Publications by authors named "Roberto Gallotti"

35 Publications

Mechanisms and outcomes of catheter ablation for biatrial tachycardia in adults with congenital heart disease.

Heart Rhythm 2021 Jun 25. Epub 2021 Jun 25.

Division of Pediatric Cardiology, UCLA Medical Center, Los Angeles, California; Ahmanson/UCLA Adult Congenital Heart Disease Center, Los Angeles, California; UCLA Cardiac Arrhythmia Center, UCLA Health System, David Geffen School of Medicine at UCLA, Los Angeles, California.

Background: Biatrial tachycardia (BiAT) is a rare form of macroreentry not previously characterized in adults with congenital heart disease (ACHD).

Objective: The purpose of this study was to determine the prevalence, mechanisms, and outcomes of catheter ablation for BiAT in ACHD.

Methods: All ACHD undergoing catheter ablation for macroreentrant atrial tachycardia over a 10-year period were evaluated for evidence of BiAT. Patients were categorized as prior Senning, Fontan, or other biventricular operation. A novel biatrial global activation histogram (GAH) analysis was used to demonstrate the presence of interatrial connections (IACs).

Results: Among 263 ACHD, BiAT was identified at 11 procedures in 10 patients (4.2%; median age 35 years; 30% male). The congenital category was Fontan in 6, Senning in 3, and biventricular in 2. Diagnosis of BiAT was associated with ablation era and mapping technology (P <.001) and could be confirmed with a novel GAH mapping approach for normally septated atrial connections. Catheter ablation targeted an IAC in 5 cases (Bjork Fontan and biventricular operations), a posterior isthmus in 3 (Senning operation), and the cavotricuspid isthmus or equivalent in 3 (lateral tunnel [LT] Fontan). Recurrence was isolated to ablation to sites at the expected location of the Bachmann bundle, and durable success could be achieved after repeat ablation.

Conclusion: BiAT occurs in approximately 4% of ACHD but is likely underrecognized. BiAT could be targeted at an IAC for normally septated atria and at a conventional critical isthmus after Senning and LT Fontan operations.
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http://dx.doi.org/10.1016/j.hrthm.2021.06.1193DOI Listing
June 2021

Electrophysiological Characteristics of Intra-Atrial Reentrant Tachycardia in Adult Congenital Heart Disease: Implications for Catheter Ablation.

J Am Heart Assoc 2021 Jul 14;10(13):e020835. Epub 2021 Jun 14.

Division of Cardiology Department of Medicine University of California at Los Angeles Medical Center, Ahmanson/Adult Congenital Heart Disease Center Los Angeles CA.

Background Ultra-high-density mapping enables detailed mechanistic analysis of atrial reentrant tachycardia but has yet to be used to assess circuit conduction velocity (CV) patterns in adults with congenital heart disease. Methods and Results Circuit pathways and central isthmus CVs were calculated from consecutive ultra-high-density isochronal maps at 2 tertiary centers over a 3-year period. Circuits using anatomic versus surgical obstacles were considered separately and pathway length <50th percentile identified small circuits. CV analysis was used to derive a novel index for prediction of postablation conduction block. A total of 136 supraventricular tachycardias were studied (60% intra-atrial reentrant, 14% multiple loop). Circuits with anatomic versus surgical obstacles featured longer pathway length (119 mm; interquartile range [IQR], 80-150 versus 78 mm; IQR, 63-95; <0.001), faster central isthmus CV (0.1 m/s; IQR, 0.06-0.25 versus 0.07 m/s; IQR, 0.05-0.10; =0.016), faster non-isthmus CV (0.52 m/s; IQR, 0.33-0.71 versus 0.38 m/s; IQR, 0.27-0.46; =0.009), and fewer slow isochrones (4; IQR, 2.3-6.8 versus 6; IQR 5-7; =0.008). Both central isthmus (=0.45; <0.001) and non-isthmus CV (=0.71; <0.001) correlated with pathway length, whereas central isthmus CV <0.15 m/s was ubiquitous for small circuits. Non-isthmus CV in tachycardia correlated with CV during block validation (=0.94; <0.001) and a validation map to tachycardia conduction time ratio >85% predicted isthmus block in all cases. Over >1 year of follow-up, arrhythmia-free survival was better for homogeneous CV patterns (90% versus 57%; =0.04). Conclusions Ultra-high-density mapping-guided CV analysis distinguishes atrial reentrant patterns in adults with congenital heart disease with surgical obstacles producing slower and smaller circuits. Very slow central isthmus CV may be essential for atrial tachycardia maintenance in small circuits, and non-isthmus conduction time in tachycardia appears to be useful for rapid assessment of postablation conduction block.
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http://dx.doi.org/10.1161/JAHA.121.020835DOI Listing
July 2021

Pulmonary vein and left atrial posterior wall isolation for the treatment of atrial fibrillation: Comparable outcomes for adults with congenital heart disease.

