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Objective Transventricular repair for acute ischemic posterior ventricular septal defect is challenging and is associated with high operative morbidity and mortality. We have adopted the alternative technique of transatrial repair and recently have added technical modifications that result in less residual or recurrent septal shunt. This study reports those modifications and the related outcomes. Methods Retrospective review of 10 patients with acute ischemic posterior ventricular septal defect operated from November 2006 through March 2013. The septal defect was repaired through the right atrium with a prosthetic patch. Interlocking sutures and an additional continuous suture line buttress around the perimeter of the patch were added to the repair in four (40%) patients. Results Killip class IV heart failure was present in nine (90%) of the patients, and all received preoperative intra-aortic balloon pump therapy. No patient who received the recent technical modifications experienced a residual or recurrent shunt. However, three (50%) patients who did not undergo this modification developed either a residual septal shunt (n = 1), an early recurrent septal shunt (n = 1), or a ventricular rupture (n = 1). There was no 30-day or in-hospital mortality after surgery, but a single patient died two years after operation due to congestive heart failure. The remaining patients are alive after surgery at a median of 2.0 years. Conclusions The transatrial repair of an acute ischemic posterior ventricular septal defect is a safe technique. The addition of interlocking pledgetted sutures and a patch suture line buttress decreases the incidence of residual and recurrent septal shunt. doi: 10.1111/jocs.12498 (J Card Surg 2015;30:233–237)

Patients who are candidates for surgical valve replacement (AVR) may benefit from diminished length of cardiopulmonary bypass time. Sutureless valve technology for AVR may facilitate the performance of the operation through smaller incisions, and more expeditiously due to the ability to anchor traditional bovine pericardial prostheses without the need for sutures. We report the first successful US implants of the Sorin PERCEVAL valve as part of the FDA IDE trial. doi: 10.1111/jocs.12333 (J Card Surg 2014;29:490–493)

Background Transapical transcatheter valve replacement is a relatively new technique for select patients with aortic valve stenosis, most of whom have severe peripheral vascular disease. We report our experience with the use of a right axillary artery conduit for arterial access during transapical valve replacement. Methods We reviewed the records of 129 patients who underwent transapical transcatheter aortic valve replacement between November 2009 and August 2013. The study group included 26 (20.2%) patients who received a right axillary artery conduit for arterial access. Median age of the patients was 84 years (63 to 90), sex was female in seven (26.9%), and Society of Thoracic Surgeons predicted risk of mortality was 8.7% (1.8 to 21.2). Results Axillary artery conduit use was significantly more common during the first half of our operative experience (24/65 patients, 36.9%) in comparison to the second half (2/64 patients, 3.1%; p

Background Most studies comparing transapical and transfemoral transcatheter aortic valve replacement include the center's early operative experience, which may negatively impact the outcomes. This study reports our experience beyond the learning curve with transapical and transfemoral transcatheter aortic valve replacement. Methods A total of 303 patients underwent transcatheter aortic valve replacement from November 2008 through August 2013. There were 153 patients (50.5%) who received transfemoral valve replacement, 130 (42.9%) received transapical valve replacement, and 20 (6.6%) received transaortic valve replacement. We retrospectively reviewed the outcomes of the most recent 100 consecutive patients each from the transfemoral and transapical valve replacement groups. Results The median age was 82 years (range, 54 to 95) and 110 patients (55%) were male; STS predicted risk of mortality was 8.1% (0.7 to 27.8) and was similar between groups (p = 0.256). Operative complications occurred in 49 patients (49%) in the transapical replacement group and in 43 (43%) in the transfemoral group (p = 0.478). Vascular complications occurred only in the transfemoral group and included nine patients (9%; p = 0.003). Paravalvular regurgitation at discharge of grade mild–moderate occurred in 23 patients (24.2%) in the transapical group in comparison to 40 (43.5%) in the transfemoral group (p = 0.006). Operative mortality occurred in two patients (2%) in the transapical group and in five (5%) in the transfemoral group (p = 0.445). Conclusions Transapical transcatheter aortic valve replacement is associated with less prevalence of vascular complications and mild–moderate paravalvular regurgitation in comparison to the transfemoral approach. Further study is necessary to determine if the transapical technique is the preferred option. doi: 10.1111/jocs.12323 (J Card Surg 2014;29:303–307)

Herein, we present a patient who underwent successful repair of failed mitral valve repair in whom intraoperative 3D transesophageal echocardiography provided accurate assessment of the mechanism of mitral regurgitation. In addition, we review the potential advantages and limitations of 3D echocardiography and its role in cardiac surgery.

