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Mitral regurgitation in hypertrophic obstructive cardiomyopathy (HOCM) is mainly due to systolic anterior motion (SAM) and may be abolished in most of the patients by extended myectomy alone. However, a minority of HOCM patients may present mitral regurgitation due to organic mitral valve (MV) anomalies (such as MV leaflet prolapse, chordal rupture, leaflet cleft, and fibrosis) which need to be addressed. In addition, when the thickness of the interventricular septum is not particularly pronounced, shallow myectomy may not be enough to eliminate SAM and additional procedures have been proposed, including MV replacement, anterior leaflet plication/extension, reorientation of papillary muscles, secondary chordae cutting, and edge-to-edge technique. MV repair in the context of hypertrophic cardiomyopathy is certainly more challenging due to the suboptimal exposure of the MV related to the presence of a hypertrophic left ventricle and a not particularly dilated left atrium. The simplest, least time-consuming repair technique should, therefore, be chosen. In this setting, the edge-to-edge technique has the great advantage of being an easy, quick, and reproducible procedure. The disease process of HOCM is not confined to the myocardium, but also involves the MV apparatus, which plays a critical role in dynamic left ventricular outflow tract (LVOT) obstruction. A comprehensive approach utilizing multimodality imaging, particularly echocardiography and cardiac magnetic resonance, has identified multiple abnormalities of the MV complex that have enhanced our understanding of the mechanisms of SAM and LVOT obstruction in HOCM.

OBJECTIVES To assess by a continuous implantable rhythm monitoring (ILR) the mid-term outcomes of a staged-hybrid approach for patients with persistent/long-standing persistent atrial fibrillation (AF) and dilated atria. METHODS Fifty patients [age 57 (standard deviation, SD: 8.3), previous catheter ablation 66%, AF history 6.5 (2–12) years, left ventricular ejection fraction 56 (SD: 7.9)%, left atrial volume index 44 (38–56) ml/m2] with persistent (44%) or long-standing persistent (56%) AF, underwent a 2-staged hybrid ablation (thoracoscopic epicardial procedure with Cobra-Fusion system and transcatheter Rhythmia mapping with endocardial touch-up of gaps). All patients received an ILR. RESULTS No hospital deaths and no stroke occurred. Follow-up was 98% complete [median 22 (11–34) months]. The 2-year arrhythmia-free survival off class I–III antiarrhythmic drugs/electrical cardioversion/redo catheter ablation and the arrhythmia control (maintenance of sinus rhythm with or without antiarrhythmic drugs/electrical cardioversion) were 65 (SD: 7.1)% and 82 (SD: 5.8)%, respectively. The occurrence of AF in the blanking period was identified as an independent predictor of AF recurrence (odds ratio 26.6, 95% confidence interval 5.3, 132.3; P CONCLUSIONS A staged hybrid approach yields promising results in selected patients with persistent/long-standing persistent AF and dilated left atrium who are at very high risk of AF recurrence. The use of ILR in this setting should become a standard to optimize patient management.

OBJECTIVES The aim of this study was to assess the long-term outcomes of different surgical strategies in patients with hypertrophic obstructive cardiomyopathy (HOCM) with septal thickness ≤18 mm and systolic anterior motion (SAM)-related moderate-to-severe mitral regurgitation (MR). METHODS Seventy-six HOCM patients with septal thickness 17 [16; 18] mm, resting left ventricle outflow tract gradient 60 [41; 85] mmHg and SAM-related MR ≥2+/4+, underwent septal myectomy alone (54%) or mitral valve (MV) surgery ± myectomy (46%). RESULTS No hospital death and no ventricular septal defect occurred. Patients undergoing MV surgery ± myectomy had longer cardiopulmonary bypass and X-clamp times (77 [60–106] vs 51 [44–62] min, P CONCLUSIONS In HOCM patients with moderate septal thickness and SAM-related MR, as the degree of septal hypertrophy decreases, addressing the abnormalities of the MV apparatus may become necessary to provide a durable resolution of left ventricle outflow tract obstruction and SAM-related MR. However, performing myectomy alone, whenever possible, seems to be associated to a better postoperative course and a trend towards lower cardiac mortality at follow-up, despite a higher rate of residual moderate MR.

