[Show abstract][Hide abstract] ABSTRACT: Direct aortic trans-catheter aortic valve implantation is an alternative approach to treat high risk for surgery patients affected by severe aortic stenosis and concomitant peripheral vascular disease.We describe a case of direct aortic CoreValve implantation made via a right anterior thoracotomy in a 78-year-old male affected by severe aortic stenosis and severe peripheral vasculopathy, who previously underwent coronary artery bypass grafting, with patent bilateral mammary artery grafts and chronic aortic arch dissection.
[Show abstract][Hide abstract] ABSTRACT: Infective endocarditis during pregnancy carries a high mortality risk, both for the mother and for the foetus and requires
a multidisciplinary team in the management of complicated cases. We report our experience with a 39-year old patient, affected
by an acute active mitral endocarditis due to Abiotrophia defectiva at the 14th gestational week, strongly motivated to continue the pregnancy. Our patient successfully underwent mitral valve
replacement with a normothermic high-flow cardiopulmonary bypass under continuous intraoperative foetal monitoring. Caesarean
section occurred at the 38th gestational week. The delivery was uneventful and both the mother and child are doing well at
the 16-month follow-up.
Full-text · Article · Oct 2015 · Interactive Cardiovascular and Thoracic Surgery
[Show abstract][Hide abstract] ABSTRACT: Transcatheter aortic valve implantation (TAVI) is used to treat elderly patients with severe aortic stenosis who are considered extremely high-risk surgical candidates. The safety and effectiveness of TAVI have been demonstrated in numerous studies. The self-expanding CoreValve bioprosthesis (Medtronic Inc., Minneapolis, MN, USA) was the first transcatheter aortic valve to be granted the Conformité Européene (CE) mark in May 2007 for retrograde transfemoral implantation. However, TAVI patients are also often affected by severe iliofemoral arteriopathy. In these patients, the retrograde transfemoral approach carries a high risk of vascular injury, making this approach unusable. Alternative arterial access sites, such as the subclavian artery, the ascending aorta, and the carotid artery, have been used for retrograde implantation of the CoreValve bioprosthesis. In the present report, we present the procedural considerations, risks, and benefits of the different types of arterial access used to implant the CoreValve bioprosthesis.
Full-text · Article · Feb 2015 · Expert Review of Medical Devices
[Show abstract][Hide abstract] ABSTRACT: Redo cardiac surgery represents a clinical challenge due to a higher rate of perioperative morbidity and mortality. Mitral
valve (MV) re operations can particularly be demanding in patients with patent coronary grafts, previous aortic valve replacement,
calcified aorta or complications following a previous operation (abscesses, leaks or thrombosis). In this article we describe
our technique to manage complex mitral reoperations using a minimally invasive approach, moderate hypothermia and avoiding
aortic cross-clamping. Minimally invasive procedures with an unclamped aorta have the potential to combine the benefits of
less invasive access and continuous myocardial perfusion. The advantage of a right mini-thoracotomy is the avoidance of sternal
re-entry and limited dissection of adhesions, reducing the risk of cardiac structures or patent graft injury. Moderate hypothermia
and continuous blood perfusion can guarantee adequate myocardial protection particularly in the case of patent grafts, decreasing
the dangers of an incomplete or imperfect aortic clamping at mild hypothermia and potential lesions due to demanding clamp
placing. Complex MV reoperations can be safely and effectively performed through a smaller right thoracotomy in the fourth
intercostal space with an unclamped aorta.
Full-text · Article · Jan 2014 · Multimedia Manual of Cardiothoracic Surgery
[Show abstract][Hide abstract] ABSTRACT: Redo cardiac surgery represents a clinical challenge due to a higher rate of peri-operative morbidity and mortality. Mitral valve re-operations can be particularly demanding in patients with patent coronary artery bypass grafts, previous aortic valve replacement, calcified aorta or complications following a previous operation (abscesses, perivalvular leaks, or thrombosis). Risk of graft injuries, hemorrhage, the presence of dense adhesions and complex valve exposure can make redo valve operations challenging through a median sternotomy. In this review article we provide an overview of minimally invasive approaches for redo mitral valve surgery discussing indications, techniques, outcomes, concerns and controversies. Scientific literature about minimally invasive approach for redo mitral surgery was reviewed with a MEDLINE search strategy combining "mitral valve" with the following terms: 'minimally invasive', 'reoperation', and 'alternative approach'. The search was limited to the last ten years. A total of 168 papers were found using the reported search. From these, ten papers were identified to provide the best evidence on the subject. Mitral valve reoperations can be safely and effectively performed through a smaller right thoracotomy in the fourth intercostal space termed "mini" thoracotomy or "port access". The greatest potential benefit of a right mini-thoracotomy is the avoidance of sternal re-entry and limited dissection of adhesions, avoiding the risk of injury to cardiac structures or patent grafts. Good percentages of valve repair can be achieved. Mortality is low as well as major complications. Minimally invasive procedures with an unclamped aorta have the potential to combine the benefits of minimally invasive access and continuous myocardial perfusion. Less invasive trans-catheter techniques could be considered as the natural future evolution for management of structural heart disease and mitral reoperations. The safety and efficacy of these procedures has never been compared to open reoperations in a randomized trial, although published case series and comparisons to historical cohorts suggest that they are an effective and feasible alternative. Ongoing follow-up on current series will further define these procedures and provide valuable clinical outcome data.
