Surgical Technology International
37th Edition
Contains 62 peer-reviewed articles featuring the latest advances in surgical techniques and technologies.
432 pages
Nov 2020 - ISSN:1090-3941
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Latest Advances in the Treatment of Bicuspid Aortic Valve
Alessandro Della Corte, MD, PhD, Associate Professor of Cardiac Surgery, University of Campania “L. Vanvitelli”, Naples, Italy, Federica Lo Presti, MD, Senior Resident of Cardiac Surgery, Cardiac Surgery Unit, Heart and Vessels Department, Casa di Cura San Michele, Maddaloni, Italy
1352
Bicuspid aortic valve (BAV) is the most frequent congenital cardiac defect, and affects 0.5-2% of live births. Almost half of BAV subjects develop different degrees of valvular dysfunction during their lifetime. In both echocardiographic cohorts and surgical series, pure aortic regurgitation is significantly less common than stenosis. BAV also carries a higher risk of aortic aneurysm, aortic dissection or aortic valve endocarditis compared to the general population.
Once aortic insufficiency reaches threshold criteria for surgical treatment, the valve has to be replaced (conventional aortic valve replacement, the outcomes of which are well established) or repaired. Repair techniques for regurgitant BAVs and valve-sparing surgery for BAV-related aneurysms have evolved remarkably over the past several decades. Improvements in our understanding of the mechanisms of normal and pathological BAV function and the development of criteria and techniques to address all the pathologic components of valve and root have supported better repair results.
The more frequent stenotic BAV is treated by prosthetic valve replacement or, in recent years, by trans-catheter prosthetic replacement (TAVR), the application of which in the BAV setting is increasing, as with tricuspid aortic valve (TAV) stenosis, especially since indications are extended to medium-risk patients. It has been reported that the risk of paravalvular leak and/or prosthesis malposition is higher in BAV than in TAV stenosis, due to the more elliptical annulus and the calcified raphe of the bicuspid valve. New-generation balloon-expandable devices seem to be capable of lowering the rates of these complications.
As research in this field keeps filling in the gaps in current knowledge about bicuspid malformation and its common complications, further advancements in their treatment are awaited.
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Transcatheter Mitral Valve Replacement for Degenerated Bioprosthetic Valves and Failed Annuloplasty Rings
Andreas Schaefer, MD, MHBA, Lenard Conradi, MD, Professor of Cardiac Surgery, Surgical Director of Programs for Minimally-Invasive and Transcatheter Heart Valve Procedures, University Heart and Vascular Center Hamburg, Hamburg, Germany
1339
The risk of recurrent mitral regurgitation after surgical mitral valve repair for ischemic functional mitral regurgitation is 28 % at 10 years. Also, an increasing number of patients with degenerated mitral bioprostheses are seen in daily clinical practice due to a dramatic shift from mechanical to biological bioprostheses over the past few decades. Therefore, it can be anticipated that there will be growing need for therapy options to treat high-risk patients in case of recurrent mitral regurgitation subsequent to surgical mitral valve repair or replacement. Interventional therapy for failing surgical mitral valve replacement and repair is an appealing option in patients who are ineligible for redo surgery. The efficacy and safety of transcatheter mitral valve replacement have been reported in patients with failing mitral rings or degenerated mitral bioprostheses. However, crucial limitations remain, including possible device malpositioning, left ventricular outflow tract obstruction and postprocedural mitral regurgitation. Partially, these complications can be explained by the most frequently used transcatheter heart valves, which are balloon-expanding bioprostheses intended for transcatheter aortic valve implantation that cannot be repositioned. Currently, frequently used approaches for transcatheter mitral valve replacement include retrograde transapical and antegrade transseptal techniques, most often with the use of transcatheter heart valves from the Sapien family (Edwards Lifesciences Inc., Irvine, CA, USA) followed by the mechanical expandable Lotus valve (Boston Scientific, Marlborough, MS, USA). Anecdotal reports have described the application of self-expandable transcatheter heart valves (Centera; Edwards) or dedicated transcatheter mitral valve replacement devices.