OBJECTIVES: Atrial fibrillation (AF) is common in patients with hypertrophic cardiomyopathy (HCM) and it is often poorly tolerated because of loss of atrial contraction and reduced filling time with rapid ventricular rates. Restoring sinus rhythm is of great clinical benefit to HCM patients. Very few data exist regarding surgical ablation of concomitant AF in this setting. The aim of this study was to evaluate the mid-term outcome of surgical AF ablation in patients who underwent cardiac surgery due to HCM. METHODS: Thirty-one consecutive patients with primary HCM and drug-refractory symptomatic AF underwent surgical ablation with concomitant septal myectomy (77%) and/or mitral valve repair/replacement (39%). Follow-up was 97% complete with a median of 6.4 years [3.8-9.1]. RESULTS: Hospital mortality was 6% and the overall survival at 7 years was 87 ± 6.1%. No stroke and thromboembolic events were documented at follow-up. The arrhythmia-free survival off antiarrhythmic drugs was 82 ± 7.3% at 1 year and 52 ± 10.2% at 6 years. The 1- and 6- year arrhythmia control (maintenance of sinus rhythm with or without antiarrhythmic drugs) was 96 ± 3.5 and 80 ± 8.1%, respectively. The recurrent arrhythmia was AF in all patients. No predictors of AF recurrence were detected. CONCLUSIONS: Concomitant surgical ablation of AF is a reasonable treatment option for drug refractory AF in patients with HCM undergoing surgical myectomy and/or mitral valve surgery. However, chronic antiarrhythmic drugs are needed to achieve a satisfactory mid-term arrhythmia control.

Background: To assess the long-term clinical and echocardiographic outcomes of the edge-to-edge mitral repair added to septal myectomy in patients with mitral regurgitation (MR) and hypertrophic obstructive cardiomyopathy. Methods: This is a single-center study of 26 patients with hypertrophic obstructive cardiomyopathy (septal thickness 17 ± 3 mm, resting left ventricular outflow tract gradient 63 ± 20 mm Hg, MR ≥ 2+/4+) who underwent an EE mitral procedure combined with ventricular septal myectomy. The EE procedure was used to treat MR due to systolic anterior motion in 19 patients (73%) and to posterior leaflet prolapse/flail in 7 (27%). Results: Hospital mortality was 4%. Follow-up was 100% complete (median 6.5 years; interquartile range, 2.7 to 9). Freedom from cardiac death was 88% ± 8.4% at 8 years. The 8-year cumulative incidence function of reoperation with death as competing risk was 7.7% ± 5.2%. At 8 years, the cumulative incidence function of recurrence of MR 3+ or greater with death as competing risk was 7.9% ± 5.3%. Residual MR at discharge (hazard ratio 8.3; 95% confidence interval, 2.1 to 32.6; P = .002) and preoperative systolic pulmonary artery pressure (hazard ratio 1.0; 95% confidence interval, 1.0 to 1.1; P = .005) were identified as predictors of MR recurrence. At the last follow-up, 92% of patients were in New York Heart Association functional class I-II, and 72% were in sinus rhythm. The last echocardiographic follow-up showed a median resting left ventricular outflow tract gradient of 9 mm Hg (interquartile range, 7 to 12; P < .001 vs preoperative). Conclusions: In hypertrophic obstructive cardiomyopathy patients, when septal thickness was considered inadequate to allow a safe and effective myectomy, the edge-to-edge technique provided a simple, quick, and effective solution by abolishing at the same time residual gradient and systolic anterior motion-related MR. Organic mitral valve lesions such as prolapse and flail could be addressed as well, whenever indicated. Satisfactory clinical and echocardiographic results were maintained at long-term follow-up.

