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ABSTRACT: BACKGROUND: The aim of this retrospective study was to explore whether different tethering patterns in chronic ischemic mitral regurgitation have different distributions of left ventricular (LV) systolic longitudinal, circumferential, and radial strain before and after mitral valve repair. METHODS: Sixty-one patients with chronic ischemic mitral regurgitation who underwent mitral repair were divided on the basis of the preoperative anterior/posterior tethering angle ratio (cutoff value, 0.76). There were 29 patients with symmetric (group 1) and 32 with asymmetric (group 2) preoperative tethering patterns. Assessment of longitudinal peak systolic strain was performed offline by applying speckle-tracking imaging to the apical two-chamber, three-chamber, and four-chamber views of the left ventricle. Peak systolic radial and circumferential strain was obtained from short-axis views at the basal, middle, and apical levels. Twenty healthy subjects served as controls. RESULTS: In group 1, baseline LV strain was impaired in all LV segments, with the worst values in the anterolateral, anterior, and inferolateral segments at the midventricular and basal levels. In contrast, asymmetric patients showed higher values in the inferior and inferoseptal walls and values closer to normal in the other segments. After surgery, all strain measurements showed significant improvements in all LV segments in group 2, whereas in Group 1, strain worsened in the inferoseptal, inferior, and anteroseptal walls and did not change in the other segments CONCLUSIONS: Patients with baseline symmetric tethering patterns showed more extensive abnormal strain, which was observed in all LV segments and was not reverted by surgery. These findings require confirmation in additional larger studies.
Journal of the American Society of Echocardiography: official publication of the American Society of Echocardiography 02/2013; · 2.98 Impact Factor
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Fabiana Lucà,
Leen van Garsse,
Carmelo Massimiliano Rao, Orlando Parise,
Mark La Meir,
Calogero Puntrello,
Gaspare Rubino,
Rocco Carella,
Roberto Lorusso,
Gian Franco Gensini,
Jos G Maessen,
Sandro Gelsomino
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ABSTRACT: In the recent years minimally invasive mitral valve surgery (MIMVS) has become a well-established and increasingly used option for managing patients with a mitral valve pathology. Nonetheless, whether the purported benefits of MIMVS translate into clinically important outcomes remains controversial. Therefore, in this paper we provide an overview of MIMVS and discuss results, morbidity, mortality, and quality of life following mitral minimally invasive procedures. MIMVS has been proven to be a feasible alternative to the conventional full sternotomy approach with low perioperative morbidity and short-term mortality. Reported benefits of MIMVS include also decreased postoperative pain, improved postoperative respiratory function, reduced surgical trauma, and greater patient satisfaction. Finally, compared to standard surgery, MIMVS demonstrated comparable efficacy across a range of long-term efficacy measures such as freedom from reoperation and long-term survival.
Minimally invasive surgery. 01/2013; 2013:179569.
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ABSTRACT: We explored the influence of global longitudinal strain (GLS) measured with two-dimensional speckle-tracking echocardiography on left ventricular mass regression (LVMR) in patients with pure aortic stenosis (AS) and normal left ventricular function undergoing aortic valve replacement (AVR). The study population included 83 patients with severe AS (aortic valve area <1 cm(2)) treated with AVR. Bioprostheses were implanted in 58 patients (69.8 %), and the 25 remaining patients (30.2 %) received mechanical prostheses. Peak systolic longitudinal strain was measured in four-chamber (PLS(4ch)), two-chamber (PLS(2ch)), and three-chamber (PLS(3ch)) views, and global longitudinal strain was obtained by averaging the peak systolic values of the 18 segments. Median follow-up was 66.6 months (interquartile range 49.7-86.3 months). At follow-up, values of PLS(4ch), PLS(2ch), PLS(3ch), and GLS were significantly lower (less negative) in patients who did not show left ventricular (LV) mass regression (all P < 0.001). Baseline global strain was the strongest predictor of lack of LVMR (odds ratio 3.5 (95 % confidence interval 3.0-4.9), P < 0.001), and GLS value ≥-9.9 % predicted lack of LVMR with 95 % sensitivity and 87 % specificity (P < 0.001). Other multivariable predictors were the preoperative LV mass value (cutoff value ≥147 g/m(2), P < 0.001), baseline effective orifice area index (cutoff ≤0.35 cm(2)/m(2), P = 0.01), and baseline mean gradient (cutoff ≥58 mmHg, P = 0.01). Finally, we failed to find interactions between GLS and other significant parameters (all P < 0.05). Global longitudinal strain accurately predicts LV mass regression in patients with pure AS undergoing AVR. Our findings must be confirmed by further larger studies.