In this report, we give an overview of current interventional techniques, available evidence and reported outcomes for transcatheter mitral valve replacement for degenerated bioprosthetic valves and failed annuloplasty rings.
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A Review of the Evolution of Abdominal Aortic Endografts and Future Directions
Mallika Gopal, MD, Ignatius Lau, MD, Joshua Harris, MD, Kelsey Berger, MD, Peter Faries, MD, Professor of Vascular Surgery, Michael Marin, MD, Professor, Rami Tadros, MD, Associate Professor, Mount Sinai Hospital, New York, New York
1252
Introduction: Over the years, endovascular aortic aneurysm repair (EVAR) has become the gold-standard of therapy for abdominal aortic aneurysm (AAA) repairs. This study aims to analyze the evolution of stent graft devices and discuss the future direction of technological development.
Materials and Methods: In this paper, we will review prior eras of graft development (1992 to 2019) that included physician-made devices (era one), industry-made devices (era two), branch devices (era three), and fenestrated devices (era four). Additionally, future advancements that aim to overcome issues with short aneurysm necks, involvement of proximal visceral branches, and formation of endoleaks will be discussed.
Results: Future devices of note include a more conformable version of the EXCLUDER® device (W. L. Gore & Associates, Inc., Newark, Delaware) to better steer the top of the graft and modify for angulated necks, a version of the Endurant® device to include EndoAnchors (Medtronic plc, Minneapolis, Minnesota) to prevent formation of endoleaks, a novel Nellix® EVAS II device (Endologix Inc., Irvine, California) with aneurysm sac filling to prevent endoleaks and exclude the aneurysm sac, and an expanded Zenith® fenestrated device (Cook Medical Inc., Bloomington, Indiana) to include more visceral branches. This is in the setting of more recent advancements like pivoting fenestrated branch devices for “off-shelf” use and aneurysm repair that now extends to the thoracic aorta.
Conclusion: With each iteration of devices, EVAR has evolved to overcome technical challenges and offer expanded applicability to different types of AAAs.
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Heart Valve Endocarditis
Francesco Nappi, MD, Centre Cardiologique du Nord, Saint-Denis, Paris, France Sanjeet Singh Avtaar Singh, MD, Cristiano Spadaccio, MD, PhD, Golden Jubilee National Hospital, Glasgow, UK, Pierluigi Nappi, MD, University of Messina, Messina, Italy, Antonio Nenna, MD, Massimo Chello, MD, Full Professor, Università Campus Bio-Medico di Roma, Rome, Italy, Federico Gentile, MD, FACC, Cardiovascular Disease Diagnostic Medical Center, Naples, Italy
1299
Heart valve replacement is the most common cardiac surgical operation performed worldwide for infective endocarditis (IE). Long-term durability and avoidance of infection relapse are the goals of the procedure. However, no detailed guidelines on prosthesis selection and surgical strategies are available, which should be guided by a comprehensive evaluation of the extent of the infection and its microbiological characteristics, the clinical profile of the patient and the risk of infection recurrence. Conventional mechanical or stented xenografts are the preferred choice for localized heart infection. In cases of complex IE with involvement of the root or the aorto-mitral continuity, the use of homograft is suggested according to the surgeon’s and center’s experience. The use of homograft needs to be balanced against the risk of structural degeneration. Prosthetic bioroot and prosthetic valved conduit with a mechanical or bioprosthetic valve are also considered acceptable alternatives in patients with aortic valve endocarditis. The further development of preservation techniques to enable the longer durability of allogeneic substitutes is required. We discuss current evidence for the use of valve substitutes in heart valve endocarditis and propose an evidence-based algorithm for the choice of treatment.