Purpose Left ventricle assist devices (LVAD) have contributed to improve survival and quality of life in patients with advanced heart failure, in temporary or lifetime support. Despite technological, bio-compatibility and hemodynamic progress, patients with LVAD have still a relevant incidence of adverse events, such as disabling stroke. The outflow cannula (OC) position and angulation, and the anastomosis site seem to modify the flow in the ascending aorta (AA), and consequently the incidence of cerebral embolism and aortic cusps stress. Methods We evaluated the combination of LVAD flow and the residual cardiac output pulsatile flow with computational fluid dynamics (CFD) software based on CT Scan images. Results Two patients with centrifugal pump LVAD underwent CT Scan regardless of this study, respectively at 7 months and 1.5 years after LVAD implant. We analyzed CT images and made a CFD reconstruction of the anastomosis site, to evaluate the flow in AA. At the same time, in a bench validation test we anastomosed a dacron 32 mm graft (reproducing the AA) and a 14 mm graft (reproducing the OC). We simulated the difference in flow and turbulence, according to different angles of the anastomosis, and the alternative distances from the major cranial branches. Following results of the CFD analysis, we can affirm that it is possible to simulate the optimal flow, improving the laminar flow and reducing the turbulence in the aortic lumen. Moreover, based on the desired angle of the aortic-graft anastomosis, the surgeon can perform the anastomosis with the best shape of the OC (cutting the graft with the angle obtained by the CFD simulation, and incising the AA with the right extension). Conclusion The optimized combination of flows could reduce the incidence of thromboembolic events, aortic endothelium stress, and aortic cusps stress/thrombosis. Further studies are necessary to validate this technology in clinical and surgical practice.

Tricuspid valve disease affects millions of patients worldwide. It has always been considered less relevant than the left-side valves of the heart, but this “forgotten valve” still represents a great challenge for the cardiac surgeons, especially in the most difficult symptomatic scenarios. In this review we analyze the wide spectrum of surgical techniques for the treatment of a diseased tricuspid valve.

Background The objective of this study was to assess the fate at long term of mild-to-moderate functional tricuspid regurgitation (TR) left untreated at the time of mitral valve repair in patients with dilated cardiomyopathy. Methods We selected from our prospective hospital database 84 patients (age, 64 ± 9.6 years; ejection fraction, 0.31 ± 0.064) who underwent mitral repair for secondary mitral regurgitation in whom concomitant mild-to-moderate TR (nonlinear scale 1 to 4+) was left untreated. Tricuspid regurgitation was classified as mild in 61 patients (72.6%) and moderate in 23 patients (27.3%). Annular dilatation itself was not systematically measured and was not used as a trigger for tricuspid annuloplasty. Most of the patients were in New York Heart Association functional class III or IV (56 of 84; 66.7%). Results At a median follow-up of 7.3 years (interquartile range, 4.5 to 9.3), 17 patients (20.2%) had moderate-to-severe TR and 21 patients (25%) showed a progression of at least two grades of their untreated preoperative TR. Freedom from moderate-to-severe TR or from progression of at least two grades of the baseline TR was 77% ± 5% at 5 years and 56.7% ± 8.4% at 10 years. Multivariate analysis identified preoperative right ventricular dysfunction (hazard ratio, 7.2; 95% confidence interval, 2.8 to 23; p = 0.001) and age (hazard ratio, 1; 95% confidence interval, 1.0 1.1; p = 0.03) as independent predictors of TR worsening. Conclusions A significant number of dilated cardiomyopathy patients with mild-to-moderate TR left untreated at the time of mitral repair show important TR at follow-up. In this setting, a more aggressive policy should be used taking into consideration the degree of annular dilatation and the function of the right ventricle and not simply the grade of TR.

Tricuspid valve disease remains an intricate and debated field in terms of pathophysiology, surgical indications and treatment options. In this chapter, surgical techniques, both for repair and replacement of the tricuspid valve will be described in details. Functional (secondary) and organic (primary) tricuspid regurgitation will be addressed and a challenging scenario, like late tricuspid regurgitation following previous mitral valve surgery, will be emphasized.

