Background: Arteriotomy repair through the preclosure technique during elective arterial access procedures is well documented. Outcomes associated with application of this technique to the removal of arterial access cannulas in patients undergoing urgent venoarterial extracorporeal membrane oxygenation (VA-ECMO) have not previously been reported. Methods: We reviewed the records of consecutive patients who required VA-ECMO for cardiogenic shock. Patients were compared by use of the preclosure device (Perclose ProGlide Suture-Mediated Closure System; Abbott Vascular, Abbott Park, III) at time of VA-ECMO cannulation. The rate of limb complications (composite of limb ischemia, infection, and site necrosis) and secondary end points of bleeding events, pseudoaneurysm, distal part embolization, and intensive care unit length of stay after decannulation were compared between the groups. Results: Ninety-nine consecutive patients managed with VA-ECMO were identified and the preclosure device was utilized in 51 of these patients. Preclosure device failure occurred in 5 instances (9.8%) and was successfully managed with surgical repair in 4 cases and endovascular intervention in another. Use of the preclosure device was associated with both fewer limb complications (odds ratio, 0.19; 95% confidence interval, 0.03-0.78) and bleeding events (odds ratio, 0.21; 95% confidence interval, 0.04-0.89). Pseudoaneurysm (n = 0) and distal part embolization (n = 1) were infrequently encountered in the cohort and no difference in intensive care unit length of stay after decannulation was noted between the groups. Conclusions: In this cohort, use of the preclosure technique in weaning from VA-ECMO was technically feasible, safe, and associated with an approximate 80% lower likelihood of limb complications and bleeding events compared with surgical removal.

•Inversion of the LAA is very rare and is associated with negative intracardiac pressure.•High LVAD speeds induce negative intracardiac pressure and can cause LAA inversion.•LAA inversion can lead to mitral valve outflow obstruction and RV failure.•This has the potential to be a catastrophic complication after LVAD implantation.