Heart and Vessels 11/2012; · 2.05 Impact Factor
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ABSTRACT: Minimally invasive atrial fibrillation surgery (MIAFS) has become a well established and increasingly used option for managing patients with stand-alone arrhythmia. Pulmonary veins (PVs) isolation continues to be the cornerstone of ablation strategies. Indeed, in most cases, atrial fibrillation (AF) is triggered in or near the PVs. Nevertheless, ectopic beats initiating AF may occasionally arise from non-PV foci. The knowledge of the anatomy and underlying morphology of PVs and non-PV foci is essential for cardiac surgeons treating AF patients with epicardial minimally invasive procedures. The anatomical structures relevant to the pathogenesis and the epicardial treatment of AF include the PVs, the pericardial space, the pericardial sinuses, the phrenic nerve, the left atrium, the retro-atrial and caval ganglionated plexuses, the ligament of Marshall, the caval veins and the left atrial appendage. In this review, we briefly describe the basic anatomy of these structures and discuss their specific correlations for cardiac surgeons interested in performing MIAFS.
European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 10/2012; · 2.40 Impact Factor
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ABSTRACT: AIMS: We retrospectively evaluated left atrial (LA) strain and strain rate (SR) before and after undersized mitral ring annuloplasty (UMRA) for chronic ischaemic mitral regurgitation (CIMR) with two-dimensional speckle-tracking echocardiography. METHODS AND RESULTS: Left atrial volumes, LA reservoir, LA conduit, LA contractile phases, and LA ejection fraction (LAEF) were measured in 95 CIMR patients who underwent coronary bypass grafting and UMRA. Left atrial peak global strain (ε), LA reservoir (SR(p)), LA conduit (SR(E)), and LA contractile phase (SR(A)) strain rates were obtained at the baseline and at the follow-up (median 41.5 months, interquartile range 23-61). Based on the recurrence of mitral regurgitation (MR) at the follow-up, the patients were divided into two groups: patients with (group MR+, n = 30) or without (group MR-, n = 65) recurrent MR. Twenty age-and gender-matched healthy adults were controls. In the MR- group, baseline ε (P < 0.001), SR(P) (P < 0.001), SR(E) (P < 0.001), and SR(A) (P < 0.001) were enhanced, while in MR+ group, ε (P < 0.001), SR(P) (P = 0.03), SR(E) (P = 0.03), and SR(A) (P = 0.003) were worse than controls. At the follow-up, none of these indices changed in the MR+ group while all returned to normal values in patients belonging to the MR- group. Left atrial deformation correlated with corresponding volumetric parameters. Furthermore, we found a direct correlation between SR(E) and early peak diastolic velocity (E) (ρ = 0.52, P = 0.02) and E-wave deceleration time (ρ = 0.50, P = 0.02). Finally, there was a strong correlation between ε, SR(P), and SR(A) (ρ = 0.72, P < 0.001 and ρ = 0.79, P < 0.001, respectively) and SR(E) (ρ = 0.69, P < 0.001 and ρ = 0.71, P < 0.001, respectively). Finally, ε, SR(P), and SR(E) (all, P < 0.001) were co-factors associated to recurrent MR. CONCLUSION: Left atrial peak global strain, peak systolic SR, and peak early diastolic SR were cofactors associated to recurrent MR. The assessment of LA strain and SR, in addition to other echocardiographic parameters, can be helpful in detecting patients undergoing UMRA who are unlikely to benefit from annuloplasty.