J Cardiovasc Electrophysiol 2021 Jul 14;32(7):1868-1876. Epub 2021 Apr 14.

UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine, Los Angeles, California, USA.

Introduction: Optimal treatment strategies for ACHD with AF are unknown. This study sought to assess outcomes of pulmonary vein isolation (PVI) ± left atrial (LA), posterior wall isolation (PWI) for adults with congenital heart disease (ACHD), and atrial fibrillation (AF).

Methods: A retrospective review of all cryoballoon (CB) PVI ± PWI procedures at a single center over a 3-year period were performed. Clinical characteristics and outcomes for patients with and without ACHD were compared. The primary outcome was the occurrence of atrial tachyarrhythmia at 12-months postablation after a 90-day blanking period.

Results: Three-hundred and sixteen patients (mean: 63 ± 12 years, [63% male]) underwent CB PVI ± PWI during the study, including 31 (10%) ACHD (simple 35%, moderate 39% complex 26%; nonparoxysmal AF in 52%). ACHD was younger (51 vs. 64 years; p < .001) with a lower CHADS DS -VASc score (1.2 vs. 2.1; p = .001) but had a greater LA diameter (4.9 vs. 4.0 cm; p < .001) and a number of prior cardioversions (0.9 vs. 0.4; p < .001) versus controls. 12-month freedom from recurrent AF was similar for ACHD and controls (76% vs. 80%; p = .6) and remained nonsignificant in multivariate analysis (hazard ratio: 1.8, 95% confidence interval: 0.7-5.1; p = .22). At 12-months postablation, 75% of ACHD versus 93% of control patients were off antiarrhythmic drug therapy (p = .07).

Conclusion: This study demonstrates younger age and lower conventional stroke risk, yet clinically advanced AF for ACHD relative to controls. CB PVI ± PWI was an effective strategy for the treatment of AF among all forms of ACHD with similar 12-month outcomes as compared to controls.
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http://dx.doi.org/10.1111/jce.15027DOI Listing
July 2021

Genotype Predicts Outcomes in Fetuses and Neonates With Severe Congenital Long QT Syndrome.

JACC Clin Electrophysiol 2020 11 26;6(12):1561-1570. Epub 2020 Aug 26.

Joe DiMaggio Children's Hospital Heart Institute, Memorial Healthcare System, Hollywood, Florida, USA.

Objectives: This study sought to determine the relationship between long QT syndrome (LQTS) subtype (LTQ1, LTQ2, LTQ3) and postnatal cardiac events (CEs).

Background: LQTS presenting with 2:1 atrioventricular block or torsades de pointes in the fetus and/or neonate has been associated with risk for major CEs, but overall outcomes and predictors remain unknown.

Methods: A retrospective study involving 25 international centers evaluated the course of fetuses/newborns diagnosed with congenital LQTS and either 2:1 atrioventricular block or torsades de pointes. The primary outcomes were age at first CE after dismissal from the newborn hospitalization and death and/or cardiac transplantation during follow-up. CE was defined as aborted cardiac arrest, appropriate shock from implantable cardioverter-defibrillator, or sudden cardiac death.

Results: A total of 84 fetuses and/or neonates were identified with LQTS (12 as LQT1, 35 as LQT2, 37 as LQT3). Median gestational age at delivery was 37 weeks (interquartile range: 35 to 39 weeks) and age at hospital discharge was 3 weeks (interquartile range: 2 to 5 weeks). Fetal demise occurred in 2 and pre-discharge death in 1. Over a median of 5.2 years, there were 1 LQT1, 3 LQT2, and 23 LQT3 CEs (13 aborted cardiac arrests, 5 sudden cardiac deaths, and 9 appropriate shocks). One patient with LQT1 and 11 patients with LQT3 died or received cardiac transplant during follow-up. The only multivariate predictor of post-discharge CEs was LQT3 status (LQT3 vs. LQT2: hazard ratio: 8.4; 95% confidence interval: 2.6 to 38.9; p < 0.001), and LQT3, relative to LQT2, genotype predicted death and/or cardiac transplant (p < 0.001).