The aortic valve reimplantation technique described and popularized by David and associates1David T.E. Feindel C.M. Webb G.D. Colman J.M. Armstrong S. Maganti M. Long-term results of aortic valve-sparing operations for aortic root aneurysm.J Thorac Cardiovasc Surg. 2006; 132: 347-354Abstract Full Text Full Text PDF PubMed Scopus (234) Google Scholar has demonstrated consistently excellent long-term outcomes during the past 2 decades in patients with aortic root dilatation but structurally normal, trileaflet aortic valves. The success of this operation, originally conceived as an alternative to aortic root replacement in patients with Marfan syndrome, has encouraged the broader application of derivative techniques to a number of distinct clinical scenarios, including bicuspid aortic valve (BAV) syndrome with root dilatation and aortic insufficiency.2Aicher D. Langer F. Kissinger A. Lausberg H. Fries R. Schäfers H.J. Valve-sparing aortic root replacement in bicuspid aortic valves: a reasonable option?.J Thorac Cardiovasc Surg. 2004; 128: 662-668Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar Transposition of these valve-sparing techniques, all of which depend on restoration of functionally normal annular and leaflet geometry, to this geometrically unique patient population requires a thorough understanding of normal 3-dimensional BAV root complex geometry.3Schäfers H.J. Langer F. Aicher D. Graeter T. Wendler O. Remodeling of the aortic root and reconstruction of the bicuspid aortic valve.Ann Thorac Surg. 2000; 70: 542-546Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar To date, our collective understanding of root geometry in this patient population has largely been limited to 2-dimensional and anecdotal descriptors, which vary markedly among clinicians and institutions.4De Paulis R. De Matteis G.M. Nardi P. Scaffa R. Bassano C. Chiariello C. Analysis of valve motion after the reimplantation type of valve-sparing procedure (David I) with a new aortic root conduit.Ann Thorac Surg. 2002; 74: 53-57Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar, 5Grande K.J. Cochran R.P. Reinhall P.G. Kunzelman K.S. Mechanics of aortic valve incompetence: finite element modeling of aortic root dilatation.Ann Thorac Surg. 2000; 69: 1851-1857Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar In this study, we describe the rotational orientation of the aortic valve commissures in a cohort of patients with BAV without evidence of adverse remodeling. Our findings, which describe BAV root asymmetry in quantitative terms for the first time, have substantial implications for the ongoing evolution of valve-sparing operative techniques in this patient population. Real time 3-dimensional echocardiographic data sets were acquired on 8 normal patients (tricuspid n = 4 and BAV n = 4) with an iE-33 platform (Philips Medical Systems, Andover, Mass) equipped with a 2- to 7-MHz X7-2t transesophageal echocardiography matrix-array transducer. Inclusion criteria for both groups comprised maximum root diameter less than 3.8 cm, no evidence of aortic stenosis, and aortic insufficiency graded no greater than mild by an experienced echocardiographer. An additional criterion for inclusion in the BAV patient cohort was confirmed right-left cusp fusion, the most common (>85%) morphologic variant of BAV. Each full-volume data set was exported to an offline Echo-View 5.4 (TomTec Imaging Systems, Munich, Germany) software workstation for image postprocessing and quantitative analysis by means of a series of well-characterized custom algorithms. The left, noncoronary, and right leaflets in the tricuspid cohort occupied 112.79° ± 7.49°, 118.38° ± 17.70°, and 128.83° ± 20.10° of the total annular circumference, respectively, corresponding conceptually to commissural peak orientations of 120°:120°:120°, as illustrated in Figure 1, A. In contrast, the noncoronary leaflet in the BAV cohort occupied 139.62° ± 16.43° of the total annular circumference, while the fused leaflet occupied 220.38° ± 16.43°, corresponding conceptually to commissural peak orientations of 150°:210°, with the raphe located at the midpoint of the fused leaflet (105°:105°), as illustrated in Figure 1, B. High resolution, 3-dimensional annular analysis reveals that aortic valve commissural peaks are distributed symmetrically around the annular circumference in trileaflet aortic roots. In contrast, the commissural peaks in patients with right-left fusion bileaflet aortic roots are highly asymmetric; in these patients, the fused leaflet occupies 210° of the annular circumference and is bisected by the raphe (105°:105°), while the noncoronary leaflet occupies 150° of the annular circumference. These findings have significant implications for aortic valve reimplantation in this patient population. In the trileaflet variants of David aortic valve reimplantation procedures, the 3 commissural peaks are resuspended within the neosinus at evenly spaced rotational increments (120°:120°:120°). In view of our findings, it follows that analogous attempts to create a symmetrically suspended (180°:180°) neoroot in patients with BAV are potentially ill-advised, because this orientation does not reproduce native geometry. Our data suggest that the reproduction of native geometry requires that the principal commissures be spaced 210° apart along the annular circumference and with the raphe located at the midpoint of the 210° segment. Although many experienced surgeons advocate asymmetric repair strategies in the context of BAV, their recommendations are based largely on intraoperative observation and surgical judgment. Our data provide a reproducible and unambiguous geometric target for repair and may improve repair durability by replicating native leaflet geometry. Our findings are, however, based on a small sample size and are relevant to only the right-left fusion variant of BAV. Further studies are necessary both to assess the consistency of these findings and to assess the physiologic and clinical outcomes associated with these distinct repair strategies.

OBJECTIVES Primary cusp repair + aortic root reimplantation in bicuspid aortic valve (BAV) disease presenting with root aneurysm with aortic insufficiency (AI) is an effective surgical treatment. We assessed whether the geometric orientation of the repaired BAV into its reimplanted neoroot affects outcomes-180°/180° orientation was compared with the 150°/210° orientation. METHODS From 2005 to 2012, 66 BAV repairs were performed. This is a retrospective review of all types of Ib/II BAV AI patients undergoing root reimplantation (n = 26) at two different geometric orientations: 180°/180° (n = 11) vs 150°/210° (n = 15). In the 180°/180° group, reimplantation into the neoroot was such that both conjoint and non-conjoint cusps occupied 180° of the annular circumference. In the 150°/210° group, the repaired valve was configured to the more typical native orientation of a type I BAV: the non-conjoint cusp occupied 150°, and the conjoint cusp occupied 210° of the annular circumference. RESULTS Preoperative characteristics were similar in both groups. In-hospital mortality, stroke, reoperation, renal failure and pacemaker rates were zero in both groups. No patient left the operating room with >1+ AI and one had a peak gradient >20 mmHg. Transvalvular gradients were higher in the 180°/180° group, but not significant (P > 0.05). M.ean follow-ups for the 180°/180° and 150°/210° group were 48 and 33 months, respectively. Actuarial freedom from AI >2+ at 5 years was 100% in both groups. Freedom from AI >1+ at 5 years was 90 ± 10% in the 150°/210° group and 86 ± 13% in the 180°/180° group (P = 0.71). Freedom from peak gradient >20 mmHg was 80% (n = 8) in the 180°/180° group and 100% in the 150°/210° group at 1-year follow-up. Transvalvular gradients were higher in the 180°/180° group (16 ± 8 vs 10 ± 4 mmHg, P = 0.02; 9 ± 3 vs 5 ± 3 mmHg, P = 0.01). Five-year actuarial survival and freedom from aortic reoperation have remained at 100% in the entire cohort. CONCLUSION Cusp repair + root reimplantation for BAV type Ib/II AI can be safely performed at either geometric orientation. Conceptually, 150°/210° orientation respects the natural type I BAV anatomy with regard to cusp surface area and leaflet insertion perimeter. The 180°/180° group may have higher transvalvular gradients and smaller coaptation zones than the 150°/210° group. Further follow-up may reveal the superiority of one geometric orientation over the other.

