued from left ventricular systolic dysfunction by cardiac compression under direct vision. The aortic valve pressure gradient decreased from 80.3 ± 20.8 mmHg preoperatively to 16.0 ± 3.6 mmHg immediately postoperatively (P < 0.001). None of the patients developed significant aortic insufficiency. The fluoroscopy time was 6.2 ± 2.9 min. Intraoperative blood transfusions and pacing were not required. The patients were all alive and healthy at the end of the follow-up period (mean 21.3 months; range 3-41 months), and the aortic valve pressure gradient remained low (21.7 ± 5.3 mmHg). Reintervention was not required in any of the patients. Hybrid balloon valvuloplasty through the ascending aorta via median sternotomy is an effective and safe procedure for infants with severe congenital aortic stenosis.