Choosing to perform mitral valve (MV) repair or replacement remains a hot and highly debated topic. The current guidelines seem to be conflicting in this specific field and the evidences at our disposal are scarce, only one small randomized trial and few larger retrospective studies. The meta-analysis by Gamal and coworkers tries to summarize the current evidences, concluding that MV replacement for the treatment of ischemic mitral regurgitation is at least as safe as repair and certainly offers a more stable result over time than the latter. Obviously, the implantation of a prosthesis, especially a mechanical one, brings with it a series of problems, such as anticoagulation and, above all, a possible lack of ventricular remodeling, especially if a chordal sparing replacement is not performed. It must be said, on the other hand, that isolated annuloplasty cannot act as a counterpart to replacement, because ischemic MR cannot be considered only an annular disease. Therefore, wanting to mimic the nature that, after an infarction, enacts a series of changes involving also the mitral leaflets and chordae, the surgeons are called to act also on these two entities and not only to downsize the annulus. In a nutshell, a procedure should not be opposed in a fundamentalist way to another one, but we must accept the concept of armamentarium where both procedures are present and tail on the single patient, and also on the surgeon’s expertise, the technique guaranteeing the best possible result.
The COVID-19 pandemic has remarkably impacted the hospital management and the profile of patients suffering from acute cardiovascular syndromes. Among them, acute infective endocarditis (AIE) represented a rather frequent part of these urgent/emergent procedures. The paper by Li and colleagues has clearly shown the higher risk features which patients with diagnosis of AIE presented at hospital admission during the first part (first and second waves) of the outbreak, often requiring challenging operations, but fortunately not associated with worse outcome if compared to results obtained prior to the SARS-2 pandemic. The report discussed herein presents several other aspects worth of discussion and comments, particularly in relation to hospital management and post-discharge outcome which certainly deserve to be highlighted, but also further investigations.
Background and aim of the study. Wrapping of the ascending aorta (AA), isolated or associated with aortoplasty, has never been completely accepted. Some complications, as folding of the aortic wall, compression of the vasa vasorum and changes in the flow pattern, with consequent dilatation of the proximal arch, have been described. We used fresh autologous pericardium (FAP), so far never reported, to wrap the AA, with the aim to stabilize its size when moderately dilated, maintaining the preoperative dimension or limiting the reduction to a few mm. Material and Methods. From 2015 to 2019, 10 patients, who were operated on for valve or coronary surgery or both, underwent wrapping of the AA with FAP. Mean age was 69±7 years and ESII 3.5±1.7. Four patients had moderately impaired ejection fraction (35-49%). Results. There was no early or late mortality. One patient was reoperated on after 48 months for severe mitral regurgitation. At a follow up of 53±14 months, a transthoracic echocardiogram showed that the AA size reduced slightly but significantly, from 45.2±2.0 to 42.5±4.1 mm, p=0.03. The diameter of the proximal arch remained unchanged, from 37.1±1.6 to 36.3±2.9 mm, p=0.20. Conclusions. In presence of moderately dilated AA wrapping can be a reasonable option. The use of FAP stabilizes the size of the aorta after a follow up of 53 months. Maintaining a size similar to the preoperative one avoids the complications related to the procedure.
The meta-analysis by He and collaborators [has the worth to cover, as much as possible, a gap of scientific evidence where conducting a randomized trial appears very complex for ethical and logistical reasons. The authors concluded that mitral valve repair (MVP) provide better pooled results, both early and late, with respect to mitral valve replacement (MVR). However, the superiority of MVP is driven by some single large cohort-studies where surgeons had wide experience in the field of MVP for IE. This finding is also confirmed by other studies. But if mitral repair produces such a better short- and long-term survival than replacement, why are there no clear indications from consensus and guidelines pushing surgeons toward the pursuit of a reconstructive procedure at almost any cost? We wonder but to repair or not to repair, is that really the question? The AATS consensus suggests to repair “whenever possible” but without providing more specific indications. If the two primary goals of surgery are total removal of infected tissues and reconstruction of cardiac morphology, including repair or replacement of the affected valve(s), probably MVP as to perform in case of less extensive tissue detriment by the infection. In more wide valve involvement, MVP may be the choice but only in very expert hands and in Centers with very large volume of valve repairing. This decision cannot therefore be the result of the choice of an individual but must derive from a careful multidisciplinary discussion to be held in an EndoTeam.
Resection or exclusion of scars following a myocardial infarction on the LAD territory started even before the beginning of the modern era of cardiac surgery. Many techniques were developed, but there is still confusion on who did what. The original techniques underwent modifications that brought to a variety of apparently new procedures that, however, were only a “revisitation” of what described before. In some case old techniques were reproposed and renamed, without giving credit to the surgeon that was the original designer. Herein we try to describe which are the seminal procedures and some of the most important modifications, respecting however the merit of who first communicated the procedure to the scientific world.
Since the first in-human implantation, trans-catheter aortic valve replacement (TAVR) has shown an exciting development in both technical and technological terms, becoming the standard of care for many patients, even not only inoperable ones. Although trans-femoral (TF) access has the scepter of first-line route for TAVR, in some cases, this access is not feasible, so several alternative routes were introduces over time. The network meta-analysis by Hameed et al has the great merit to provide a comprehensive picture. Hence, through either direct and indirect comparison, the authors confirmed as TF is the gold standard as access, followed by trans-carotid and trans-subclavian. Conversely, trans-thoracic (trans apical and trans-aortic) routes are the least safe and should be reserved only to sporadic cases.