A significant fraction of patients who survive repair of a DeBakey type I aortic dissection will require a secondary intervention to address ongoing aortic remodeling. Strategic treatment of this population mandates that the technical feasibility of secondary operations be considered at the index procedure. We evaluated a hybrid-based modification of a widely accepted surgical approach that obviates the need for advanced perfusion management techniques and facilitates secondary endografting. Hybrid technology allows for the physiologic equivalent of a total arch replacement without the operative complexity associated with a traditional approach while allowing for strategic planning if a secondary operation is warranted. (C) 2013 by The Society of Thoracic Surgeons

Levack, Melissa MD; Jassar, Arminder S. MD; Ryan, Liam P. MD; Jackson, Benjamin M. MD; Keane, Martin G. MD; St John Sutton, Martin G. MD; Ferrari, Victor A. MD; Gorman, Joseph H. III MD, FACS; Gorman, Robert C. MD, FACS Author Information

Background— Although localized delivery of biocomposite materials, such as calcium hydroxyapatite (CHAM), have been demonstrated to potentially attenuate adverse left ventricular (LV) remodeling after myocardial infarction (MI), the underlying biological mechanisms for this effect remain unclear. This study tested the hypothesis that targeted CHAM injections would alter proteolytic pathways (matrix metalloproteinases [MMPs] and tissue inhibitors of MMPs [TIMPs]) and would be associated with parameters of post-MI LV remodeling. Methods and Results— MI was induced in adult sheep followed by 20 targeted injections of a total volume of 1.3 mL (n=6) or 2.6 mL of CHAM (n=5) or saline (n=13) and LV end-diastolic volume (EDV) and MMP/TIMP profiles in the MI region were measured at 8 weeks after MI. LV EDV decreased with 2.6 mL CHAM versus MI only (105.4±7.5 versus 80.6±4.2 respectively, P<0.05) but not with 1.3 mL CHAM (94.5±5.0, P=0.32). However, MI thickness increased by 2-fold in both CHAM groups compared with MI only (P<0.05). MMP-13 increased 40-fold in the MI only group (P<0.05) but fell by >6-fold in both CHAM groups (P<0.05). MMP-7 increased approximately 1.5-fold in the MI only group (P<0.05) but decreased to referent control values in both CHAM groups in the MI region (P<0.05). Collagen content was reduced by approximately 30% in the CHAM groups compared with MI only (P<0.05). Conclusions— Differential effects on LV remodeling and MMP/TIMP profiles occurred with CHAM. Thus, targeted injection of a biocomposite material can favorably affect the post-MI remodeling process and therefore holds promise as a treatment strategy in and of itself, or as a matrix with potentially synergistic effects with localized pharmacological or cellular therapies.