Background Patients with cirrhosis who undergo cardiac operation with extracorporeal circulation are at high risk for operative morbidity and mortality. Transcatheter aortic valve replacement (TAVR) can obviate the need for cardiopulmonary bypass and may reduce operative morbidity in comparison to standard aortic valve replacement (SAVR) in select patients. Methods Review of 18 patients with aortic valve stenosis and cirrhosis treated with TAVR (n = 6) or SAVR (n = 12). Patient age was 71 years (58 to 83) and STS Predicted Risk of Mortality was 3.2% (0.7 to 12.3). There were 15 males (83%). Child–Turcotte–Pugh stage was A in 10 patients (56%), B in four (22%), and C in two (11%); the median MELD score was nine (7 to 14). Results TAVR was successful in all patients without the need for mechanical or cardiopulmonary bypass support. Blood transfusion occurred in four patients (67%) in the TAVR group and in the entire SAVR group. No deaths occurred in the TAVR group, and two (17%) occurred in the SAVR group. Operative complications occurred in two patients (33%) in TAVR group and in eight (67%) in the SAVR group. Hospital stay was five days (3 to 10) in the TAVR group and six (3 to 38) in the SAVR group. All TAVR patients were alive at last follow-up of 219 days (29 to 723), while only five were alive in the SAVR group at 228 days (36 to 719). Conclusions Our initial experience with TAVR in patients with cirrhosis is encouraging. The technique may be a viable alternative to SAVR in this high-risk subset of patients. doi: 10.1111/jocs.12177 (J Card Surg 2013;28:492–495)

Background We describe our contemporary experience for the management of patients with an acute postinfarction basal ventricle septal defect (VSD) using the transatrial (TA) and transventricular (TV) approaches. Methods Retrospective review of all patients diagnosed with an ischemic basal VSD since January 2000. There were 20 patients with a median age of 68 years (39 to 85); 13 (65%) were males. Median time from diagnosis of the ischemic basal VSD to operation was 22 hours (6 to 144). Results All patients received standard patch closure of the septal defect with exposure of the VSD through the TA approach in eight patients (40%) and the TV approach in 12 (60%). All TA group patients received tricuspid valve replacement, while in the TV group, two had tricuspid valve replacement and two repair. Five patients (25%) had clinically insignificant (

Background Vascular complications associated with transfemoral transcatheter aortic valve insertion (TAVI) are a frequent untoward consequence of arterial sheath insertion. We report the prevalence of anatomic arterial injury with open artery access TAVI. Methods This review consisted of 53 consecutive patients who received transfemoral Sapien 23 or 26 mm TAVI via the 22- or 24-French sheath through open artery access from November 2008. The median age of the patients was 83 years (range, 59 to 94), and there were 31 males (58%). All arteries were examined to determine the optimal point of access and then explored after removal of the sheath to document injury. Results The accessed artery had a minimal lumen diameter of 8.9 mm (7.2 to 14.7) and a sheath-to-artery ratio of 1.0 (0.6 to 1.2). The point of access was the common femoral artery in 33 patients (62%) and the external iliac artery in 20 (38%). Exploration of the artery demonstrated localized arterial injury in 22 patients (42%). Female gender was predictive of injury (p = 0.03), but arterial access site location, presence of arterial access calcification, sheath-to-artery ratio, and sheath size were not. Techniques of artery repair included primary closure in 34 patients (64%), pericardial patch angioplasty in 15 (28%), and graft interposition in 4 (8%). There was one minor groin wound complication. Conclusions Open artery access allows for direct examination and optimal access site choice of the vessel during transfemoral TAVI. Localized arterial injury was commonly encountered after 22- and 24-French sheath insertion, but the associated artery repair complication rate was low. doi: 10.1111/jocs.12140 (J Card Surg 2013;28:348–352)