European heart journal cardiovascular Imaging. 10/2012;
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Leen van Garsse,
Sandro Gelsomino,
Fabiana Lucà, Orlando Parise,
Roberto Lorusso,
Emile Cheriex,
Sabina Caciolli,
Enrico Vizzardi,
Carmelo Massimiliano Rao,
Rocco Carella,
Gian Franco Gensini,
Jos Maessen
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ABSTRACT: BACKGROUND: In our study, we investigated the impact of papillary muscle systolic dyssynchrony (DYS-PAP) obtained by 2D speckle-tracking echocardiography (2D-STE) in the prediction of recurrent ischemic mitral regurgitation (MR) after restrictive annuloplasty. METHODS: The study population consisted of 524 consecutive patients who survived coronary artery bypass grafting (CABG) and restrictive annuloplasty, performed between 2001 and 2010 at 3 different Institutions and who met inclusion criteria. The assessment of DYS-PAP was performed preoperatively and at follow-up (median 45.3months [IQR 26-67]) by 2D-STE in the apical four-chamber view for the anterolateral papillary muscle (ALPM) and apical long-axis view for the posteromedial papillary muscle (PMPM). RESULTS: Recurrence of MR (≥2+ in patients with no/trivial MR at discharge) was found in 112 patients (21.3%) at follow-up. Compared to patients without recurrence of MR, these patients had higher DYS-PAP values at baseline (60.6±4.4ms vs. 47.2±2.9ms, p<0.001) which significantly worsened at follow-up (74.4±5.2ms, p=0.002 vs. baseline). In contrast, in patients with no MR recurrence, DYS-PAP was significantly reduced (25.3±4.4ms, p=0.002 vs. baseline). At logistic regression analysis DYS-PAP (odds ratio [OR]: 4.8, 95% Confidence Interval [CI]: 3.4-8.2, p<0.001), was the strongest predictor of recurrent MR with a cutoff ≥58ms (95%CI 51-66ms). The model showed an area under the Receiver Operating Characteristic (ROC) curve of 0.97 (CI 0.94-0.99 [optimism-corrected 0.94; CI 0.89-0.95]) with 98% sensitivity (CI 96-100% [optimism-corrected 95%; CI 91-96%]) and 90% specificity (CI 85-94% [optimism-corrected 87%; CI 82-90%]). CONCLUSIONS: DYS-PAP represents a reliable tool to identify patients with ischemic MR who can benefit from restrictive annuloplasty.
International journal of cardiology 10/2012; · 7.08 Impact Factor
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ABSTRACT: Objective: We investigated the impact of papillary muscle dyssynchrony (DYS-PAP) in predicting recurrent mitral regurgitation (MR) in patients with ischemic cardiomyopathy (ICM) undergoing undersized mitral ring annuloplasty (UMRA). Methods: One hundred forty-four ICM patients (left ventricular ejection fraction <35%) in sinus rhythm undergoing UMRA between January 2001 and December 2010 at three Institutions (University Hospital, Maastricht, The Netherlands; Careggi Hospital, Florence, Italy; Civic Hospital, Brescia, Italy) were recruited. The primary endpoint was the recurrence of MR at the latest echocardiographic study defined as insufficiency ≥2+ in patients with no/trivial MR at discharge. The assessment of DYS-PAP was performed by applying two-dimensional (2D) speckle-tracking imaging. Results: In patients with MR recurrence, DYS-PAP significantly worsened (84.1 ± 8.8 msec vs.65.4 ± 8.8 msec at baseline, P < 0.001) whereas in patients with no MR recurrence, DYS-PAP did not vary (22.3 ± 5.3 msec vs. 25.9 ± 7.2 msec at baseline, P = 0.8). Recurrent MR was positively correlated with preoperative DYS-PAP (P < 0.001), baseline anterior mitral leaflet tethering angle α (P < 0.001) and tethering symmetry index α/β before surgery (P < 0.001). There was no significant correlation between MR recurrence and other echocardiographic parameters. Logistic regression analysis revealed that baseline values of DYS-PAP (OR: 5.4 [95% CI: 3.1-7.7], P < 0.001), α (OR: 5.0 [2.6-6.7], P < 0.001), and α/β (OR: 3.9 [2.5-5.7], p < 0.001) were predictors of recurrent MR. A DYS-PAP value ≥ 58 msec predicted recurrence of MR with 100% sensitivity and 83% specificity (area under the curve [AUC]: 0.92 [0.7-1], P < 0.001). Conclusions: A DYS-PAP cutoff value of 58 msec is useful to identify patients in whom UMRA is likely to fail. That way decision making in ischemic functional MR might be facilitated.
