1796
CASE REPORT GARATTI ET AL MITRACLIP AS A BRIDGE PROCEDURE TO HEART TRANSPLANT
Ann Thorac Surg 2015;99:1796–9
hemodynamic response and relationship to stroke volume and rate reduction protocols. ASAIO J 2006;52:228–33. 6. Slaughter MS, Silver MA, Farrar DJ, Tatooles AJ, Pappas PS. A new method of monitoring recovery and weaning the Thoratec left ventricular assist device. Ann Thorac Surg 2001;71:215–8.
Mitraclip Procedure as a Bridge Therapy in a Patient With Heart Failure Listed for Heart Transplantation Andrea Garatti, MD, Serenella Castelvecchio, MD, Francesco Bandera, MD, Massimo Medda, MD, and Lorenzo Menicanti, MD
FEATURE ARTICLES
Fig 2. Parasternal long-axis echocardiographic view during the pump-off evaluation demonstrates left ventricular internal dimension at diastole (LVIDd) of 4.8 cm. (EDV ¼ end-diastolic volume; IVSd ¼ interventricular septal thickness at diastole; IVS/LVPW ¼ ratio of thickness of interventricular septum and left ventricular posterior wall; LVPWd ¼ left ventricular posterior wall dimension.)
accommodate his activity level and symptoms; for example, if the patient had a day when he felt less energetic, he might choose to keep the pump at a higher speed. Over time, however, the trend was a gradual decrease in his pump speed. Other continuous-flow devices would require a clinic visit to program an alteration of the speed setting/flow rate. Furthermore, instead of making LVAD changes based solely on decompression, septal shift, and other echocardiographic variables, this approach engages the patient and allows the patient’s symptoms to help drive management. This sequential decrease in LVAD support allowed a slow, progressive increase in loading, thereby retraining the ventricle. In conclusion, the Jarvik 2000 LVAD allows for adaptable, patient-controlled speed variability to facilitate sequential weaning and explantation in the event of myocardial recovery. Although this report carries the inherent flaws of case reports, sequential conditioning of the LVAD-supported heart is a promising strategy for bridging patients to recovery and pump removal.
References 1. Drakos SG, Kfoury AG, Stehlik J, et al. Bridge to recovery: understanding the disconnect between clinical and biological problems. Circulation 2012;126:230–41. 2. Birks EJ, Tansley PD, Hardy J, et al. Left ventricular assist device and drug therapy for the reversal of heart failure. N Engl J Med 2006;355:1873–84. 3. Dandel M, Weng Y, Siniawski H, Potapov E, Lehmkuhl HB, Hetzer R. Long-term results in patients with idiopathic dilated cardiomyopathy after weaning from left ventricular assist devices. Circulation 2005;112(9 Suppl):I37–45. 4. Drakos SG, Wever-Pinzon O, Selzman CH, et al. Magnitude and time course of changes induced by continuous-flow left ventricular assist device unloading in chronic heart failure. J Am Coll Cardiol 2013;61:1985–94. 5. Slaughter MS, Sobieski MA, Koenig SC, Pappas PS, Tatooles AJ, Silver MA. Left ventricular assist device weaning: Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
Cardiac Surgery and Heart Failure Units, IRCCS Policlinico San Donato, Milan, Italy
Functional mitral regurgitation (MR) is frequently detected in patients with dilated cardiomyopathy and advanced heart failure, worsening quality of life and predicting poor survival. However, the optimal treatment of patients with advanced heart failure and severe MR has been controversial. We present the case of a 55-yearold man with previous aortic valve replacement, severe MR with high-grade pulmonary hypertension, and refractory heart failure (HF). He was listed for cardiac transplant and underwent percutaneous MitraClip implantation as bridge therapy. The postoperative course was uneventful, with significant improvement in New York Heart Association functional class. The patient underwent a successful heart transplant 8 months after the procedure. (Ann Thorac Surg 2015;99:1796–9) Ó 2015 by The Society of Thoracic Surgeons
F
unctional mitral regurgitation (MR) is a complication of idiopathic dilated cardiomyopathy, occurring secondary to left ventricle geometrical distortion [1]. MR complicating congestive heart failure (CHF) predicts poor survival [2]. Decreasing the severity of MR has been shown to decrease CHF symptoms and improve the patients’ quality of life. However, the optimal treatment of patients with advanced heart failure and severe MR has been controversial. We present the case of a patient listed for heart transplantation (HTx) with end-stage HF and severe MR who underwent percutaneous MitraClip (Abbott Vascular, Menlo Park, CA) implantation in order to improve clinical status and reduce pulmonary hypertension while awaiting a suitable donor.