Conclusions: In this large multicenter study, fetuses and/or neonates with LQT3 but not those with LQT1 or LQT2 presenting with severe arrhythmias were at high risk of not only frequent, but lethal CEs.
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http://dx.doi.org/10.1016/j.jacep.2020.06.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7679474PMC
November 2020

Peripheral venous pressure accurately predicts central venous pressure in the adult Fontan circulation.

Int J Cardiol 2021 03 13;326:77-80. Epub 2020 Nov 13.

Ahmanson/UCLA Adult Congenital Heart Disease Center, Division of Cardiology, Department of Medicine, University of California Los Angeles, Los Angeles, CA, United States of America.

Background: Patients with the Fontan circulation lack a subpulmonary ventricular pump and thus the main driver for pulmonary blood flow is a high central venous pressure. Peripheral venous pressure (PVP) measurement has been shown to be a reproducible and fairly accurate surrogate for central venous pressure (CVP), but not specifically for the adult Fontan circulation. This study aims to determine the relationship of PVP to CVP in adult Fontan patients.

Methods: All adult patients (≥18 yo) with a Fontan circulation undergoing cardiac catheterization were included. Both CVP and PVP were measured during the catheterization. The relationship between the peripheral venous and central venous pressures was assessed using simple linear regression and the Bland-Altman plot analysis for differences.

Results: Thirty-eight adult Fontan patients (mean age 30.7 ± 8.5, range 18-52 years) undergoing 43 cardiac catheterizations were analyzed. The mean CVP was 17.3 +/- 4.7 mmHg. The mean PVP was 18.4 +/- 5 mmHg. CVP and PVP were highly correlated, with an R value of 0.83 (p < 0.001). The CVP can be estimated with PVP measurements using the formula CVP = (0.86 * PVP) + 1.3. A Bland-Altman plot for PVP and CVP demonstrated that the PVP overestimated CVP by a mean of 1.2 mmHg, with a 95% limit of agreement of -5.2 mmHg to 2.8 mmHg.

Conclusions: In adult Fontan patients, measuring PVP is a reliable, less-invasive, and accurate method of estimating the CVP during cardiac catheterization procedures. These findings may enable outpatient monitoring of Fontan hemodynamics.
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http://dx.doi.org/10.1016/j.ijcard.2020.11.007DOI Listing
March 2021

Ten-year outcomes of transcaval cardiac puncture for catheter ablation after extracardiac Fontan surgery.

Heart Rhythm 2020 10 11;17(10):1752-1758. Epub 2020 May 11.

Division of Pediatric Cardiology, UCLA Medical Center, Los Angeles, California; Ahmanson/UCLA Adult Congenital Heart Disease Program, Los Angeles, California.

Background: Although they are at lower risk, patients with previous extracardiac conduit (EC) Fontan still may require catheter ablation for supraventricular arrhythmia.

Objective: The purpose of this study was to determine the optimal approach to pulmonary venous atrium (PVA) access after EC Fontan operation.

Methods: All electrophysiological procedures requiring PVA over a 10-year period at the UCLA Medical Center were reviewed. PVA was grouped by transcaval cardiac puncture (TCP) or direct conduit puncture. Procedural characteristics and outcomes were compared.

Results: Between June 2009 and November 2019, 23 electrophysiological procedures requiring PVA access were performed in 17 EC Fontan patients (53% male; median age 25 years; interquartile range 11-34). Cavoatrial overlap was identified in 14 patients by preprocedural imaging (10 cardiac computed tomography, 4 cardiac magnetic resonance). PVA access was obtained via TCP in 11, direct conduit puncture in 6, pre-existing fenestration in 5, and pulmonary artery puncture in 1. Time to PVA was significantly shorter for TCP vs direct conduit puncture (0.2 vs 1.1 hours, respectively; P = .03). The only predictor of successful TCP was the length of cavoatrial overlap by preprocedural imaging (14 vs 3 mm; P = .02). No procedural complications occurred. No change in oxygen saturation was noted, and no evidence of residual shunting was detected by follow-up echocardiography.