It is well known that the left internal mammary artery (LIMA) should be the first conduit of choice. Similarly, especially in patients younger than 70 years, other conduits should be search among arterial grafts such as right internal mammary artery (RIMA) or radial artery (RA). If the RA can be harvested in the meanwhile of LIMA harvesting without time consuming, it is well established that former one has to be grafted only on presence of a good run-off. One of the main criticisms moved to the use of RIMA are linked to technical difficulties in its harvesting it. Edgar Aranda-Michel and coworkers tried to answer to the age-old question is “RIMA has to be used in situ or free-graft?” In a retrospective study on 667 patients (442 had free RIMA and 245 had free RIMA) that were also matched through propensity analysis (202 patients per group), they did not find any differences between the two groups in the major outcomes, including heart failure specific readmissions. This finding is consistent with the literature, hence the take-home message is whatever happens, two mammary is better than one.
The meta-analysis by Di Tommaso et al demonstrated as elderly patients with mitral regurgitation (MR) undergoing mitral valve repair (MVr) had lower short-term mortality and higher long-term survival with respect to patients undergoing mitral valve replacement (MVR). The benefit of repair is such, that initial surgical strategy is advisable in the elderly even in case of mild symptoms if compared with conservative management. However, even if repair can be performed in presence of some specific etiologies, as degenerative MR or secondary MR, there are always cases where a replacement can be an acceptable solution compared to a repair with uncertain future, regardless of our believes and our technical ability. In this subset of patients, the literature does not show any improvement in outcome of transcatheter mitral repair. Mitral valve repair has to be always done, but look at the etiologies and to the consequences that what is done today can cause tomorrow.
OBJECTIVE. For many years, functional tricuspid regurgitation (FTR) was considered negligible after treatment of left-sided heart valve surgery. The aim of the present network meta-analysis is to summarize the results of four approaches in order to establish the possible gold standard. METHODS A systematic search was performed to identify all publications reporting the outcomes of four approach for FTR, not tricuspid annuloplasty (no TA), suture annuloplasty (SA), flexible (FRA), rigid rings (RRA). All studies reporting at least one the four endpoints (early and late mortality, early and late moderate or more TFR) were included in a Bayesian network meta-analysis. RESULTS There were 31 included studies with 9,663 patients. Aggregate early mortality was 5.3% no TA, 7.2% SA, 6.6% FRA and 6.4% RRA; Early TR moderate-or-more was 9.6%, 4.8%, 4.6% and 3.8%; Late mortality was 22.5%, 18.2%, 11.9% and 11.9%; Late TR moderate-or-more was 27.9%, 18.3%, 14.3% and 6.4%. Rigid or semirigid ring annuloplasty was the most effective approach for decreasing the risk of late moderate or more FTR (–85% vs. no TA; –64% vs. SA; –32% vs. FRA). Concerning late mortality, no significant differences were found among different surgical approaches, however, flexible or rigid rings reduced significantly the risk of late mortality (78% and 47%, respectively) compared with not performing TA mortality. No differences were found for early outcomes. CONCLUSIONS. Ring annuloplasty seems to offer better late outcomes compare to either suture annuloplasty or not performing TA. In particular rigid or semirigid rings provides more stable FTR across time.
Mitral valve (MV) repair for mitral regurgitation (MR) due to posterior leaflet (PL) prolapse is achieved nowadays with a great success rate and a good survival, similar, in certain subgroups. In this paper, Sakaguchi et al describe their results in two groups of patients with PL prolapse. Some patients underwent resection (resection group) and others chordal replacement with/out limited resection (respect group). Results were similar in terms of survival and MR recurrence. Our goal is to eliminate, as much as possible, MR when a patient with degenerative MR is operated on. Reduction of the mitral orifice and consequently an increase of the transmitral gradient is the rule. MV repair for degenerative MR provides great results, but there is not a single surgical technique. A close evaluation of the anatomical findings will allow us to choose the best strategy for the individual patient. An open mind is the most important characteristic that a surgeon should have to repair a prolapsing PL without residual regurgitation and dangerous gradients.
Large studies demonstrated that moderate or severe patient-prosthesis mismatch (PPM) occurs in 44.2% to 65% of patients undergoing aortic valve replacement. If there is general agreement that patients with PPM have worse outcome than patients without, it is difficult to understand how to prevent this dangerous complication. The formula used to calculate the effective orifice area (EOA) of an implanted aortic prosthesis has many weak points that produce inconsistent results using the same prosthetic valve (type and size). The observed EOA (3 to 6 months postoperatively) of a #23 biological prosthesis can range from 0.9 to 3.5 cm², making PPM prevention impossible using projected EOA, where only the mean value is reported (1.83 cm² for the same #23 biological prosthesis). An EACTS-STS-AATS Valve Labelling Task Force has been established to suggest the manufacturers to present essential information on valvular prosthesis characteristics in standardized Valve Charts. For valves used in the aortic position, Valve Charts should include a standardized PPM chart to assess the probability of PPM after implantation. This will not solve completely the conundrum of prevention, but most likely it will be a step ahead.