Accepted for publication July 14, 2014. Address correspondence to Dr Garatti, Department of Cardiovascular Disease “E. Malan”, Cardiac Surgery Unit, Policlinico S. Donato Hospital, Via Morandi 30, 20097, S. Donato Milanese, Milan, Italy; e-mail: agaratti@ tiscali.it.
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.07.079
Ann Thorac Surg 2015;99:1796–9
CASE REPORT GARATTI ET AL MITRACLIP AS A BRIDGE PROCEDURE TO HEART TRANSPLANT
1797
Fig 1. Apical four-chamber echocardiography showing the reduction of mitral regurgitation from severe to mild.
pulmonary hypertension (pulmonary artery systolic pressure [PAPs] ¼ 57 mm Hg) was detected. The patient underwent a cardiopulmonary exercise test (incremental ramp of 8 watts/min) combined with exerciseechocardiography. His functional capacity resulted severely depressed (peak VO2 ¼ 8 mL/kg/min; predicted peak VO2 ¼ 27%) with severely impaired ventilator efficiency (VE/VCO2 ¼ 79) and exercise oscillatory ventilation, both markers of advanced cardiopulmonary disease. The patient was considered not suitable for conventional MV repair because of severe advanced HF, redo surgery, and comorbidities (The Society of Thoracic Surgeons [STS] mortality þ morbidity score ¼ 59; EUROSCORE II ¼ 9.2) and was added to the HTx waiting list. Because of severe dyspnea at rest, with orthopnea and paroxysmal nocturnal dyspnea (sleeping with three pillows or sitting in a chair during the night), we decided to correct MR to slightly improve symptoms and stabilize the patient while awaiting a suitable donor. A percutaneous edge-to-edge procedure with the MitraClip system (Abbott Vascular, Menlo Park, CA) was then performed under general anesthesia in the operating room, with live real-time three-dimensional Fig 2. Apical five-chamber echocardiography showing the reduction of mitral regurgitation from severe to mild.
FEATURE ARTICLES
A 55-year-old man, previously implanted with a mechanical aortic prosthesis, was referred to our department for chronic CHF and severe MR. In the last 6 months, because of HF symptoms worsening (New York Heart Association [NYHA] class III–IV), the patient underwent recurring hospital admission for intravenous treatment with levosimendan and furosemide twice per month. He was implanted with an implantable cardioverter defibrillator (ICD)/biventricular pacemaker (PM) for cardiac resynchronization therapy. Rest echocardiography at admission showed advanced left ventricular (LV) remodeling (indexed end-diastolic volume [iEDV] ¼ 138 mL/m2; indexed end-systolic volume [iESV] ¼ 108 mL/ m2; LV indexed mass ¼ 201 g/m2) associated with severe systolic and diastolic dysfunction (LVEF ¼ 22%). Severe MR (effective regurgitant orifice [ERO] ¼ 32 mm2; regurgitant volume ¼ 51 mL; vena contracta ¼ 6) occurred because of symmetric leaflets tethering and annular dilatation. Notably, severe right ventricle dysfunction (tricuspid annular plane systolic excursion [TAPSE] ¼ 13 mm; right ventricular [RV] fractional area ¼ 0.17%; tricuspid annular tissue Doppler imaging [TDI] ¼ 6 cm/s) with associated severe tricuspid regurgitation and
1798
CASE REPORT GARATTI ET AL MITRACLIP AS A BRIDGE PROCEDURE TO HEART TRANSPLANT
Ann Thorac Surg 2015;99:1796–9
FEATURE ARTICLES
Fig 3. Parasternal short axis echocardiography showing the position of the MitraClip (arrow) close to the anterior mitral commissure. (Left panel: before clip; Right panel: after clip.)