Conclusion: TCP is feasible in most patients after EC Fontan surgery and can be predicted by preprocedural advanced imaging. TCP is associated with shorter time to PVA and was uncomplicated in this single-center study. Preoperative assessment of cavoatrial overlap should be considered before catheter ablation for EC Fontan.
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http://dx.doi.org/10.1016/j.hrthm.2020.05.007DOI Listing
October 2020

Permanent Conduction System Pacing for Congenitally Corrected Transposition of the Great Arteries.

Heart Rhythm 2020 Feb 10. Epub 2020 Feb 10.

University of Chicago Medicine, Chicago, IL.

Background: Congenitally corrected transposition of the great arteries (CCTGA) is associated with spontaneous AV block and pacing-induced cardiomyopathy. His bundle pacing (HBP) is a potential alternative to conventional CRT.

Objectives: To determine the outcomes of HBP for CCTGA.

Methods: Retrospective data were collected from 10 international centers.

Results: HBP or left bundle branch pacing (LBBP) was attempted for 15 CCTGA patients (median 23 yrs, 87% male). Prior surgery had been performed in 5 and chronic ventricular pacing in 6. Conduction system pacing (HBP=11, LBBP=2; non-selective in 10, selective in 3) was acutely successful in 13 (86%) without complication. In 9 cases, electro-anatomical mapping was available and identified the distal His bundle and proximal LBBs within the morphologic LV below the pulmonary valve separate from the mitral annulus. The median implant HV interval was 42 ms (IQR 35 - 48), R wave 6 mV (IQR 5 - 18) and threshold 0.5V (IQR 0.5 - 1.2) at median 0.5 ms. The QRSd was unchanged as compared to junctional escape rhythm (124 vs 110 ms, p=0.17) and decreased significantly compared to baseline ventricular pacing (112 vs 164 ms, p<0.01). At a median of 8 months, all patients were alive without significant change in pacing threshold or lead dysfunction. NYHA class improved in 5 patients.

Conclusions: Permanent conduction system pacing is feasible in CCTGA by either HBP or proximal LBBP. Narrow paced QRS and stable lead thresholds were observed at intermediate follow-up. Unique anatomical characteristics may favor this approach over conventional CRT.
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http://dx.doi.org/10.1016/j.hrthm.2020.01.033DOI Listing
February 2020

Permanent conduction system pacing for congenitally corrected transposition of the great arteries: A Pediatric and Congenital Electrophysiology Society (PACES)/International Society for Adult Congenital Heart Disease (ISACHD) Collaborative Study.

Heart Rhythm 2020 Mar 13. Epub 2020 Mar 13.

University of Chicago Medicine, Chicago, Illinois.

Background: Congenitally corrected transposition of the great arteries (CCTGA) is associated with spontaneous atrioventricular block and pacing-induced cardiomyopathy. Conduction system pacing is a potential alternative to conventional cardiac resynchronization therapy (CRT).

Objective: The purpose of this study was to determine the outcomes of conduction system pacing for CCTGA.

Methods: Retrospective data were collected from 10 international centers.

Results: His bundle (HBP) or left bundle branch pacing (LBBP) was attempted in 15 CCTGA patients (median age 23 years; 87% male). Previous surgery had been performed in 8 and chronic ventricular pacing in 7. Conduction system pacing (11 HBP, 2 LBBP 2; nonselective in 10, selective in 3) was acutely successful in 13 (86%) without complication. In 9 cases, electroanatomic mapping was available and identified the distal His bundle and proximal left bundle branches within the morphologic left ventricle below the pulmonary valve separate from the mitral annulus. Median implant HV interval was 42 ms (interquartile range [IQR] 35-48), R wave 6 mV (IQR 5-18), and threshold 0.5 V (IQR 0.5-1.2) at median 0.5 ms. QRSd was unchanged compared to junctional escape rhythm (124 vs 110 ms; P = .17) and decreased significantly compared to baseline ventricular pacing (112 vs 164 ms; P <.01). At a median of 8 months, all patients were alive without significant change in pacing threshold or lead dysfunction. New York Heart Association functional class improved in 5 patients.

Conclusion: Permanent conduction system pacing is feasible in CCTGA by either HBP or proximal LBBP. Narrow paced QRS and stable lead thresholds were observed at intermediate follow-up. Unique anatomic characteristics may favor this approach over conventional CRT.
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http://dx.doi.org/10.1016/j.hrthm.2020.01.033DOI Listing
March 2020

Leadless pacemaker placement in an 18-kilogram child: Procedural approach and technical considerations.

