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Functional mitral regurgitation is a common finding among heart failure patients with ischemic and non-ischemic dilated cardiomyopathies. The presence of moderate or severe mitral regurgitation is associated with higher morbidity and mortality. Heart failure patients meeting electrocardiogram and left ventricle function criteria are good candidates for cardiac resynchronization therapy, which may reduce the degree of functional mitral regurgitation in the short and long term, specifically targeting myocardial dyssynchrony and inducing left ventricle reverse remodeling. In this article, we analyze data from the literature about predictors of mitral regurgitation improvement after cardiac resynchronization therapy implantation.

Transcather aortic valve implantation (TAVI) has become a safe and indispensable treatment option for patients with severe symptomatic aortic stenosis who are at high surgical risk. Recently, outcomes after TAVI have improved significantly and TAVI has emerged as a qualified alternative to surgical aortic valve replacement in the treatment of intermediate risk patients and greater adoption of this procedure is to be expected in a wider patients population, including younger patients and low surgical risk patients. However since the aortic valve has close spatial proximity to the conduction system, conduction anomalies are frequently observed in TAVI. In this article, we aim to review the key aspects of pathophysiology, current incidence, predictors and clinical association of conduction anomalies following TAVI.

A 67-year-old patient with rheumatic heart valve disease had undergone two cardiac surgeries at the age of 30 years, then re-do with mitral valve replacement at 50 years. She presented with congestive heart failure and hemolytic anemia. Doppler echocardiography showed moderate-severe mitral regurgitation due to paravalvular mitral valve leak (PVML) and severe pulmonary hypertension. Transesophageal echocardiography demonstrated severe PVML secondary to a large 20 mm-long PVML defect. Due to comorbidities, the heart team deemed a third reoperation at very high surgical risk; therefore, the patient was considered most suitable for a transcatheter approach to PVML closure. Two Occlutech paravalvular leak devices were successfully delivered using a simultaneous double-transapical access with double-wire technique.

Objectives Percutaneous catheterization of the coronary sinus (CS) to enable the administration of retrograde cardioplegia may play an important role in minimally invasive cardiac surgery. A new specially designed device (ProPlege; Edwards Lifesciences, Irvine, CA) is described that can be placed under transesophageal echocardiography (TEE) and pressure guidance with a high rate of success and low rate of complications. Design Case series. Setting A university-affiliated private hospital. Participants Patients undergoing minimally invasive cardiac surgery. Interventions The ProPlege device was placed under TEE and pressure guidance only. Measurements and Main Results Records of 70 patients managed with ProPlege were reviewed and analyzed. Successful placement was attained in 69 patients (98.6%) as confirmed by the ventricularization of the CS pressure curve and TEE images. Direct imaging of the ProPlege tip was possible in 34 patients (49.2%). The capacity to generate a CS pressure>30 mmHg during retrograde cardioplegia administration at a flow>150 mL/min was obtained in 64 patients; ProPlege displacement occurred in 5 cases (7.2%). Successful retrograde cardioplegia was delivered in 91.4% of cases. No CS perforation or other injuries to the right heart were noted at intraoperative TEE or direct surgical inspection. Conclusions Percutaneous CS catheterization with ProPlege was performed with a high rate of success for positioning and low complication rate using TEE and pressure guidance only. Further studies are needed to more accurately determine complication rates and to establish the possible complementary role of fluoroscopy.

We report the first known cases of successful implantation of the Edwards INTUITY (Edwards Lifesciences LLC, Irvine, CA) rapid-deployment valve in 3 patients with aortic stenosis presenting under emergency cardiogenic shock. At the 6-month follow-up, the 3 patients showed improved left ventricular function and improved functional capacity.

Background Self-management improves oral anticoagulation control. Here we provide data of a preplanned interim analysis of very low-dose early self-controlled anticoagulation. Methods In a prospective, randomized, multicenter trial, 1,137 patients performed low-dose international normalized ratio (INR) self-management with a target INR range of 1.8. to 2.8 for aortic valve replacement recipients and 2.5 to 3.5 for mitral or double valve replacement recipients for the first six postoperative months. Thereafter, 379 patients continued to achieve the aforementioned INR target range (LOW group), whereas the INR target value was set at 2.0 (range, 1.6 to 2.1) for the remaining patients with aortic valve replacement and 2.3 (range, 2.0 to 2.5) for the remaining patients with mitral valve or double valve replacement. One half of this latter group had to check their INR values once a week (VL1 group) the other half twice a week (VL2 group). Patients were followed up for 24 months. Results Beyond study month six, the incidence of thromboembolic events that required hospital admission was 0.58%, 0.0%, and 0.58% in the LOW, VL1, and VL2 groups, respectively (p = 0.368). The incidence of bleeding events per patient-year was 1.16%, 1.07%, and 0.58% in the LOW, VL1, and VL2 groups, respectively (p = 0.665). Mortality rate did not differ among study groups. Conclusions Data demonstrate the efficacy and safety of very low-dose INR self-management.