Background A comprehensive three-dimensional echocardiography based approach is applied to preoperative mitral valve (MV) analysis in patients with ischemic mitral regurgitation (IMR). This method is used to characterize the heterogeneous nature of the pathologic anatomy associated with IMR. Methods Intraoperative real-time three-dimensional transesophageal echocardiograms of 18 patients with IMR (10 with anterior, 8 with inferior infarcts) and 17 patients with normal MV were analyzed. A customized image analysis protocol was used to assess global and regional determinants of annular size and shape, leaflet tethering and curvature, relative papillary muscle anatomy, and anatomic regurgitant orifice area. Results Both mitral annular area and MV tenting volume were increased in the IMR group as compared with patients with normal MV (mitral annular area=1,065 ± 59 mm2 versus 779 ± 44 mm2, p = 0.001; and MV tenting volume=3,413 ± 403 mm3 versus 1,696 ± 200 mm3, p = 0.001, respectively). Within the IMR group, patients with anterior infarct had larger annuli (1,168 ± 99 mm2) and greater tenting volumes (4,260 ± 779 mm3 versus 2,735 ± 245 mm3, p = 0.06) than the inferior infarct subgroup. Papillary-annular distance was increased in the IMR group relative to normal; these distances were largest in patients with anterior infarcts. Whereas patients with normal MV had very consistent anatomic determinants, annular shape and leaflet tenting distribution in the IMR group were exceedingly variable. Mean anatomic regurgitant orifice area was 25.8 ± 3.0 mm2, and the number of discrete regurgitant orifices varied from 1 to 4. Conclusions Application of custom analysis techniques to three-dimensional echocardiography images allows a quantitative and systematic analysis of the MV, and demonstrates the extreme variability in pathologic anatomy that occurs in patients with severe IMR.

While extracorporeal membrane oxygenation (ECMO) is a useful mechanism of providing support in pediatric patients with cardiopulmonary dysfunction following surgery for congenital heart disease, outcomes have varied dramatically between distinct cardiac diagnoses. Reported outcomes of ECMO support following a bidirectional Glenn procedure in patients with single ventricle physiology are uniformly poor due in part to physiological and anatomical challenges inherent to cannulation in this population. We describe a unique veno-venous cannulation that can be applied to this patient population and has allowed for successful decannulation in our practice.

BACKGROUND:This experiment assessed the dose-dependent effect of a unique allogeneic STRO-3-positive mesenchymal precursor cell (MPC) on postinfarction left ventricular (LV) remodeling. The MPCs were administered in a manner that would simulate an off-the-self, early postinfarction, preventative approach to cardiac cell therapy in a sheep transmural myocardial infarct (MI) model. METHODS:Allogeneic MPCs were isolated from male crossbred sheep. Forty-six female sheep underwent coronary ligation to produce a transmural LV anteroapical infarction. One hour after infarction, the borderzone myocardium received an injection of 25, 75, 225, or 450 x 10(6) MPCs, or cell medium. Echocardiography was performed at 4 and 8 weeks after MI to quantify LV end-diastolic (LVEDV) and end-systolic volumes (LVESV), ejection fraction (EF), and infarct expansion. CD31 and smooth muscle actin (SMA) immunohistochemical staining was performed on infarct and borderzone specimens to quantify vascular density. RESULTS:Compared with controls, low-dose (25 and 75 x 10(6) cells) MPC treatment significantly attenuated infarct expansion and increases in LVEDV and LVESV. EF was improved at all cell doses. CD31 and SMA immunohistochemical staining demonstrated increased vascular density in the borderzone only at the lower cell doses. There was no evidence of myocardial regeneration within the infarct. CONCLUSION:Allogeneic STRO-3 positive MPCs attenuate the remodeling response to transmural MI in a clinically relevant large-animal model. This effect is associated with vasculogenesis and arteriogenesis within the borderzone and infarct and is most pronounced at lower cell doses.

OBJECTIVES:Using 3-dimensional echocardiography in conjunction with novel geometric modeling and rendering techniques, we have developed a high-resolution, quantitative, 3-dimensional methodology for imaging the human mitral valve. Leaflet and annular geometry are important determinants of mitral valve stress. Repair techniques that optimize valvular geometry will reduce stress and potentially increase repair durability. The development of such procedures will require image-processing methodologies that provide a quantitative description of 3-dimensional valvular geometry.METHODS:Ten healthy adult subjects underwent mitral valve imaging with real-time 3-dimensional echocardiography. By using specially designed image analysis software, multiple valvular geometric parameters, including 2- and 3-dimensional leaflet curvature, leaflet surface area, annular height, intercommissural width, septolateral annular diameter, and annular area were determined for each subject. Image-rendering techniques that allow for the clear and concise presentation of this detailed information are also presented.RESULTS:Although 3-dimensional annular and leaflet geometry were found to be highly conserved between healthy human subjects in general, substantial intrasubject and intersubject regional geometric heterogeneity was observed in the midposterior leaflet, the region most commonly involved in leaflet flail in subjects with myxomatous disease.CONCLUSIONS:The image-processing and graphic-rendering techniques that we have developed can be used to provide a complete description of 3-dimensional mitral valve geometry in human subjects. Widespread application of these techniques to healthy subjects and patients with mitral valve disease will provide insight into the geometric basis of both valvular pathology and repair durability.