Background Evidence suggests that metabolic syndrome (MbS) is associated with early senescence of bioprosthetic aortic valve prostheses. The purpose of this study was to determine whether MbS is also associated with accelerated failure of bioprosthetic valves prostheses in the mitral position. Methods Records of all patients undergoing bioprosthetic mitral valve replacement (MVR) from 1993 to 2000 were reviewed. Results Of 114 patients undergoing bioprosthetic MVR, 48 (42%) had MbS. Mean age was 73 years (vs. 74 years for no MbS). Patients underwent MVR for regurgitation (n = 97; 85%), stenosis (n = 12; 11%), or mixed lesions (n = 4; 4%). Etiology was degenerative (n = 35; 32%), rheumatic (n = 26; 24%), ischemic (n = 30; 28%), calcific (n = 9; 8%), and endocarditis (n = 8; 8%). Mean follow-up was 4.5 years. Overall survival at 5 and 10 years was 56% and 26%, respectively. Survival was similar between groups (p = 0.15). Five patients (2 MbS; 4% vs. 3 no MbS; 5%) required mitral reoperation at a mean of 3.8 years after initial MVR. The risk of prosthetic valve failure was not different between groups (p = 0.66). Despite no initial difference in transmitral gradients, gradients beyond five-year follow-up were greater for those with MbS (6.8 mmHg MbS vs. 4.7 mmHg no MbS, p = 0.007). Independent predictors of gradient progression beyond two years were MbS (p = 0.027) and female gender (p = 0.012). There were no significant differences in valve area, regurgitation, or ejection fraction. Conclusions Although overall survival following bioprosthetic MVR is challenging, MbS did not predict diminished survival or excess reoperative risk compared to non-MbS patients. The trend toward more rapid progression of transprosthetic gradients in MbS patients warrants further investigation.

The finding of a mobile calcific plaque attached to the aortic valve cusp during transcatheter aortic valve implantation (TAVI/TAVR) necessitated utilization of an embolic protection device, for cerebral protection. We report the urgent but successful deployment of such a filter in a patient with a single patent internal carotid artery. Although stroke rates observed in first-generation TAVI trials were higher than those reported following conventional open aortic valve replacement, adjunctive neuroprotective measures, particularly in patients with a large amount of threatened cerebral territory, may minimize potential neurologic injury.

This paper reports the outcomes of patients initially deemed inoperable for standard aortic valve replacement who received transcatheter aortic valve insertion. Each patient experienced a transcatheter valve insertion complication and was then subsequently reconsidered for urgent standard valve replacement. We review the outcomes of these inoperable patients and discuss recommendations for managing this complication. doi: 10.1111/jocs.12127 (J Card Surg 2013;28:336–338)

Early valve thrombosis is uncommon after pericardial aortic valve replacement. In this report, we describe such a complication after transcatheter aortic valve insertion.

Transventricular repair for acute ischemic posterior ventricular septal defect is challenging and is associated with high operative morbidity and mortality. We have adopted the alternative technique of transatrial repair and recently have added technical modifications that result in less residual or recurrent septal shunt. This study reports those modifications and the related outcomes.Retrospective review of 10 patients with acute ischemic posterior ventricular septal defect operated from November 2006 through March 2013. The septal defect was repaired through the right atrium with a prosthetic patch. Interlocking sutures and an additional continuous suture line buttress around the perimeter of the patch were added to the repair in four (40%) patients.Killip class IV heart failure was present in nine (90%) of the patients, and all received preoperative intra-aortic balloon pump therapy. No patient who received the recent technical modifications experienced a residual or recurrent shunt. However, three (50%) patients who did not undergo this modification developed either a residual septal shunt (n = 1), an early recurrent septal shunt (n = 1), or a ventricular rupture (n = 1). There was no 30-day or in-hospital mortality after surgery, but a single patient died two years after operation due to congestive heart failure. The remaining patients are alive after surgery at a median of 2.0 years.The transatrial repair of an acute ischemic posterior ventricular septal defect is a safe technique. The addition of interlocking pledgetted sutures and a patch suture line buttress decreases the incidence of residual and recurrent septal shunt.

The finding of a mobile calcific plaque attached to the aortic valve cusp during transcatheter aortic valve implantation (TAVI/TAVR) necessitated utilization of an embolic protection device, for cerebral protection. We report the urgent but successful deployment of such a filter in a patient with a single patent internal carotid artery. Although stroke rates observed in first-generation TAVI trials were higher than those reported following conventional open aortic valve replacement, adjunctive neuroprotective measures, particularly in patients with a large amount of threatened cerebral territory, may minimize potential neurologic injury.