Bivalirudin is a direct thrombin inhibitor that is increasingly used in patients undergoing mechanical circulatory support as it presents many advantages compared with unfractionated heparin. The aim of this study was to describe our experience with bivalirudin as primary anticoagulant in patients undergoing ventricular assist device (VAD) implantation. An observational study was performed on 12 consecutive patients undergoing VAD implantation at our institution. Patients received a continuous infusion of bivalirudin, with a starting dose of 0.025 mg/kg/h; the target activated partial thromboplastin time (aPTT) was between 45 and 60 s. Patients never received heparin during hospitalization nor had a prior diagnosis of heparin-induced thrombocytopenia (HIT). All patients received a continuous flow pump except one. Preoperative platelets count was 134 000 ± 64 000 platelets/mm(3) . Mean bivalirudin dose was 0.040 ± 0.026 mg/kg/h over the course of therapy (5-12 days). Lowest platelets count during treatment was 73 000 ± 23 000 platelets/mm(3) . No thromboembolic complications occurred. Two episodes of minor bleeding from chest tubes that subsided after reduction or temporary suspension of bivalirudin infusion were observed. Intensive care unit stay was 8 (7-17) days, and hospital stay was 25 (21-33) days. Bivalirudin is a valuable option for anticoagulation in patients with a VAD and can be easily monitored with aPTT. The use of a bivalirudin-based anticoagulation strategy in the early postoperative period may overcome many limitations of heparin and, above all, the risk of HIT, which is higher in patients undergoing VAD implantation. Bivalirudin should no longer be regarded as a second-line therapy for anticoagulation in patients with VAD. [Correction added on 6 December 2013, after first online publication: The dose of bivalirudin in the Abstract to 0.025 mg/kg/h].

The Levitronix CentriMag is approved in Europe for 30 days as uni- or biventricular support in acute heart failure as a bridge to recovery, bridge to heart transplantation or to a long-term left ventricular assist device (LVAD). We report the case of a patient who was supported with the same Levitronix CentriMag pump for 119 days without changing any components of the circuit or the pump head because of an anatomical condition which precluded the feasibility of pump exchange and who did not experience any mechanical failure of the impeller but eventually died due to the rupture of the cannulae. This is the first report of failure of paracorporeal short-term LVAD due to disruption of one cannula with a properly functioning pump. doi: 10.1111/jocs.12149 (J Card Surg 2013;28:472–474)

OBJECTIVES: To assess long-term outcomes of tricuspid valve replacement (TVR) after previous left-side heart surgery. METHODS: We reviewed reoperative TVR after left-side heart surgery performed at our institution between March 1997 and June 2012. In-hospital data were retrieved from our institutional database or medical records; follow-up was performed through telephone call, surviving patients being asked to provide a recent (2 in 79.5% of patients, right ventricle (RV) dysfunction >mild in 23.9% of patients and mean systolic pulmonary artery pressure (sPAP) 48.4 mmHg. A mechanical prosthesis was implanted in 5.1% of patients. A right thoracotomy was preferred to median sternotomy in 8.6% of cases. Isolated-TVR (I-TVR) was performed in 52.1% of patients, a beating-heart approach being used in 85.2% of I-TVR cases. Postoperative RV failure occurred in 46.1% of patients. Median length-of-stay was 11.5 days. Thirty-day mortality was 6.0% overall and 8.2% in the I-TVR group. Higher preoperative LES (P = 0.002), ascites (P = 0.004), RV dysfunction (P = 0.033) and sPAP (P = 0.046) were associated with acute mortality. No significant difference in acute outcomes was observed between beating and arrested-heart I-TVR, except for postoperative median length-of-stay (9 vs 28 days, respectively, P = 0.007). Among survivors median follow-up time was 5.1 years. Five-year and 10-year freedom from cardiac death were 79.4 and 61.0%, freedom from tricuspid reoperation were 97.3 and 87.5%, freedom from bioprosthesis degeneration were 92.8 and 74.3%, respectively. Five-year and 10-year survival in the I-TVR subgroup were respectively 74.4 and 61.6%. Higher preoperative sPAP was associated with increased follow-up mortality (P = 0.048). At the last follow-up, NYHA class I-II was found in 86.1% of surviving patients. CONCLUSIONS: In selected cases, TVR is currently feasible with low acute mortality, especially if performed in the absence of ascites, significant RV dysfunction and pulmonary hypertension. Long-term mortality remains more difficult to predict, although it appeared to be also associated with higher preoperative pulmonary pressure. The global high-complexity profile of these patients is likely to impair long-term outcomes.