HeartRhythm Case Rep 2019 Nov 28;5(11):555-558. Epub 2019 Aug 28.

Division of Pediatric Cardiology, UCLA Medical Center, Los Angeles, California.

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http://dx.doi.org/10.1016/j.hrcr.2019.08.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6926214PMC
November 2019

Ultrahigh-density mapping supplemented with global chamber activation identifies noncavotricuspid-dependent intra-atrial re-entry conduction isthmuses in adult congenital heart disease.

J Cardiovasc Electrophysiol 2019 12 10;30(12):2797-2805. Epub 2019 Nov 10.

UCLA Medical Center, Ahmanson/UCLA Adult Congenital Heart Disease Center, Los Angeles, California.

Objective: To evaluate the role of ultrahigh-density mapping for conduction isthmus (CI) characterization in adult congenital heart disease (ACHD).

Background: Catheter ablation remains suboptimal for ACHD with atypical intra-atrial reentrant tachycardias (IART) that can be challenging to define using existing mapping technology.

Methods: An ultrahigh-density mapping system was selectively employed over a 1-year period for procedures involving noncavotricuspid isthmus-dependent-IART. A global activation histogram (GAH) was assessed for the ability to predict ablation targets. Procedural characteristics were compared to a group of matched controls.

Results: Twenty patients (mean age 43 ± 15, 70% male) underwent 20 procedures targeting 34 tachycardias during the study period. Diagnoses included single ventricle (8), tetralogy of Fallot (2), left heart obstruction (3), Ebstein's anomaly (2) atrial septal defect (2), Mustard operation (2), and Rasteilli operation (1). Prior catheter ablation/Maze operation had been performed in 12 (60%). The median time per map was 21 minutes (interquartile range [IQR], 16-32), representing 14 834 points per map (IQR 9499-43 191; P < .001 vs controls). Review of GAH maps showed lower trough values were associated with more favorable IART CI characteristics (P ≤ =.001 for all). Acute success was achieved in 19/20 (95%) procedures, with tachycardia termination during the first lesion in eight cases (P = .02 vs controls). There was one recurrence during 0.6 years follow-up.

Conclusions: Ultrahigh-density mapping supplemented with the GAH tool was effective for CI identification in a cohort of complex ACHD patients. Catheter ablation was more efficient compared to controls, suggesting precise CI characterization using this technology.
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http://dx.doi.org/10.1111/jce.14251DOI Listing
December 2019

Catheter ablation of supraventricular tachycardia after tricuspid valve surgery in patients with congenital heart disease: A multicenter comparative study.

Heart Rhythm 2020 01 23;17(1):58-65. Epub 2019 Jul 23.

Division of Cardiology, Department of Medicine, UCLA Medical Center, Ahmanson/UCLA Adult Congenital Heart Disease Center, Los Angeles, California.

Background: Tricuspid valve (TV) surgery is often required for adult congenital heart disease (ACHD), but may hinder catheter ablation when an artificial material or imbricated tissue covers the tricuspid annulus.

Objective: The purpose of this study was to determine the outcomes of catheter ablation after TV surgery in a large ACHD cohort.

Methods: An international retrospective study involving 7 centers was conducted. Patients who did and did not undergo TV surgery were matched for age, lesion classification, and postsurgical duration. TV operations were classified as valve ring/replacement vs repair.

Results: One hundred thirty-six patients (42 ring/replacement, 39 repair, and 55 no TV surgery; median 32 years [IQR 20 - 46]) underwent 180 procedures targeting 239 tachycardias (cavotricuspid-isthmus dependent intraatrial reentrant tachycardia 36%, other intraatrial reentrant tachycardia 29%, focal atrial tachycardia 18%, and other supraventricular tachyarrhythmia 17%). Post-TV surgery, procedures were longer (4.3 hours vs 3.3 hours; P = .003) and required longer fluoroscopy time (31 minutes vs 18 minutes; P = .001). At least partial acute success was achieved in 81% of procedures in the TV ring/replacement group vs 94% in both TV repair and no TV surgery groups (P = .03). The difference was driven mainly by ablation of annular substrates, with acute success in 73% of TV ring/replacement, 92% of TV repair, and 94% of no TV surgery groups (P = .01). Over a median of 3.0 years, tachycardia recurred after 26% of procedures. TV ring/replacement predicted recurrence in the multivariable analysis (hazard ratio 2.4; 95% confidence interval 1.2-5.2; P = .009).