Echocardiography 08/2012; · 1.24 Impact Factor
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ABSTRACT: We evaluated the papillary muscle systolic dyssynchrony (DYS-PAP) using two-dimensional speckle tracking echocardiography (2D-STE) in patients with chronic ischemic mitral regurgitation (CIMR) showing different preoperative leaflet pattern and investigated the impact of baseline tethering pattern in the prediction of significant post-repair desynchronized papillary muscle contraction.
We recruited 152 CIMR consecutive patients (64.4% male, mean age 65.9 ± 7.1 years) who survived coronary artery bypass grafting (CABG) and (undersized mitral ring annuloplasty, performed between 2001and 2010. The assessment of DYS-PAP was performed preoperatively and at follow-up (median 41.5 months [IQR 23-61]) by 2D-STE in the apical 4-chamber view for anterolateral papillary muscle and apical long-axis view for posteromedial papillary muscle). Based on the cutoff value (anterior-posterior tethering angle ratio α/β ≥ 0.76) patients were classified in 2 groups; symmetrical (group 1, n = 73, mean α/β = 0.81 ± 0.6) and asymmetrical preoperative tethering pattern (group 2, n = 79, mean α/β = 0.66 ± 0.4).
Recurrent MR occurred in 67.1% (n = 49) in group 1 versus 3.8% (n = 3) in group 2 (p < 0.001). Comparing both groups at baseline, patients in group 1 had higher DYS-PAP (57.7 ± 5.3 vs 29.8 ± 2.4 ms in group 2, p < 0.001) that significantly worsened at follow-up (78.1 ± 8.8 ms, p < 0.001 versus baseline), whereas in group 2 it improved (26.6 ± 6.0 ms, p < 0.001 versus baseline). Tethering symmetry significantly correlated with DYS-PAP (r = 0.90, p < 0.001) and it was a strong multivariable predictor of significant postoperative DYS-PAP (odds ratio 4.2; 95% confidence level 3.4 to 5.2, p < 0.001).
Tethering symmetry is an easy and immediate tool to identify CIMR patients with advanced DYS-PAP who are unlikely to benefit from mitral repair with undersized mitral ring annuloplasty.
The Annals of thoracic surgery 08/2012; 94(5):1418-28. · 3.74 Impact Factor
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ABSTRACT: The hybrid technique combines a mono or bilateral epicardial approach with a percutaneous endocardial ablation in a single-step procedure. We present our early results with this technique employing a monopolar radiofrequency source through a right thoracoscopy in patients with lone atrial fibrillation (LAF).
Between June 2009 and December 2010 nineteen consecutive patients (mean 60.8 ± 8.6 years, 84.2% male) underwent right unilateral minimally invasive hybrid procedure for LAF at our Institution. Ten patients (52.6.6%) had long-standing persistent AF while four (21.1%) had persistent and five (26.3%) paroxysmal AF. All patients were followed-up according the Heart Rhythm Society/European Heart Rhythm Association/European Cardiac Arrhythmia Society (HRS/EHRA/ECA) and Society of Thoracic Surgeon (STS) guidelines.