echocardiography and fluoroscopic guidance. Procedural details has been reported previously [3]. Briefly, by means of transeptal puncture, a MitraClip device was implanted in relation to the origin of the main regurgitant jet, between P3 and A3 scallops, perpendicularly to the coaptation line. Transesophageal echocardiography at the end of the procedure showed a mild residual MR (Figs 1-3). The postoperative course was uneventful, and the patient was discharged home on postoperative day 4. In the following months, the patient experienced a significant improvement in clinical status (NYHA Class ¼ II–III). Furthermore, intravenous therapy was stopped, and the patient was subsequently managed with high-dose oral diuretics. Three-month follow-up echocardiography showed a mild to moderate MR (ERO ¼ 19 mm2; regurgitant volume ¼ 29 mL), associated with a dramatic reduction in pulmonary hypertension (PAPs ¼ 38 mm Hg) and improvement of RV function (TAPSE ¼ 15; RV fractional area ¼ 37%) as well as of tricuspid regurgitation (Table 1). The patients remained clinically stable in the following months, without further increase in MR nor in pulmonary artery pressure, and underwent a successful heart transplant 8 months after the MitraClip implantation.
Comment The advantages and the rationale of the present approach are, in our opinion, the following. First, treating severe MR achieved improvement of patient’s symptoms allowing him a better quality of life while waiting a suitable donor. Second, improving MR achieved a significant reduction in LV filling pressure and pulmonary hypertension, which is particularly harmful in HTx recipient. Third, treating severe MR in patients with advanced HF by a percutaneous approach minimizes the procedural risk and avoids the chest opening, which could complicate the surgical approach of the future HTx. Patients with CHF are frequently affected by functional MR (45% to 75% of patients with systolic heart failure) owing to the distortion of valve apparatus secondary to global and local remodeling of the left ventricle [4]. Management of functional MR in end-stage CHF patients is challenging. In such cases, surgical reconstruction of the mitral valve could be performed, but the only published case-control study showed no long-term survival benefit in patients with CHF and severe functional MR who were treated with mitral valve repair [5]. Heart transplantation is the most effective treatment for well-selected patients with end-stage HF. However, it is available to only a fraction of those who could benefit
Table 1. Changes Over Time of Left Ventricular Echocardiographic Parameters Between Preoperative and Transplantation Echocardiographic Parameters LV EDD (mm) LV ESD (mm) EDV (mL) ESV (mL) EF (%) PaPs (mm Hg) Mitral regurgitation Tricuspid regurgitation EDD ¼ end diastolic diameter; volume; LV, left ventricular;
Preoperative
At Discharge
73 64 277 217 22 57 Severe Severe
69 66 260 200 23 48 Mild Moderate
EDV ¼ end diastolic volume; EF ¼ ejection fraction; PaPs ¼ systolic pulmonary artery pressure.
3-Month Follow-Up
At Transplant
70 64 265 205 25 38 Mild/moderate Mild
69 65 262 200 25 30 Mild/moderate Mild
ESD ¼ end systolic diameter;
ESV ¼ end systolic
Ann Thorac Surg 2015;99:1799–801
References 1. Yiu SF, Enriquez-Sarano M, Tribouilloy C, Seward JB, Tajik AJ. Determinants of the degree of functional mitral regurgitation in patients with systolic left ventricular dysfunction: a quantitative clinical study. Circulation 2000;102: 1400–6. 2. Rossi A, Dini FL, Faggiano P, et al. Independent prognostic value of functional mitral regurgitation in patients with heart failure. A quantitative analysis of 1256 patients with ischaemic and non-ischaemic dilated cardiomyopathy. Heart 2011;97: 1675–80. 3. Feldman T, Foster E, Glower DD, et al. Percutaneous repair or surgery for mitral regurgitation. N Engl J Med 2011;364: 1395–406. 4. Grayburn PA, Appleton CP, DeMaria AN, et al. Echocardiographic predictors of morbidity and mortality in patients with advanced heart failure: the BEST Trial. J Am Coll Cardiol 2005;45:1064–71. 5. Wu AH, Aaronson KD, Bolling SF, et al. Impact of mitral valve annuloplasty on mortality risk in patients with mitral regurgitation and left ventricular systolic dysfunction. J Am Coll Cardiol 2005;45:381–7. 6. Johnson RJ, Bradbury LL, Martin K, Neuberger J, UK Transplant Registry. Organ donation and transplantation in the Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
1799
UK—the last decade: a report from the UK national transplant registry. Transplantation 2014;97(suppl 1):S1–27. 7. Chen JM, Levin HR, Michler RE, Prusmack CJ, Rose EA, Aaronson KD. Reevaluating the significance of pulmonary hypertension before cardiac transplantation: determination of optimal thresholds and quantification of the effect of reversibility on perioperative mortality. J Thorac Cardiovasc Surg 1997;114:627–34. 8. Maisano F, Franzen O, Baldus S, et al. Percutaneous mitral valve interventions in the real world: early and 1-year results from the ACCESS-EU, a prospective, multicenter, nonrandomized post-approval study of the MitraClip therapy in Europe. J Am Coll Cardiol 2013;62:1052–61.