Objectives: High leaflet and chordal stresses contribute to recurrent mitral regurgitation after repair procedures. We hypothesized that a saddle-shaped annuloplasty ring would reduce leaflet stress compared to a similarly sized flat annuloplasty ring. To test this hypothesis we used a novel 3D echocardiographically-based finite element modeling (FEM) technique for quantifying regional mitral valve stress. Methods: Real-time 3D echocardiography was performed in 8 sheep before and after placement of either a 30mm flat annuloplasty (n=4) or a 30mm saddle-shaped annuloplasty. Full-volume data sets of the MV were obtained using an IE33 platform(Philips Medical Systems, Andover, Massachusetts) and exported to Cardio-View (Tomtec Imaging Systems, Munich, Germany) for image analysis. Individual leaflet data were then interpolated using Matlab (The Mathworks, Natick, Massachusetts). Triangulated leaflet surfaces were extracted and the data imported into a commercial finite element program (ABAQUS/Explicit 6.3, HKS Inc. Pawtucket, RI) to quantify regional stress distributions in all segments (P1, P2, P3 and A1, A2, A3) of the MV. Results: Peak anterior and posterior leaflet stresses after flat annuloplasty placement were 0.20±0.001MPa and 21±0.02MPa. Peak anterior and posterior leaflet stress after saddle-shaped annuloplasty placement was 0.19±0.02MPa and 13±0.01MPa (p<0.05 for the posterior leaflet stresses) Conclusions: Saddle-shaped annuloplasty design results in greater stress reduction in the posterior leaflet than standard flat annuloplasty rings and may, therefore, result in more durable repairs. This research has received full or partial funding support from the American Heart Association, AHA Great Rivers Affiliate (Delaware, Kentucky, Ohio, Pennsylvania & West Virginia).

Objectives Leaflet and annular geometry are important determinants of mitral valve (MV) stress. Repair techniques which optimize valvular geometry will reduce stress and potentially increase repair durability. The development of such procedures will require image processing methodologies that provide a quantitative description of three-dimensional valvular geometry. Using three-dimensional echocardiography in conjunction with novel geometric modeling and rendering techniques, we have developed a high-resolution, quantitative, three-dimensional methodology for imaging the human MV. Methods Five normal adults underwent MV imaging using real-time three-dimensional echocardiography. Using specially designed image analysis software, multiple valvular geometric parameters, including the magnitude and orientation of leaflet curvature, leaflet surface area, annular height, intercommissural width, septolateral annular diameter, and annular area were determined for each subject. Image rendering techniques that allow for the clear and concise presentation of this detailed information are also presented. Results Although three-dimensional annular and leaflet geometry were found to be highly conserved among normal human subjects, substantial regional variation in leaflet geometry was observed. Interestingly, leaflet geometric heterogeneity was most pronounced in the midposterior leaflet, the region most commonly involved in leaflet flail in subjects with myxomatous disease. Conclusions The image processing and graphical rendering techniques that we have developed can be used to provide a complete description of three-dimensional MV geometry in human subjects. Widespread application of these techniques to normal subjects and patients with MV disease will provide insight into the geometric basis of both valvular pathology and repair durability.

Mitral regurgitation is a clinically significant and increasingly common problem in the elderly population. Traditionally, mitral valve surgery has been considered high risk in this population, with a relatively high reported mortality and disappointing long-term survival. Consequently, mitral valve surgery has been reserved for severely symptomatic patients or avoided altogether. However, recently reported improvements in operative outcomes in both younger and elderly patient populations suggest that such a restrictive approach to operative intervention is not necessary. In this current manuscript, we discuss the various etiologies of mitral regurgitation in the elderly population as well as a rational approach to risk stratification and the indications for surgical intervention. Furthermore, we discuss the results of several recent studies that deal with the question of operative outcomes in the elderly population, and conclude with our recommendations for managing this challenging clinical problem.