There were neither early nor late deaths. It was possible to complete all the procedures as planned without any conversion to cardiopulmonary bypass. No patient died during the follow up. At one year, 7/19 (36.8%) patients were in sinus rhythm with no episode of AF and off antiarrhythmic drugs (AAD). Time-related prevalence of postoperative AF peaked at 44.4% (41.3-47.4) at two weeks, was 30.4% (27.3-34.9) at three months, fell to 14.2% (11.6-18.1) by 6 months and was 13.3% (11.0-17.4) at 12 months Among patients with long-standing persistent (LSP) AF, 20% (2/10) were in Sinus rythm and off AAD. One-year success rates were 50% (2/4) in persistent and 60% (3/5) in paroxysmal AF. At 12 months estimated prevalence of antyarrhythmic drugs and Warfarin use were 26% (22.4-33.1) and 48% (37.2-53.2), respectively.
One year results combining the percutaneous endocardial with the right thoracoscopic epicardial technique were, in our experience, not satisfactory, particularly in patients with LSP and persistent AF. Our findings need to be confirmed by larger studies.
Journal of Cardiothoracic Surgery 07/2012; 7:71. · 1.19 Impact Factor
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ABSTRACT: BACKGROUND: We compared short-term results of a hybrid versus a standard surgical bilateral thoracoscopic approach employing radiofrequency (RF) sources in the surgical treatment of lone atrial fibrillation (LAF). METHODS: Between January 2008 and July 2010 sixty-three consecutive patients with LAF underwent minimally invasive surgery. Thirty-five (55.5%) underwent surgery with the hybrid approach whereas 28 (45.5%) underwent bilateral thoracoscopic standard procedure (no-hybrid group). All patients underwent continuous 7-day Holter Monitoring (HM) at 3months, 6months and 1year. RESULTS: At 1year, 91.4% and 82.1% (time-related prevalence 5.2% vs.6.0% [p=0.56]) of the patients were free of AF and AAD. The hybrid group yielded better results in long standing persistent AF (8.2% [time related prevalence 81.8% vs. 44.4%, p=0.001] vs.14.9%, p=0.04). One-year success rates were 87.5% vs. 100% (p=0.04) in persistent [time related prevalence 3.8% vs. 0%, p<0.001] and 87.5% vs. 100% (p=0.04) in paroxysmal AF [time related prevalence 3.2% vs. 0%, p<0.001] in the two groups. One-year prevalence of Warfarin use was significantly higher in the hybrid group (29.0% [26.2-33.1] and 13.4% [9.9-16.3]) with no difference by AF type. LA reverse remodeling occurred in 81.7% (n=30) of hybrid patients and 67.8% (n=19) of no-hybrid patients at latest control (p=0.02). Left atrial emptying fraction increased in both groups (50±14%, p<0.001and 52±12%, p=0.004 in hybrid and no-hybrid, respectively) without differences between groups (p=0.6). CONCLUSIONS: The hybrid procedure yielded excellent results in long-standing persistent AF. Our findings need to be confirmed by further larger studies.
International journal of cardiology 05/2012; · 7.08 Impact Factor
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ABSTRACT: We present our results with minimally invasive surgical treatment of lone atrial fibrillation (LAF) employing a radiofrequency (RF) source through a bilateral thoracoscopy.
Between January 2007 and January 2011, 28 consecutive patients (85.7% male, mean age 67.1 ± 9.1 years) with LAF underwent video-assisted bilateral RF ablation. Fourteen patients (50%) had paroxysmal, five (17.8%) persistent, and nine (32.2%) long-persistent LAF. All patients were followed-up according to the Heart Rhythm Society/ European Heart Rhythm Association/European Cardiac Arrhythmia Society (HRS/EHRA/ECA) and success/failure was reported as suggested by Society of Thoracic Surgeon (STS) guidelines. Mean follow-up was 27.8 ± 8.6 months.