Large Primary Right Ventricular Teratoma in an Adult Makoto Mori, BS, Soh Hosoba, MD, Sebastian Iturra, MD, Elrond Teo, MBBS, Rajat Jhanjee, MD, and Vinod H. Thourani, MD Structural Heart and Valve Center, Division of Cardiothoracic Surgery, Joseph B. Whitehead Department of Surgery, Emory University School of Medicine, Atlanta; and Division of Cardiology, Tanner Medical Center, Carrollton, Georgia
We report an unusual case of a 30-year-old man with a primary mature cystic teratoma in the right ventricle. This case constitutes the third case of primary intramyocardial teratoma in an adult and the first that describes its benign form. In this report, we discuss surgical implications of such a rare cardiac tumor. (Ann Thorac Surg 2015;99:1799–801) Ó 2015 by The Society of Thoracic Surgeons
P
rimary cardiac neoplasms are rare, with a reported prevalence of 0.001% to 0.03% [1]. Cardiac teratoma is an extremely rare tumor, and most of the cardiac teratomas described in the literature are intrapericardial rather than intramyocardial. Furthermore, most of the reported intramyocardial teratomas are in the pediatric population, with few reported cases of secondary metastasis manifesting in the adults. Only two cases of primary intracardiac teratoma in adults have been reported in the medical literature, both of which were malignant teratoma. Here, we report a surgical resection of the first case of primary intracardiac benign teratoma in an adult patient. An active 30-year-old African American man with no significant medical history presented to the Tanner
Accepted for publication July 14, 2014. Address correspondence to Dr Thourani, Emory Hospital Midtown, 550 Peachtree St, 6th Flr Medical Office Tower, Atlanta, GA 30308; e-mail: [email protected].
Dr Thourani discloses a financial relationship with Edwards Lifesciences.
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.07.060
FEATURE ARTICLES
because of the chronic shortage of available donors. Furthermore, the average time on the waiting list ranges from 106 to 293 days, while the proportion of adult recipients who die awaiting a graft or are removed from the waiting list ranges from 19% to 27% according to different registries [6]. In this setting, achieving the optimization of medical and interventional therapies could improve the clinical status of the recipient while waiting for a suitable donor. Furthermore, counteracting the remodeling and limiting the increase in LV filling pressure and consequent pulmonary hypertension is particularly important in HTx recipients, because elevated pulmonary vascular resistance is a risk factor for mortality in the early and late courses after orthotopic heart transplantation [7]. MitraClip therapy is a percutaneous treatment for MR based on edge-to-edge surgical technique pioneered by Alfieri and colleagues and has been used successfully to treat functional or degenerative mitral valve regurgitation [8]. However, there is no evidence to date on whether MitraClip therapy can be conducted safely in patients with advanced HF, because patients with these characteristics have been excluded from prospective randomized controlled trials of the technique. In the experience documented here, MitraClip implantation achieved a significant clinical improvement and a reverse remodeling in LV filling pressure and pulmonary hypertension. Of note, we did not observe significant reverse remodeling in LV dimensions early or late after the procedure, probably because end-stage cardiomyopathy was so advanced in the patient that simple reduction in MR was not able to significantly reverse LV enlargement. However, we believe that the underlying mechanism of clinical improvement was the reduction in pulmonary hypertension, which was significantly affected by the clip implant. Further study is needed to elucidate the risk-benefit ratio of MitraClip therapy in the important subgroup of patients with CHF and significant MR.