Objective: Left internal mammary artery harvesting through a mini-thoracotomy makes gaining the proximal portion of this vessel very difficult and exposes the patient to the risk of chest wall trauma due to excessive spreading of the ribs. The adoption of video thoracoscopic assistance can give several advantages to the procedure. Methods: With the patient in a 30° left-side-up thoracotomy position, a 8‐12 cm anterior thoracotomy is performed in the left fourth or fifth intercostal space. Two thoracoscopic ports are inserted in the third and fourth left intercostal spaces in the midaxillary line. Complete mobilization of the left internal mammary artery is performed with a mixed surgical and thoracoscopic technique. Results: Since July 1996, 12 patients underwent myocardial revascularization with the left internal mammary artery through a mini-thoracotomy, with the aid of video assisted thoracoscopy. There were no deaths or perioperative infarctions. Mean hospital stay was 4 days (3‐6). In nine patients a postoperative angiographic study was performed: in all cases the length of the mammary artery pedicle was adequate; one patient underwent a successful angioplasty on a narrowed anastomosis on the left anterior descending artery. In another patient the left internal mammary artery had been grafted to a diagonal branch. In all other cases angiography showed good results. Conclusions: Thoracoscopic assistance helps achieving complete mobilization of the left internal mammary artery, maximizing its useful length, without an extended thoracotomy. © 1998 Elsevier Science B.V. All rights reserved

Introduction and Background: Respiratory distress following cardiac surgery is a troublesome complication. In several cases it is associated to cool-related phrenic nerve injury (PNI) after adoption of iced slush or hypothermic cardiopulmonary bypass. We compare two different strategies for myocardial protection: the “shallow technique” (ST) (dripping and prompt removal of cold saline solution from the epicardial surface) plus normothermic cardiopulmonary bypass, versus mild hypothermic cardiopulmonary bypass plus iced slush. Methods: Two hundred forty-nine patients undergoing elective cardiac surgery were randomly assigned to receive either ST (Group A) or iced slush (Group B). Occurrence of postoperative PNI (abnormal diaphragmatic movement plus alteration of nerve conduction) was evaluated. Multivariate analysis was performed for identification of factors associated to PNI. Patients had a 6-month follow-up. Results: PNI and failure of extubation occurred more frequently in Group B (p = 0.009 and p = 0.034, respectively), but there was no statistically significant difference in mean intensive care unit stay. Diabetes and the use of iced slush were independent predictors of phrenic dysfunction, while internal thoracic artery (ITA) harvest was a significant risk factor only among Group B patients. Abnormal diaphragmatic movement was persistent at 6 months only in 30% of Group B individuals who suffered this complication in the early postoperative. Conclusions: ST likely reduces the incidence of postoperative PNI and might be protective mainly in the event of ITA harvest. It should be considered as a valuable tool for myocardial protection protocols.

Objective: The aim of the present study was to evaluate early and late results of two different surgical techniques for left ventricular aneurysms repair. The conventional aneurysmectomy and direct closure of the ventricular wall and the endoventricular patch plasty. Methods: We retrospectively reviewed 118 patients operated on for postinfarction left ventricular aneurysm from 1981 to 1994. Eighty-seven patients (Group A) were operated upon between 1981 and 1991 with the conventional technique and 31 patients (Group B) between 1992 and 1994 with the endoventricular patch plasty technique. Preoperative clinical, hemodynamic and echocardiographic evaluation with operative procedures and early postoperative results of all patients are reported. We also analyzed results of late clinical and echocardiographic controls of 34 patients of Group A and all patients of Group B after a mean follow-up of 42 and 28 months, respectively. Results: Mean number of by-pass grafts was 1.9 in Group A and 2.6 in Group B (P0.01). The left anterior descending coronary artery was revascularized in 27 patients of Group A (34.6%) and 26 of Group B (89.7%) (PB0.001); the left internal mammary artery was used in seven patients of Group A (8.9%) and 24 of Group B (82.8%) (PB0.001). Hospital mortality in Group A was 10.3% (9:87), in Group B there was no hospital mortality (P\0.05). Thirty-two patients of Group A (36.8%) and 3 of Group B (9.7%) suffered of low cardiac output syndrome (P 0.01). At late control, improvements observed in NYHA and CCS classes, left ventricular ejection fraction (all PB 0.001 in both groups versus preoperative values) and left ventricular end-diastolic diameter (P\ 0.05 in Group A and PB 0.001 in Group B) proved to be statistically higher in patients of Group B. Conclusions: Endoventricular patch plasty associated with a complete myocardial revascularization, in particular of the anterior descending coronary, and a larger use of the internal mammary artery, permits, by means of reconstruction of the left ventricular geometry, a better outcome for patients undergoing left ventricular aneurysmectomy. © 1997 Elsevier Science B.V.