Background— To assess the long-term results of the edge-to-edge mitral repair performed without annuloplasty in degenerative mitral regurgitation (MR). Methods and Results— From 1993 to 2002, 61 patients with degenerative MR were treated with an isolated edge-to-edge suture without any annuloplasty. Annuloplasty was omitted in 36 patients because of heavy annular calcification and in 25 for limited annular dilatation. A double-orifice repair was performed in 53 patients and a commissural edge-to-edge in 8. Hospital mortality was 1.6%. Follow-up was 100% complete (mean length, 9.2±4.21 years; median, 9.7; longest, 18.1). Survival at 12 years was 51.3±7.75%. At the last echocardiographic examination, MR ≥3+ was demonstrated in 33 patients (55%). At 12 years, freedom from reoperation was 57.8±7.21% and freedom from recurrence of MR ≥3+ was 43±7.6%. Residual MR >1+ at hospital discharge was identified as a risk factor for recurrence of MR ≥3+ (hazard ratio, 3.8; 95% confidence interval, 1.7–8.2; P =0.001). In patients with residual MR ≤1+ immediately after surgery, freedom from MR ≥3+ at 5 and 10 years was 80±6% and 64±7.58%, respectively. Conclusions— In degenerative MR, the overall long-term results of the surgical edge-to-edge technique without annuloplasty are not satisfactory. Early optimal competence (residual MR ≤1+) was associated with higher freedom from recurrent severe regurgitation.

Bivalirudin is a direct thrombin inhibitor that is increasingly used in patients undergoing mechanical circulatory support as it presents many advantages compared with unfractionated heparin. The aim of this study was to describe our experience with bivalirudin as primary anticoagulant in patients undergoing ventricular assist device (VAD) implantation. An observational study was performed on 12 consecutive patients undergoing VAD implantation at our institution. Patients received a continuous infusion of bivalirudin, with a starting dose of 0.025 mg/kg/h; the target activated partial thromboplastin time (aPTT) was between 45 and 60 s. Patients never received heparin during hospitalization nor had a prior diagnosis of heparin-induced thrombocytopenia (HIT). All patients received a continuous flow pump except one. Preoperative platelets count was 134 000 ± 64 000 platelets/mm(3) . Mean bivalirudin dose was 0.040 ± 0.026 mg/kg/h over the course of therapy (5-12 days). Lowest platelets count during treatment was 73 000 ± 23 000 platelets/mm(3) . No thromboembolic complications occurred. Two episodes of minor bleeding from chest tubes that subsided after reduction or temporary suspension of bivalirudin infusion were observed. Intensive care unit stay was 8 (7-17) days, and hospital stay was 25 (21-33) days. Bivalirudin is a valuable option for anticoagulation in patients with a VAD and can be easily monitored with aPTT. The use of a bivalirudin-based anticoagulation strategy in the early postoperative period may overcome many limitations of heparin and, above all, the risk of HIT, which is higher in patients undergoing VAD implantation. Bivalirudin should no longer be regarded as a second-line therapy for anticoagulation in patients with VAD. [Correction added on 6 December 2013, after first online publication: The dose of bivalirudin in the Abstract to 0.025 mg/kg/h].