Patients who are candidates for surgical valve replacement (AVR) may benefit from diminished length of cardiopulmonary bypass time. Sutureless valve technology for AVR may facilitate the performance of the operation through smaller incisions, and more expeditiously due to the ability to anchor traditional bovine pericardial prostheses without the need for sutures. We report the first successful US implants of the Sorin PERCEVAL valve as part of the FDA IDE trial.

Transapical transcatheter valve replacement is a relatively new technique for select patients with aortic valve stenosis, most of whom have severe peripheral vascular disease. We report our experience with the use of a right axillary artery conduit for arterial access during transapical valve replacement.We reviewed the records of 129 patients who underwent transapical transcatheter aortic valve replacement between November 2009 and August 2013. The study group included 26 (20.2%) patients who received a right axillary artery conduit for arterial access. Median age of the patients was 84 years (63 to 90), sex was female in seven (26.9%), and Society of Thoracic Surgeons predicted risk of mortality was 8.7% (1.8 to 21.2).Axillary artery conduit use was significantly more common during the first half of our operative experience (24/65 patients, 36.9%) in comparison to the second half (2/64 patients, 3.1%; p 0.0001). Inadequate iliofemoral artery diameter for cardiopulmonary bypass support was present in six patients (23.1%) who received a conduit. All patients underwent successful placement of the axillary artery conduit and subsequent conduit access for catheter-based procedures. Cardiopulmonary bypass support was provided to five (19.2%) patients. Operative mortality occurred in three (11.5%) patients and complications in 12 (46.2%), neither of which were related to the axillary artery conduit.Creation of an axillary artery conduit provides a safe arterial access platform for transapical transcatheter aortic valve replacement.

Most studies comparing transapical and transfemoral transcatheter aortic valve replacement include the center's early operative experience, which may negatively impact the outcomes. This study reports our experience beyond the learning curve with transapical and transfemoral transcatheter aortic valve replacement.A total of 303 patients underwent transcatheter aortic valve replacement from November 2008 through August 2013. There were 153 patients (50.5%) who received transfemoral valve replacement, 130 (42.9%) received transapical valve replacement, and 20 (6.6%) received transaortic valve replacement. We retrospectively reviewed the outcomes of the most recent 100 consecutive patients each from the transfemoral and transapical valve replacement groups.The median age was 82 years (range, 54 to 95) and 110 patients (55%) were male; STS predicted risk of mortality was 8.1% (0.7 to 27.8) and was similar between groups (p = 0.256). Operative complications occurred in 49 patients (49%) in the transapical replacement group and in 43 (43%) in the transfemoral group (p = 0.478). Vascular complications occurred only in the transfemoral group and included nine patients (9%; p = 0.003). Paravalvular regurgitation at discharge of grade mild-moderate occurred in 23 patients (24.2%) in the transapical group in comparison to 40 (43.5%) in the transfemoral group (p = 0.006). Operative mortality occurred in two patients (2%) in the transapical group and in five (5%) in the transfemoral group (p = 0.445).Transapical transcatheter aortic valve replacement is associated with less prevalence of vascular complications and mild-moderate paravalvular regurgitation in comparison to the transfemoral approach. Further study is necessary to determine if the transapical technique is the preferred option. doi: 10.1111/jocs.12323 (J Card Surg 2014;29:303-307).

Patients with cirrhosis who undergo cardiac operation with extracorporeal circulation are at high risk for operative morbidity and mortality. Transcatheter aortic valve replacement (TAVR) can obviate the need for cardiopulmonary bypass and may reduce operative morbidity in comparison to standard aortic valve replacement (SAVR) in select patients.Review of 18 patients with aortic valve stenosis and cirrhosis treated with TAVR (n=6) or SAVR (n=12). Patient age was 71 years (58 to 83) and STS Predicted Risk of Mortality was 3.2% (0.7 to 12.3). There were 15 males (83%). Child-Turcotte-Pugh stage was A in 10 patients (56%), B in four (22%), and C in two (11%); the median MELD score was nine (7 to 14).TAVR was successful in all patients without the need for mechanical or cardiopulmonary bypass support. Blood transfusion occurred in four patients (67%) in the TAVR group and in the entire SAVR group. No deaths occurred in the TAVR group, and two (17%) occurred in the SAVR group. Operative complications occurred in two patients (33%) in TAVR group and in eight (67%) in the SAVR group. Hospital stay was five days (3 to 10) in the TAVR group and six (3 to 38) in the SAVR group. All TAVR patients were alive at last follow-up of 219 days (29 to 723), while only five were alive in the SAVR group at 228 days (36 to 719).Our initial experience with TAVR in patients with cirrhosis is encouraging. The technique may be a viable alternative to SAVR in this high-risk subset of patients.