CASE REPORT MORI ET AL PRIMARY VENTRICULAR TERATOMA IN AN ADULT
CASE REPORT GARATTI ET AL MITRACLIP AS A BRIDGE PROCEDURE TO HEART TRANSPLANT
Ann Thorac Surg 2015;99:1796–9
hemodynamic response and relationship to stroke volume and rate reduction protocols. ASAIO J 2006;52:228–33. 6. Slaughter MS, Silver MA, Farrar DJ, Tatooles AJ, Pappas PS. A new method of monitoring recovery and weaning the Thoratec left ventricular assist device. Ann Thorac Surg 2001;71:215–8.
Mitraclip Procedure as a Bridge Therapy in a Patient With Heart Failure Listed for Heart Transplantation Andrea Garatti, MD, Serenella Castelvecchio, MD, Francesco Bandera, MD, Massimo Medda, MD, and Lorenzo Menicanti, MD
FEATURE ARTICLES
Fig 2. Parasternal long-axis echocardiographic view during the pump-off evaluation demonstrates left ventricular internal dimension at diastole (LVIDd) of 4.8 cm. (EDV ¼ end-diastolic volume; IVSd ¼ interventricular septal thickness at diastole; IVS/LVPW ¼ ratio of thickness of interventricular septum and left ventricular posterior wall; LVPWd ¼ left ventricular posterior wall dimension.)
accommodate his activity level and symptoms; for example, if the patient had a day when he felt less energetic, he might choose to keep the pump at a higher speed. Over time, however, the trend was a gradual decrease in his pump speed. Other continuous-flow devices would require a clinic visit to program an alteration of the speed setting/flow rate. Furthermore, instead of making LVAD changes based solely on decompression, septal shift, and other echocardiographic variables, this approach engages the patient and allows the patient’s symptoms to help drive management. This sequential decrease in LVAD support allowed a slow, progressive increase in loading, thereby retraining the ventricle. In conclusion, the Jarvik 2000 LVAD allows for adaptable, patient-controlled speed variability to facilitate sequential weaning and explantation in the event of myocardial recovery. Although this report carries the inherent flaws of case reports, sequential conditioning of the LVAD-supported heart is a promising strategy for bridging patients to recovery and pump removal.
References 1. Drakos SG, Kfoury AG, Stehlik J, et al. Bridge to recovery: understanding the disconnect between clinical and biological problems. Circulation 2012;126:230–41. 2. Birks EJ, Tansley PD, Hardy J, et al. Left ventricular assist device and drug therapy for the reversal of heart failure. N Engl J Med 2006;355:1873–84. 3. Dandel M, Weng Y, Siniawski H, Potapov E, Lehmkuhl HB, Hetzer R. Long-term results in patients with idiopathic dilated cardiomyopathy after weaning from left ventricular assist devices. Circulation 2005;112(9 Suppl):I37–45. 4. Drakos SG, Wever-Pinzon O, Selzman CH, et al. Magnitude and time course of changes induced by continuous-flow left ventricular assist device unloading in chronic heart failure. J Am Coll Cardiol 2013;61:1985–94. 5. Slaughter MS, Sobieski MA, Koenig SC, Pappas PS, Tatooles AJ, Silver MA. Left ventricular assist device weaning: Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
Cardiac Surgery and Heart Failure Units, IRCCS Policlinico San Donato, Milan, Italy
Functional mitral regurgitation (MR) is frequently detected in patients with dilated cardiomyopathy and advanced heart failure, worsening quality of life and predicting poor survival. However, the optimal treatment of patients with advanced heart failure and severe MR has been controversial. We present the case of a 55-yearold man with previous aortic valve replacement, severe MR with high-grade pulmonary hypertension, and refractory heart failure (HF). He was listed for cardiac transplant and underwent percutaneous MitraClip implantation as bridge therapy. The postoperative course was uneventful, with significant improvement in New York Heart Association functional class. The patient underwent a successful heart transplant 8 months after the procedure. (Ann Thorac Surg 2015;99:1796–9) Ó 2015 by The Society of Thoracic Surgeons
F
unctional mitral regurgitation (MR) is a complication of idiopathic dilated cardiomyopathy, occurring secondary to left ventricle geometrical distortion [1]. MR complicating congestive heart failure (CHF) predicts poor survival [2]. Decreasing the severity of MR has been shown to decrease CHF symptoms and improve the patients’ quality of life. However, the optimal treatment of patients with advanced heart failure and severe MR has been controversial. We present the case of a patient listed for heart transplantation (HTx) with end-stage HF and severe MR who underwent percutaneous MitraClip (Abbott Vascular, Menlo Park, CA) implantation in order to improve clinical status and reduce pulmonary hypertension while awaiting a suitable donor.