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The Current Role of the Percutaneous Arteriovenous Fistula for Hemodialysis Access
Krystina N. Choinski, MD, Ajit G. Rao, MD, Assistant Professor, Windsor Ting, MD, Associate Professor of Surgery, Peter L. Faries MD, FACS, Professor of Surgery and Radiology, Rami O. Tadros MD, FACS, RPVI, Associate Professor of Surgery and Radiology, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, Scott A. Sundick, MD, FACS, Overlook Medical Center, The Cardiovascular Care Group, Westfield, New Jersey
1318
Dialysis is the preferred treatment for patients with end-stage renal disease (ESRD) for the removal of accumulated toxins secondary to compromised renal function. Hemodialysis has traditionally been performed via a surgically created arteriovenous fistula (AVF) or arteriovenous graft (AVG). Novel endovascular techniques have allowed for the creation of percutaneous arteriovenous fistulas for hemodialysis access. Two devices, the Ellipsys® Vascular Access System (Avenu Medical, Inc., San Juan Capistrano, California) and the WavelinQ™ EndoAVF System (C.R. Bard, Inc., Murray Hill, New Jersey), are currently available for percutaneous AVF creation and investigation of their utility is ongoing. This paper describes the current utilization, differences, and results thus far with these devices and, additionally, investigates the contemporary advantages, disadvantages, and selection criteria for percutaneous AVFs overall.
Systolic Anterior Motion (SAM) Complicating Mitral Valve Repair: Current Concepts of Intraoperative and Postoperative Management
Antonio Nenna, MD, Mario Lusini, MD, Associate Professor, Filippo Barberi, MD, Salvatore Matteo Greco, MD, Massimo Chello, MD, Full Professor of Cardiac Surgery, Università Campus Bio-Medico di Roma, Rome, Italy, Francesco Nappi, MD, Centre Cardiologique du Nord, Paris, France, Cristiano Spadaccio, MD, PhD, Golden Jubilee National Hospital, Glasgow, UK
1308
Mitral valve repair is the gold standard for treatment of degenerative mitral regurgitation, such as that caused by leaflet prolapse, flail or annular dilatation. A variety of surgical techniques allow surgeons to achieve a high rate of success with mitral valve repair, even in complex cases, and mitral valve repair is associated with better long-term outcomes than valve replacement. However, in the setting of mitral valve surgical repair, systolic anterior motion (SAM) is a complication that determines the dynamic anterior movement of the mitral valve towards the interventricular septum during systole, and creates a left ventricular outflow tract obstruction associated with residual mitral regurgitation. Awareness of risk factors for SAM influences operative planning for repair. Predictors of SAM are known and can be definitively evaluated with intraoperative transesophageal echocardiography, but SAM still complicates mitral valve repair and, if untreated, negatively impacts short-term and long-term outcomes. A stepwise approach in SAM correction is advocated, consisting of medical therapy with aggressive volume-loading and beta-adrenoceptor blockade, but severe or persistent SAM requires surgical revision with a second cross-clamping or a redo procedure. The correct choice of surgical technique requires a deep understanding of the anatomical substrate of SAM, as SAM can be due to different mechanisms that require tailored surgical correction to avoid ineffective or potentially dangerous procedures. This paper reviews the mechanisms and predictors of SAM and summarizes the current concepts of intraoperative and postoperative SAM management.
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Thoracic Aortic Endografts: Past, Present, and Future
Shivani Kumar, MD, Krystina N. Choinski, MD, Rami O. Tadros MD, FACS, RPVI, Associate Professor of Surgery and Radiology, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, New York
1317
Introduction: Thoracic endovascular aortic repair (TEVAR) has become first-line therapy for a wide range of thoracic aortic pathologies including traumatic thoracic aortic injury, type B aortic dissection, intramural thoracic aortic hematoma, and penetrating aortic ulcers. This study aims to analyze the progress made of thoracic stent graft devices, review the current Food and Drug Administration (FDA)-approved devices, and discuss the future technological advances.
Materials and Methods: In this paper, we will review the history of TEVAR and the development of the first iteration of devices. We will discuss the four currently available TEVAR devices, the GORE® TAG® (W. L. Gore and Associates, Flagstaff, Arizona), Medtronic Navion™ (Medtronic plc, Santa Rosa, California), Bolton RELAY® (Terumo Aortic, Sunrise, Florida), and the Zenith® Alpha™ Thoracic and the Zenith® Dissection Stent Graft (Cook Medical, Bloomington, Indiana), and the features and applications of each. Finally, future advancements in TEVAR technology and grafts currently under trial will be reviewed.