Full-text · Article · Nov 2013 · Journal of Thoracic Disease
[Show abstract][Hide abstract] ABSTRACT: Introduction
Surgical repair of the aortic arch is technically demanding and requires complex circulatory management. Endovascular techniques can treat arch diseases but frequently need surgical de-branching of supra-aortic vessels.
We describe the use of a new, custom-made, branched stent-graft system to treat a penetrating atherosclerotic ulcer of the aortic arch. This system consisted of a combination of three endoluminal prostheses introduced via peripheral arteries.
The branched stent-graft system was effective and safe. Minimally invasive techniques for aortic-arch repair are attractive but technological progress and further improvements are still necessary in the endovascular treatment of complex arch anatomy.
[Show abstract][Hide abstract] ABSTRACT: Postsurgical intrapericardial adhesions are still considered an unavoidable consequence of cardiothoracic operations. They increase the technical difficulty and the risk of reoperations. The pathogenesis of postsurgical adhesions is a multistep process, and the main key players are (1) loss of mesothelial cells, (2) accumulation of fibrin in areas devoid of mesothelial cells, (3) loss of normal pericardial fibrinolysis, and (4) local inflammation. Today, very promising methods to reduce adhesions are available for clinical use. This report reviews the process of formation of adhesions and the methods to prevent them, classified according to the mechanism of action.
Full-text · Article · Apr 2013 · The Annals of thoracic surgery
[Show abstract][Hide abstract] ABSTRACT: Increased oxidative stress in a failing heart may contribute to the pathogenesis of heart failure (HF). The aim of this study was to identify the oxidised proteins in the myocardium of HF patients and analyse the consequences of oxidation on protein function. The carbonylated proteins in left ventricular tissue from failing (n = 14) and non-failing human hearts (n = 13) were measured by immunoassay and identified by proteomics. HL-1 cardiomyocytes were incubated in the presence of stimuli relevant for HF in order to assess the generation of reactive oxygen species (ROS), the induction of protein carbonylation, and its consequences on protein function. The levels of carbonylated proteins were significantly higher in the HF patients than in the controls (p<0.01). We identified two proteins that mainly underwent carbonylation: M-type creatine kinase (M-CK), whose activity is impaired, and, to a lesser extent, α-cardiac actin. Exposure of cardiomyocytes to angiotensin II and norepinephrine led to ROS generation and M-CK carbonylation with loss of its enzymatic activity. Our findings indicate that protein carbonylation is increased in the myocardium during HF and that these oxidative changes may help to explain the decreased CK activity and consequent defects in energy metabolism observed in HF.
[Show abstract][Hide abstract] ABSTRACT: Detection of S-nitrosylated CK in myocardium from HF patients and controls. (A). Nitrosylated proteins have been biotinylated and subjected to immunoprecipitation of creatine kinase (CK). Immunoblots were performed with anti-CK, to confirm the immunoprecipitation, and with an anti-biotin antibody, to identify S-nitrosylated CK. (B). The amount of S-nitrosylated CK was given by the ratio between densitometric values of the S-nitrosylated band and those of the CK band. Values are mean±SD. (C). Representative 1-DE image of total nitrosylated proteins in myocardium of controls and HF patients. Nitrosylated proteins have been biotinylated and equal amount of proteins have been subjected to immunoblotting with a biotin detection reagent.
[Show abstract][Hide abstract] ABSTRACT: We reviewed our experience to assess potential advantages of minimally invasive surgery without aortic clamping over conventional median sternotomy and cardioplegic arrest during reoperative valve surgery.
From August 2008 to August 2010, 22 reoperative valve procedures were performed through a minimally invasive approach without aortic cross-clamping [no-clamp group (NCG)]. Postoperative results were compared to a matched population in terms of sex, age, and type of surgery, and operated through median sternotomy with aortic cross-clamping and cardioplegic arrest [clamp group (CG)].