The Levitronix CentriMag is approved in Europe for 30 days as uni- or biventricular support in acute heart failure as a bridge to recovery, bridge to heart transplantation or to a long-term left ventricular assist device (LVAD). We report the case of a patient who was supported with the same Levitronix CentriMag pump for 119 days without changing any components of the circuit or the pump head because of an anatomical condition which precluded the feasibility of pump exchange and who did not experience any mechanical failure of the impeller but eventually died due to the rupture of the cannulae. This is the first report of failure of paracorporeal short-term LVAD due to disruption of one cannula with a properly functioning pump.

A 72-year-old man presented to the emergency department in cardiogenic shock; 4-days before he was diagnosed with right femoro-popliteal deep vein thrombosis after trauma. During routine monitoring and diagnostic workup, cardiac arrest with pulseless electric activity rapidly ensued and cardiopulmonary resuscitation was initiated. A transthoracic echocardiogram showed severe right ventricular dilatation and acute pulmonary embolism was suspected. No Return of Spontaneous Circulation was obtained after 10 minutes of cardiopulmonary resuscitation. The patient was transferred to the cardiac catheterization laboratory under resuscitation with autopulse (ZOLL, Chelmsford, MA) and femoro-femoral veno-arterial extracorporeal membrane oxygenation (ECMO; PLS Maquet GmbH, Rastett, Germany) was percutaneously initiated with a 23 French (Fr) venous cannula and 17 Fr arterial cannula with restoration of systemic blood flow and oxygen delivery (5 L/min, 4000 rpm). Baseline pulmonary angiography demonstrated a large amount of thrombus in both the right (Movie I in the online-only Data Supplement) and the left pulmonary arteries …

OBJECTIVES: The ‘edge-to-edge’ technique (EE) can be used as a bailout procedure in case of a suboptimal result of conventional mitral valve (MV) repair. The aim of this study was to assess the long-term outcomes of this technique used as a rescue procedure. METHODS: From 1998 to 2011, of 3861 patients submitted to conventional MV repair for pure mitral regurgitation (MR), 43 (1.1%) underwent a rescue edge-to-edge repair for significant residual MR at the intraoperative hydrodynamic test or at the intraoperative transoesophageal echocardiography. Residual MR was due to residual prolapse in 30 (69.7%) patients, systolic anterior motion in 12 (27.9%) and post-endocarditis leaflet erosion in 1 (2.3%). According to the location of the regurgitant jet, the edge-to-edge suture was performed centrally (60.5%) or in correspondence with the anterior or posterior commissure (39.5%). The original repair was left in place. RESULTS: There were no hospital deaths. Additional cross-clamp time was 15.2 ± 5.6 min. At hospital discharge, all patients showed no or mild MR and no mitral stenosis. Clinical and echocardiographic follow-up was 97.6% complete (median length 5.7 years, up to 14.6 years). At 10 years, actuarial survival was 89 ± 7.4% and freedom from cardiac death 100%. Freedom from reoperation and freedom from MR ≥3+ at 10 years were both 96.9 ± 2.9%. At the last echocardiogram, MR was absent or mild in 37 patients (88%), moderate in 4 (9.5%) and severe in 1 (2.4%). No predictors for recurrence of MR ≥2+ were identified. The mean MV area and gradient were 2.8 ± 0.6 cm 2 and 2.7 ± 0.9 mmHg. NYHA I–II was documented in all cases. CONCLUSIONS :A ‘rescue’ EE can be a rapid and effective option in case of suboptimal result of ‘conventional’ MV repair. Long-term durability of the repair is not compromised.

The number of patients undergoing surgical heart valve repair has been increasing during the last years, particularly in high-volume centers. Several factors related to poor outcomes after surgical repair have been identified in different observational studies, leading to a better preoperative patient selection and improved long-term clinical and echocardiographic follow-up.

Functional tricuspid regurgitation (FTR) is the most frequent etiology of tricuspid valve pathology in Western countries. In the last years, many investigators have reported evidence in favor of a more aggressive surgical approach to FTR and interest has been growing in the physiopathology and treatment of FTR. The purpose of this editorial is to explore the anatomical basis, pathophysiology, therapeutic approaches and the perspectives of treatment.