Time-related prevalence of postoperative AF was 4.5% at 36 months. Success was much more likely in subjects with paroxysmal (3-year prevalence, 0%) or persistent (3-year prevalence, 0%) than long-standing persistent LAF (3-year prevalence, 8.3%). At 36 months the estimated prevalence of antiarrhythmic drugs was 11.3% (8.8 to 13.7). No major thromboembolic events were detected during the follow-up period and 36-month prevalence of Warfarin use was 15.2% (11.5 to 18.1). Finally, no patient underwent electrical cardioversion.
This approach yielded satisfactory results with a high degree of safety. Further larger studies are necessary to confirm our findings.
Journal of Cardiac Surgery 07/2011; 26(4):453-9. · 0.87 Impact Factor
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Fabiana Lucà,
Mark La Meir,
Carmelo Massimiliano Rao, Orlando Parise,
Ludovico Vasquez,
Rocco Carella,
Roberto Lorusso,
Benedetto Daniela,
Jos Maessen,
Gian Franco Gensini,
Sandro Gelsomino
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ABSTRACT: atrial fibrillation (AF) is associated with a significant burden of morbidity and increased risk of mortality. Antiarrhythmic drug therapy remains a cornerstone to restore and maintain sinus rhythm for patients with paroxysmal and persistent AF based on current guidelines. However, conventional drugs have limited efficacy, present problematic risks of proarrhythmia and cause significant noncardiac organ toxicity. Thus, inadequacies in current therapies for atrial fibrillation have made new drug development crucial. New antiarrhythmic drugs and new anticoagulant agents have changed the current management of AF. This paper summarizes the available evidence regarding the efficacy of medications used for acute management of AF, rhythm and ventricular rate control, and stroke prevention in patients with atrial fibrillation and focuses on the current pharmacological agents.
Cardiology research and practice. 01/2011; 2011:874802.
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ABSTRACT: The aim of this study was to evaluate the early and long-term outcomes in patients undergoing a Bentall procedure or its button modification for chronic aortic aneurysms with aortic valve incompetence.
Between January 1986 and January 2002, 65 patients (84% males, mean age 58.9 +/- 11 years) underwent aortic root replacement with a Bentall or a button-Bentall operation. Annuloaortic ectasia was the most frequent cause of aortic disease in this series (n = 37, 56.9%), followed by atherosclerotic aneurysms (n = 22, 33.9%), and post-stenotic dilation (n = 5, 7.7%). One patient (1.5%) underwent redo aortic root replacement,3 (4.6%) had a Marfan syndrome, and 6 (9.2%) underwent a concomitant replacement of the aortic arch. The duration of follow-up ranged from 2 to 192 months (mean 89.6 +/- 21.8 months).
The 30-day mortality was 0%. Early non-fatal complications comprised: bleeding requiring surgical re-exploration (n = 1, 1.5%), low output syndrome (n = 1, 1.5%), acute renal insufficiency (n = 1, 1.5%), transient ischemic attack (n = 2, 3.1%), stroke (n = 1, 1.5%), and pulmonary insufficiency (n = 1, 1.5%). There was a late death due to a pulmonary neoplasm. The 16-year actuarial survival was 97 +/- 2% (hazard 0.02 +/- 0.02). No patient required reoperation. Furthermore, the long-term clinical follow-up was characterized by the complete absence of endocarditis, anticoagulant-related hemorrhage, valve thrombosis, and prosthetic failure. Finally, the NYHA functional status was significantly improved (1.1 +/- 0.50, p < 0.001 vs preoperatively).
The late results of the Bentall and button-Bentall procedures were excellent. Our findings confirm that these techniques still constitute the gold standard in the surgical treatment of combined valve and ascending aorta pathologies.
Italian heart journal: official journal of the Italian Federation of Cardiology 07/2003; 4(7):454-9.