Accepted for publication July 14, 2014. Address correspondence to Dr Garatti, Department of Cardiovascular Disease “E. Malan”, Cardiac Surgery Unit, Policlinico S. Donato Hospital, Via Morandi 30, 20097, S. Donato Milanese, Milan, Italy; e-mail: agaratti@ tiscali.it.
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.07.079
Ann Thorac Surg 2015;99:1796–9
CASE REPORT GARATTI ET AL MITRACLIP AS A BRIDGE PROCEDURE TO HEART TRANSPLANT
1797
Fig 1. Apical four-chamber echocardiography showing the reduction of mitral regurgitation from severe to mild.
pulmonary hypertension (pulmonary artery systolic pressure [PAPs] ¼ 57 mm Hg) was detected. The patient underwent a cardiopulmonary exercise test (incremental ramp of 8 watts/min) combined with exerciseechocardiography. His functional capacity resulted severely depressed (peak VO2 ¼ 8 mL/kg/min; predicted peak VO2 ¼ 27%) with severely impaired ventilator efficiency (VE/VCO2 ¼ 79) and exercise oscillatory ventilation, both markers of advanced cardiopulmonary disease. The patient was considered not suitable for conventional MV repair because of severe advanced HF, redo surgery, and comorbidities (The Society of Thoracic Surgeons [STS] mortality þ morbidity score ¼ 59; EUROSCORE II ¼ 9.2) and was added to the HTx waiting list. Because of severe dyspnea at rest, with orthopnea and paroxysmal nocturnal dyspnea (sleeping with three pillows or sitting in a chair during the night), we decided to correct MR to slightly improve symptoms and stabilize the patient while awaiting a suitable donor. A percutaneous edge-to-edge procedure with the MitraClip system (Abbott Vascular, Menlo Park, CA) was then performed under general anesthesia in the operating room, with live real-time three-dimensional Fig 2. Apical five-chamber echocardiography showing the reduction of mitral regurgitation from severe to mild.
FEATURE ARTICLES
A 55-year-old man, previously implanted with a mechanical aortic prosthesis, was referred to our department for chronic CHF and severe MR. In the last 6 months, because of HF symptoms worsening (New York Heart Association [NYHA] class III–IV), the patient underwent recurring hospital admission for intravenous treatment with levosimendan and furosemide twice per month. He was implanted with an implantable cardioverter defibrillator (ICD)/biventricular pacemaker (PM) for cardiac resynchronization therapy. Rest echocardiography at admission showed advanced left ventricular (LV) remodeling (indexed end-diastolic volume [iEDV] ¼ 138 mL/m2; indexed end-systolic volume [iESV] ¼ 108 mL/ m2; LV indexed mass ¼ 201 g/m2) associated with severe systolic and diastolic dysfunction (LVEF ¼ 22%). Severe MR (effective regurgitant orifice [ERO] ¼ 32 mm2; regurgitant volume ¼ 51 mL; vena contracta ¼ 6) occurred because of symmetric leaflets tethering and annular dilatation. Notably, severe right ventricle dysfunction (tricuspid annular plane systolic excursion [TAPSE] ¼ 13 mm; right ventricular [RV] fractional area ¼ 0.17%; tricuspid annular tissue Doppler imaging [TDI] ¼ 6 cm/s) with associated severe tricuspid regurgitation and
1798
CASE REPORT GARATTI ET AL MITRACLIP AS A BRIDGE PROCEDURE TO HEART TRANSPLANT
Ann Thorac Surg 2015;99:1796–9
FEATURE ARTICLES
Fig 3. Parasternal short axis echocardiography showing the position of the MitraClip (arrow) close to the anterior mitral commissure. (Left panel: before clip; Right panel: after clip.)
