Abstract:

The long-term outcomes of undersizing annuloplasty for the treatment of ischemic mitral regurgitation (IMR) is affected by the progressive dilation of the annulus, which carries increased risk for ring disinsertion. Reasons underlying this phenomenon might be found in the excess of physical stress on the annuloplasty sutures during the ventricular remodeling process. We report a technique based on the placement of a double row of overlapping sutures aiming at reducing the potential for ring disinsertion. Eleven patients with IMR undergoing mitral valve repair associated with coronary bypass grafting were treated with this technique and echocardiographically followed up at 6 and 12 months. The overall annular dimension decreased significantly with a significant reduction of the tenting area and no recurrence of mitral regurgitation at 1 year. A double row of overlapping sutures allowed firm attachment of the prosthetic ring while downsizing the annulus in IMR, limiting the consequences of changes in subannular ventricular geometry. This technique might therefore be considered a useful aid during mitral valve repair.

Authors:

Francesco Nappi, MD, PhD, Consultant Cardiac Surgeon, Centre Cardiologique du Nord, St. Denis, France, Cristiano Spadaccio, MD, PhD, Consultant Cardiac Surgeon, Department of Cardiovascular Surgery, University Campus Bio-Medico of Rome, Rome, Italy, Nawwar Al-Attar, PhD, FRCS, FETCS, Consultant Cardiac Surgeon, Golden Jubilee National Hospital, Clydebank, United Kingdom, Massimo Chello, MD, Full Professor of Cardiac Surgery, Department of Cardiovascular Surgery, University Campus Bio-Medico of Rome, Rome, Italy, Mario Lusini, MD, PhD, Consultant Cardiac Surgeon, Department of Cardiovascular Surgery, University Campus Bio-Medico of Rome, Rome, Italy, Raffaele Barbato, MD, Consultant Cardiac Surgeon, Department of Cardiovascular Surgery, University Campus Bio-Medico of Rome, Rome, Italy, Christophe Acar, MD, Professor of Cardiac Surgery, Department of Cardiac Surgery, Hopital La Pitie Salpetriere, Paris, France

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Abstract:

An original papillary muscle heads approximation procedure, commonly known as a sandwich plasty, has been successfully used for the treatment of functional mitral regurgitation (MR) associated with ischemic cardiomyopathy (ICM) and aortic valve disease (AVD). In this study, we evaluated the availability of this method as the concomitant procedure for the plasty of organic MR in comparison with the operative results in patients with functional MR. Fifty-six patients who underwent sandwich plasty were reviewed, including 45 functional MR (29 ICM and 16 AVD) patients and 11 organic MR patients. The mean age of patients was 67 years. In the organic MR patients, predominant cardiac diseases were solitary MR in six patients and combined valve diseases including aortic valve stenosis in five. Mitral valve changes included prolapse in six patients and moderate cusp thickening with calcification in five. Two heads of the papillary muscle connecting to the choldae of both the anterior and posterior leaflets are fixed with two teflon-pledgeted 3-0 TiCron™ (Covidien, Dublin, Ireland) sutures in order to achieve coaptation of the two leaflets. Prominent MR was observed in a patient with functional MR after surgery, however residual MR was not detected in organic MR patients. The tenting height (coaptation distance) of mitral valve significantly decreased after surgery from 11±1 to 7±2mm in the organic MR patients, which was similar to the results in the functional MR patients (from 12±2 to 7±2 mm). The postoperative mean mitral orifice area in the organic MR patients was 4.3±0.1cm2 without stenosis. Sandwich plasty reduces the distance of choldae connecting to anterior and posterior leaflets and achieves the better coaptation of two leaflets. This procedure is effective in the treatment of both functional and organic MR.

Authors:

Susumu Ishikawa, MD, Director, Department of Thoracic and, Cardiovascular Surgery, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan, Hideki Mishima, MD, Surgeon, Department of Thoracic and, Cardiovascular Surgery, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan, Hiroki Matsunaga, MD, Surgeon, Department of Thoracic and, Cardiovascular Surgery, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan, Yasushi Katayama, MD, Chief Surgeon, Department of Thoracic and, Cardiovascular Surgery, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan

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Abstract:

Critical limb ischemia (CLI) is an already significant and growing epidemiologic problem with substantial implications for patient mortality, quality of life, and healthcare costs. Considerable progress has been made in its treatment and prevention; however, poor outcomes, especially with regard to limb loss, warrant further development of treatment options. This article will examine new advances being made in the area of limb salvage for this morbid disease. Open surgical techniques and materials such as distal vein patches and heparin-bonded PTFE will be discussed. Additionally, new developments in endovascular therapies with particular regard to infrapopliteal interventions and drug-eluting stents will be reviewed. Beyond the simple techniques and materials, there is a growing movement in the world of vascular surgery to examine surgical and endovascular interventions with regard to angiosome-oriented revascularization of ulceration and gangrene. This paradigm has the potential to change prioritization and planning of both types of therapies as further research into this concept develops.

Authors:

Jason A Chin, MD, Integrated Vascular Surgery Resident, Section of Vascular Surgery, Yale University School of Medicine, New Haven, CT, Bauer E Sumpio, MD, Professor of Surgery and Radiology, Section of Vascular Surgery, Yale University School of Medicine, New Haven, CT

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