We performed 17 mitral valve replacements (MVRs), one mitral valve repair, one MVR associated to a tricuspid plasty (TVP), and three isolated TVP in both groups. Cardiopulmonary bypass (CPB) time was 166 and 163 minutes in NCG and CG, respectively. Intra-aortic balloon pump was necessary in two (NCG) and three (CG) patients. Two patients died in both groups from multiorgan failure. Biochemical analysis showed no significant differences in perioperative lactate or creatine kinase-MB values.
Redo valve surgery with an unclamped aorta is feasible, effective, and at least as safe as surgery using cardioplegic arrest. There was, however, no difference in biochemical or clinical outcomes from conventional surgery using aortic clamping and cardioplegic techniques.
Full-text · Article · Dec 2011 · Journal of Cardiac Surgery
[Show abstract][Hide abstract] ABSTRACT: Trans-catheter aortic valve implantation has emerged and rapidly gained credibility as a valuable alternative to treat patients with severe aortic stenosis and no surgical option; however, these patients are often affected also by severe iliac-femoral arteriopathy, rendering the transfemoral approach unemployable. From May 2008, 92 patients with severe, symptomatic aortic stenosis and no reasonable surgical option because of excessive risk underwent trans-catheter aortic valve implantation at our center. Eighty patients (34 male) with mean age 82 ± 8 years were eligible for CoreValve percutaneous femoral implantation. Twelve patients, mean age 81 ± 8 years, were excluded from percutaneous femoral CoreValve implantation because of iliac-femoral arteriopathy.
These 12 patients underwent trans-catheter aortic valve implantation through the left axillary artery in six cases, the other six directly from the ascending aorta through a right anterior mini-thoracotomy. Procedures were performed by a combined team of cardiologists, cardiac surgeons, and anesthetists.
Procedural success was obtained in 11 cases; all these patients were discharged in asymptomatic status, with midterm good prosthesis performance. Three patients required the implantation of a permanent pacemaker. One patient needed a subclavian covered stent implantation to treat a post-implant artery dissection. One patient of the direct aortic access group was converted to the femoral approach due to an extremely fragile aortic wall, but died in the intensive care unit of abdominal aortic aneurysm rupture. All discharged patients improved their New York Heart Association (NYHA) functional class and functional capacity, and echocardiograms evidenced good valve performance at 2 years.
Trans-catheter aortic valve implantation with surgical subclavian or direct aortic approach seems safe and feasible, offering a new attractive option to treat selected high-risk patients with severe aortic stenosis and peripheral vasculopathy, and has emerged as a valuable alternative route to trans-apical procedures.
Full-text · Article · Mar 2011 · European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery
[Show abstract][Hide abstract] ABSTRACT: Aortic valve disease is the most common acquired valvular heart disease in adults. With the increasing elderly population, the proportion of patients with symptomatic aortic stenosis who are unsuitable for conventional surgery is increasing. Transcatheter aortic valve implantation has rapidly gained credibility as a valuable alternative to surgery to treat these patients; however, they often have severe iliac-femoral arteriopathy, which renders the transfemoral approach unusable. We report our experience with the trans-subclavian approach for transcatheter aortic valve implantation using the CoreValve (Medtronic CV Luxembourg S.a.r.l.) in 6 patients.
In May 2008 to September 2009, 6 patients (mean age of 82 ± 5 years), with symptomatic aortic stenosis and no reasonable surgical option because of excessive risk, were excluded from percutaneous femoral CoreValve implantation because of iliac-femoral arteriopathy. These patients underwent transcatheter aortic valve implantation via the axillary artery. Procedures were performed by a combined team of cardiologists, cardiac surgeons, and anesthetists in the catheterization laboratory. The CoreValve 18F delivery system was introduced via the left subclavian artery in 6 patients, 1 with a patent left internal thoracic to left anterior descending artery graft.
Procedural success was obtained in all patients, and the mean aortic gradient decreased 5 mm Hg or less immediately after valve deployment. One patient required implantation of a permanent pacemaker. One patient required a subclavian covered stent implantation to treat a postimplant artery dissection associated with difficult surgical hemostasis. One patient was discharged in good condition but died of pneumonia 40 days after the procedure. All patients were asymptomatic on discharge, with good mid-term prosthesis performance.
Transcatheter aortic valve implantation via a surgical subclavian approach seems safe and feasible, offering a new option to treat select, inoperable, and high-risk patients with severe aortic stenosis and peripheral vasculopathy.
No preview · Article · Oct 2010 · The Journal of thoracic and cardiovascular surgery