We describe our contemporary experience for the management of patients with an acute postinfarction basal ventricle septal defect (VSD) using the transatrial (TA) and transventricular (TV) approaches.Retrospective review of all patients diagnosed with an ischemic basal VSD since January 2000. There were 20 patients with a median age of 68 years (39 to 85); 13 (65%) were males. Median time from diagnosis of the ischemic basal VSD to operation was 22 hours (6 to 144).All patients received standard patch closure of the septal defect with exposure of the VSD through the TA approach in eight patients (40%) and the TV approach in 12 (60%). All TA group patients received tricuspid valve replacement, while in the TV group, two had tricuspid valve replacement and two repair. Five patients (25%) had clinically insignificant (0.5 mm) residual septal defects; three additional patients (15%) experienced patch dehiscence and two (10%) underwent re-exploration. There were five mortalities (25%): one in the TA group (right ventricular heart failure) and four in the TV group (one right ventricular heart failure, three ventriculotomy site hemorrhage or patch dehiscence). Preoperative right atrial pressure (p=0.0003) and right ventricular dysfunction (p=0.04) were predictors of hospital mortality. Follow-up of the hospital survivors was 4.3 years (40 days to 11.5 years) with one death at seven years.Operative mortality associated with repair of postinfarction basal ventricular septal defect is high and is related to right ventricular failure and bleeding from the ventriculotomy. The TA approach avoids ventriculotomy-associated bleeding and provides excellent exposure but is associated with an increased incidence of tricuspid valve replacement.

Vascular complications associated with transfemoral transcatheter aortic valve insertion (TAVI) are a frequent untoward consequence of arterial sheath insertion. We report the prevalence of anatomic arterial injury with open artery access TAVI.This review consisted of 53 consecutive patients who received transfemoral Sapien 23 or 26 mm TAVI via the 22- or 24-French sheath through open artery access from November 2008. The median age of the patients was 83 years (range, 59 to 94), and there were 31 males (58%). All arteries were examined to determine the optimal point of access and then explored after removal of the sheath to document injury.The accessed artery had a minimal lumen diameter of 8.9 mm (7.2 to 14.7) and a sheath-to-artery ratio of 1.0 (0.6 to 1.2). The point of access was the common femoral artery in 33 patients (62%) and the external iliac artery in 20 (38%). Exploration of the artery demonstrated localized arterial injury in 22 patients (42%). Female gender was predictive of injury (p = 0.03), but arterial access site location, presence of arterial access calcification, sheath-to-artery ratio, and sheath size were not. Techniques of artery repair included primary closure in 34 patients (64%), pericardial patch angioplasty in 15 (28%), and graft interposition in 4 (8%). There was one minor groin wound complication.Open artery access allows for direct examination and optimal access site choice of the vessel during transfemoral TAVI. Localized arterial injury was commonly encountered after 22- and 24-French sheath insertion, but the associated artery repair complication rate was low.

This paper reports the outcomes of patients initially deemed inoperable for standard aortic valve replacement who received transcatheter aortic valve insertion. Each patient experienced a transcatheter valve insertion complication and was then subsequently reconsidered for urgent standard valve replacement. We review the outcomes of these inoperable patients and discuss recommendations for managing this complication.

An 80-year-old man with symptomatic severe aortic valve stenosis was referred for transcatheter aortic valve replacement (TAVR) after balloon aortic valvuloplasty (BAV). The TAVR procedure was aborted because of identification of a mobile mass attached to the leading edge of the right cusp of the aortic valve on a transesophageal echocardiography. Surgical aortic valve replacement (SAVR) was performed and this mass was found to be an aortic cusp fenestration rupture that was caused by the BAV. doi: 10.1111/jocs.12451 (J Card Surg 2015;30:251–252)