echocardiography and fluoroscopic guidance. Procedural details has been reported previously [3]. Briefly, by means of transeptal puncture, a MitraClip device was implanted in relation to the origin of the main regurgitant jet, between P3 and A3 scallops, perpendicularly to the coaptation line. Transesophageal echocardiography at the end of the procedure showed a mild residual MR (Figs 1-3). The postoperative course was uneventful, and the patient was discharged home on postoperative day 4. In the following months, the patient experienced a significant improvement in clinical status (NYHA Class ¼ II–III). Furthermore, intravenous therapy was stopped, and the patient was subsequently managed with high-dose oral diuretics. Three-month follow-up echocardiography showed a mild to moderate MR (ERO ¼ 19 mm2; regurgitant volume ¼ 29 mL), associated with a dramatic reduction in pulmonary hypertension (PAPs ¼ 38 mm Hg) and improvement of RV function (TAPSE ¼ 15; RV fractional area ¼ 37%) as well as of tricuspid regurgitation (Table 1). The patients remained clinically stable in the following months, without further increase in MR nor in pulmonary artery pressure, and underwent a successful heart transplant 8 months after the MitraClip implantation.
Comment The advantages and the rationale of the present approach are, in our opinion, the following. First, treating severe MR achieved improvement of patient’s symptoms allowing him a better quality of life while waiting a suitable donor. Second, improving MR achieved a significant reduction in LV filling pressure and pulmonary hypertension, which is particularly harmful in HTx recipient. Third, treating severe MR in patients with advanced HF by a percutaneous approach minimizes the procedural risk and avoids the chest opening, which could complicate the surgical approach of the future HTx. Patients with CHF are frequently affected by functional MR (45% to 75% of patients with systolic heart failure) owing to the distortion of valve apparatus secondary to global and local remodeling of the left ventricle [4]. Management of functional MR in end-stage CHF patients is challenging. In such cases, surgical reconstruction of the mitral valve could be performed, but the only published case-control study showed no long-term survival benefit in patients with CHF and severe functional MR who were treated with mitral valve repair [5]. Heart transplantation is the most effective treatment for well-selected patients with end-stage HF. However, it is available to only a fraction of those who could benefit
Table 1. Changes Over Time of Left Ventricular Echocardiographic Parameters Between Preoperative and Transplantation Echocardiographic Parameters LV EDD (mm) LV ESD (mm) EDV (mL) ESV (mL) EF (%) PaPs (mm Hg) Mitral regurgitation Tricuspid regurgitation EDD ¼ end diastolic diameter; volume; LV, left ventricular;
Preoperative
At Discharge
73 64 277 217 22 57 Severe Severe
69 66 260 200 23 48 Mild Moderate
EDV ¼ end diastolic volume; EF ¼ ejection fraction; PaPs ¼ systolic pulmonary artery pressure.
3-Month Follow-Up
At Transplant
70 64 265 205 25 38 Mild/moderate Mild
69 65 262 200 25 30 Mild/moderate Mild
ESD ¼ end systolic diameter;
ESV ¼ end systolic
Ann Thorac Surg 2015;99:1799–801
References 1. Yiu SF, Enriquez-Sarano M, Tribouilloy C, Seward JB, Tajik AJ. Determinants of the degree of functional mitral regurgitation in patients with systolic left ventricular dysfunction: a quantitative clinical study. Circulation 2000;102: 1400–6. 2. Rossi A, Dini FL, Faggiano P, et al. Independent prognostic value of functional mitral regurgitation in patients with heart failure. A quantitative analysis of 1256 patients with ischaemic and non-ischaemic dilated cardiomyopathy. Heart 2011;97: 1675–80. 3. Feldman T, Foster E, Glower DD, et al. Percutaneous repair or surgery for mitral regurgitation. N Engl J Med 2011;364: 1395–406. 4. Grayburn PA, Appleton CP, DeMaria AN, et al. Echocardiographic predictors of morbidity and mortality in patients with advanced heart failure: the BEST Trial. J Am Coll Cardiol 2005;45:1064–71. 5. Wu AH, Aaronson KD, Bolling SF, et al. Impact of mitral valve annuloplasty on mortality risk in patients with mitral regurgitation and left ventricular systolic dysfunction. J Am Coll Cardiol 2005;45:381–7. 6. Johnson RJ, Bradbury LL, Martin K, Neuberger J, UK Transplant Registry. Organ donation and transplantation in the Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
1799
UK—the last decade: a report from the UK national transplant registry. Transplantation 2014;97(suppl 1):S1–27. 7. Chen JM, Levin HR, Michler RE, Prusmack CJ, Rose EA, Aaronson KD. Reevaluating the significance of pulmonary hypertension before cardiac transplantation: determination of optimal thresholds and quantification of the effect of reversibility on perioperative mortality. J Thorac Cardiovasc Surg 1997;114:627–34. 8. Maisano F, Franzen O, Baldus S, et al. Percutaneous mitral valve interventions in the real world: early and 1-year results from the ACCESS-EU, a prospective, multicenter, nonrandomized post-approval study of the MitraClip therapy in Europe. J Am Coll Cardiol 2013;62:1052–61.