Results: The first generation of TEVAR grafts had several limitations including large delivery systems, the need for rapid pacing for accurate deployment, wind socking during deployment, and graft migration. The current available TEVAR grafts have novel features to address these prior pitfalls. The GORE® TAG® is initially deployed 50% with subsequent room for adjustment to increase accuracy; the Medtronic Navion™ and Bolton RELAY® are available in low-profile delivery systems; and the Cook Zenith® Alpha™ now has an open cell petticoat specific for use in dissections extending to the visceral abdominal aorta. The current generation of TEVAR devices have broadened the application of TEVAR and reduced the anatomic limitations previously encountered.
Conclusion: TEVAR has evolved to overcome technical challenges and offer expanded applicability to different types of thoracic aortic pathologies and enhanced accuracy of deployment.
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Cryopreserved Allograft Use in Vascular Surgery
Jani Lee, MD, Mabel C. Chan, MD, Crystal James, MD, Mount Sinai Morningside and West Hospitals, New York, NY, John C. Lantis II, MD, General and Vascular Surgery Board Certified Professor and Vice Chairman, Department of Surgery, Icahn School of Medicine, Mount Sinai Morningside and West Hospitals, New York, NY
1320
In vascular surgery, bypass procedures are standard treatments for many arterial and venous diseases. The choice of conduit for the bypass operation is fundamental in planning for the appropriate intervention for each individual patient. Although an autogenous conduit is superior, this option is not available in many patients, and prosthetic grafts have been the preferred conduit in a variety of clinical situations. However, since prosthetic graft infections are seen in all realms of vascular surgery, from arteriovenous access to aortic graft infections and lower-extremity bypass infections, cryopreserved arterial and venous allografts, which are relatively resistant to infection, have become the conduit of choice. This discussion will focus on the clinical applications of cryopreserved allografts in vascular surgery, specifically lower-extremity peripheral bypass, aortic disease, and dialysis access.
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Long-Term Survival and Outcomes According to VARC-2 Criteria for Subclavian, Direct Aortic, Femoral, and Apical Implantation: An 8-Year United Kingdom TAVI Surgical Experience
Francesca D’Auria, MD, PhD, David Hildick-Smith, MD, Aung Myat, MD, Brighton and Sussex University Hospital, Brighton and Hove, United Kingdom, Roberto Lorusso, MD, PhD, Heart & Vascular Centre - Maastricht University, Alberto Pilozzi Casado, MD Azienda Ospedaliera Santa Croce e Carle, Cuneo, Italy
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Objectives: The use of transcatheter aortic valve implantation (TAVI) has expanded as an alternative to aortic valve replacement, and more than 500,000 patients have been treated worldwide since April, 2002. The aim of this study was to compare complications and morbidity/mortality associated with different TAVI approaches as alternatives to a surgical-femoral approach.
Methods: From January 2007 to January 2015, 2,863 patients underwent TAVI surgery in 36 United Kingdom TAVI centers. Primary outcomes were complications according to VARC-2 criteria. The secondary outcome was long-term survival.
Results: The enrolled patients were distributed as follows: 1,150 in the surgical-femoral (SF) group, 1,216 in the trans-apical (TA) group, 207 in the direct-aortic (DA) group, and 290 in the subclavian (SC) group. There were no differences in the rates of acute myocardial infarction, emergency valve-in-valve, cardiac tamponade, or TIA among the groups. The rates of stroke and renal replacement therapy, as well as in-hospital stay, in-hospital death, and 30-day and 12-month mortality in DA and TA were higher than those in SC and SF. The rates of paravalvular leak and balloon post-dilatation in SC and DA were higher than those in TA and SF. The rates of vascular injuries and permanent pacemaker implantation in SC and SF were higher than those in DA and TA. SF provided the best long term-survival (p = 0.008).
Conclusions: This was a large study that compared outcomes and long-term survival among different TAVI surgical approaches in a national real-world setting. According to our results, SF provided the best survival. While SC provided worse survival than SF, it was still better than TA and DA, and thus may represent the safest non-femoral access if use of the femoral approach is precluded.
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