Conclusion: After surgery for ACHD, catheter ablation success was lower and tachycardia recurrence was higher after TV valve ring/replacement surgery. The findings of this retrospective report support future larger multicenter series and prospective evaluation to determine the role of empirical annular substrate ablation.
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http://dx.doi.org/10.1016/j.hrthm.2019.07.020DOI Listing
January 2020

A minimally invasive hybrid approach for cardiac resynchronization of the systemic right ventricle.

Pacing Clin Electrophysiol 2019 02 13;42(2):171-177. Epub 2018 Dec 13.

Department of Cardiothoracic Surgery, UCLA Medical Center, University of California Los Angeles, Los Angeles, California.

Background: Patients with systemic right ventricle (RV) often develop progressive heart failure and may benefit from cardiac resynchronization therapy (CRT); however, the optimal strategy for CRT has not been defined.

Methods: A retrospective review of all the patients with systemic RV failure undergoing a hybrid transcatheter-surgical approach was performed. Procedural technique and outcomes are reported.

Results: Six patients underwent detailed electroanatomical mapping of the systemic RV followed by a new hybrid approach targeting latest endocardial activation, which was followed by focused epicardial mapping. The exact site of latest endocardial activation was variable but localized to the basolateral RV in all cases. Sites of latest activation tended to be more superior during contralateral ventricular pacing versus intact atrioventricular conduction (P = 0.06). Latest endocardial activation at the targeted site occurred at 157 ms (interquartile range [IQR] = 120-181 ms) and corresponding epicardial activation at 174 ms (IQR = 140-198 ms), after the onset of the QRS complex. Following the hybrid CRT, the QRS duration decreased from a median of 193 to 147 ms and the fractional area of change increased from a median of 15.5% to 30% (P < 0.001). Patients were discharged to home after a median of 4 days. Of the three patients who were initially referred for transplant evaluation, two (66%) of them no longer met the criteria following CRT.

Conclusions: Whereas latest endocardial activation for the systemic RV appears to localize to the basolateral region, the optimal lead position may be variable. An approach utilizing endocardial mapping followed by a limited surgical incision and confirmation of latest activation may result in minimally invasive surgery and a favorable acute CRT response.
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http://dx.doi.org/10.1111/pace.13568DOI Listing
February 2019

Catheter Ablation of Ventricular Arrhythmia for Ebstein's Anomaly in Unoperated and Post-Surgical Patients.

JACC Clin Electrophysiol 2018 10 27;4(10):1300-1307. Epub 2018 Jun 27.

Arrhythmia Center, Department of Cardiology, University of California, Los Angeles, Los Angeles, California.

Objectives: The purpose of this study was to determine the ventricular arrhythmia (VA) substrates in patients with unoperated and post-surgical Ebstein's Anomaly (EA).

Background: EA is associated with variable atrialization of the right ventricle and a propensity for VA and sudden death. There are scant data on catheter ablation for VA in this population.

Methods: This was a retrospective study involving 11 congenital heart disease centers.

Results: A total of 24 patients (median age 17 [interquartile range (IQR): 11 to 37] years; age range 1 to 68 years; 42% men) with EA undergoing catheter ablation were identified. Prior tricuspid valve (TV) surgery had been performed in 12 (50%). Presenting symptoms were palpitations in 15, syncope in 4, aborted cardiac arrest in 4, and none in 1. At procedure, 28 VA substrates were encountered and 25 were completely characterized (median 1 per patient; cycle length 305 [IQR: 268 to 400] ms). In 3 cases, premature ventricular contraction (PVC) foci were targeted (1 with a history of PVC-induced ventricular fibrillation). VA mechanisms were focal in 15 and macro-re-entrant in 10, and did not differ significantly between those with and those without prior TV surgery (p = 0.7). Focal VAs predominantly localized to the atrialized right ventricle ARV in unoperated patients and to diseased myocardium or Purkinje tissue after TV surgery. Macro-re-entry was related to isolated scar or split potentials in the ARV in unoperated patients, and larger, more diffuse scar after TV surgery. Complete success was achieved in 22 (92%). There were 2 of 13 complications in patients <18 years of age and none in patients >18 years of age. There was a single recurrence over a median follow-up of 3.4 years.