Large Primary Right Ventricular Teratoma in an Adult Makoto Mori, BS, Soh Hosoba, MD, Sebastian Iturra, MD, Elrond Teo, MBBS, Rajat Jhanjee, MD, and Vinod H. Thourani, MD Structural Heart and Valve Center, Division of Cardiothoracic Surgery, Joseph B. Whitehead Department of Surgery, Emory University School of Medicine, Atlanta; and Division of Cardiology, Tanner Medical Center, Carrollton, Georgia
We report an unusual case of a 30-year-old man with a primary mature cystic teratoma in the right ventricle. This case constitutes the third case of primary intramyocardial teratoma in an adult and the first that describes its benign form. In this report, we discuss surgical implications of such a rare cardiac tumor. (Ann Thorac Surg 2015;99:1799–801) Ó 2015 by The Society of Thoracic Surgeons
P
rimary cardiac neoplasms are rare, with a reported prevalence of 0.001% to 0.03% [1]. Cardiac teratoma is an extremely rare tumor, and most of the cardiac teratomas described in the literature are intrapericardial rather than intramyocardial. Furthermore, most of the reported intramyocardial teratomas are in the pediatric population, with few reported cases of secondary metastasis manifesting in the adults. Only two cases of primary intracardiac teratoma in adults have been reported in the medical literature, both of which were malignant teratoma. Here, we report a surgical resection of the first case of primary intracardiac benign teratoma in an adult patient. An active 30-year-old African American man with no significant medical history presented to the Tanner
Accepted for publication July 14, 2014. Address correspondence to Dr Thourani, Emory Hospital Midtown, 550 Peachtree St, 6th Flr Medical Office Tower, Atlanta, GA 30308; e-mail: [email protected].
Dr Thourani discloses a financial relationship with Edwards Lifesciences.
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.07.060
FEATURE ARTICLES
because of the chronic shortage of available donors. Furthermore, the average time on the waiting list ranges from 106 to 293 days, while the proportion of adult recipients who die awaiting a graft or are removed from the waiting list ranges from 19% to 27% according to different registries [6]. In this setting, achieving the optimization of medical and interventional therapies could improve the clinical status of the recipient while waiting for a suitable donor. Furthermore, counteracting the remodeling and limiting the increase in LV filling pressure and consequent pulmonary hypertension is particularly important in HTx recipients, because elevated pulmonary vascular resistance is a risk factor for mortality in the early and late courses after orthotopic heart transplantation [7]. MitraClip therapy is a percutaneous treatment for MR based on edge-to-edge surgical technique pioneered by Alfieri and colleagues and has been used successfully to treat functional or degenerative mitral valve regurgitation [8]. However, there is no evidence to date on whether MitraClip therapy can be conducted safely in patients with advanced HF, because patients with these characteristics have been excluded from prospective randomized controlled trials of the technique. In the experience documented here, MitraClip implantation achieved a significant clinical improvement and a reverse remodeling in LV filling pressure and pulmonary hypertension. Of note, we did not observe significant reverse remodeling in LV dimensions early or late after the procedure, probably because end-stage cardiomyopathy was so advanced in the patient that simple reduction in MR was not able to significantly reverse LV enlargement. However, we believe that the underlying mechanism of clinical improvement was the reduction in pulmonary hypertension, which was significantly affected by the clip implant. Further study is needed to elucidate the risk-benefit ratio of MitraClip therapy in the important subgroup of patients with CHF and significant MR.
CASE REPORT MORI ET AL PRIMARY VENTRICULAR TERATOMA IN AN ADULT