Conclusions: VA in EA may be either focal or macro-re-entrant. In the absence of surgery, substrates chiefly involve the ARV. After surgery, focal VA involves injured myocardium or Purkinje tissue and re-entrant ventricular tachycardia is related to post-surgical scar. Catheter ablation is a reasonable therapeutic approach for these patients.
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http://dx.doi.org/10.1016/j.jacep.2018.05.009DOI Listing
October 2018

Clinical and electrophysiological properties of atrial tachycardia after pediatric heart transplantation.

Pacing Clin Electrophysiol 2018 09 11;41(9):1093-1100. Epub 2018 Jul 11.

Department of Pediatric Cardiology, University of California Los Angeles, Los Angeles, CA, USA.

Background: Pediatric heart transplant recipients are at an elevated risk for development of atrial tachycardia (AT); however, the underlying mechanisms and long-term outcomes are unclear.

Objective: We hypothesized that occurrence of AT in pediatric heart transplant recipients would be associated with a higher frequency of adverse events during follow-up.

Methods: A single-center retrospective review of all pediatric heart transplant recipients with suspected AT between 1997 and 2017 was performed. Unaffected controls were matched with cases for age and transplant era. Clinical characteristics and long-term outcomes were compared between groups.

Results: Of 294 heart transplant recipients, 13 with AT at electrophysiology study (4.4%) were identified and compared with 29 controls. The most common mechanism was focal (11), followed by atrial flutter (two), and electrical reconnection of a surgical atrial anastomosis (two). Focal AT was only observed in the right atrium or atrial septum, and was frequently found on or near the crista terminalis. Relative to controls, cases exhibited more frequent clinical evidence of rejection (9/13 vs 10/29, P  =  0.037). For patients with AT, there was a higher rate of death/retransplant among cases (log-rank P  =  0.022), which remained significant in multivariate analysis.

Conclusion: In this cohort, the most common form of AT after pediatric heart transplantation was focal, with predilection for sites near the crista terminalis. Transplant patients with AT experienced a higher rate of clinical rejection and the composite end-point of retransplantation or death relative to unaffected controls.
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http://dx.doi.org/10.1111/pace.13415DOI Listing
September 2018

Subvalvular catheter ablation of the cavotricuspid isthmus in a patient with Ebstein's anomaly and tricuspid valve replacement.

HeartRhythm Case Rep 2017 Jul 30;3(7):336-339. Epub 2017 May 30.

Division of Pediatric Cardiology, UCLA Medical Center, Los Angeles, California.

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http://dx.doi.org/10.1016/j.hrcr.2017.04.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5511987PMC
July 2017

Single-Center Experience Using Selexipag in a Pediatric Population.

Pediatr Cardiol 2017 Oct 13;38(7):1405-1409. Epub 2017 Jul 13.

Department of Pediatric Cardiology, Mattel Children's Hospital UCLA, 200 UCLA Medical Plaza, Suite 224, Los Angeles, CA, 90095, USA.

Pulmonary arterial hypertension (PAH) is a rare and progressive disorder. Current treatment in the pediatric population includes phosphodiesterase 5 inhibitors (PDE-5i), endothelin receptor antagonists (ERA), and both inhaled and intravenous prostacyclin pathway agonists. As of December 22, 2015 the first oral prostacyclin pathway agonist, selexipag (Uptravi), was FDA approved in the US. In this case series, we discuss our single-center experience using selexipag in a pediatric population, composed of both patients with idiopathic PAH, and patients with congenital heart disease and PAH.
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http://dx.doi.org/10.1007/s00246-017-1677-7DOI Listing
October 2017

Mechanisms and predictors of recurrent tachycardia after catheter ablation for d-transposition of the great arteries after the Mustard or Senning operation.

Heart Rhythm 2017 03 28;14(3):350-356. Epub 2016 Nov 28.

Department of Pediatrics, Division of Pediatric Cardiology, UCLA Medical Center, Los Angeles, California,; Ahmanson/UCLA Congenital Heart Disease Center, Los Angeles, California. Electronic address:

Background: The Senning and Mustard operations for dextro-transposition of the great arteries are associated with an increased risk for supraventricular tachycardia. Catheter ablation has been shown to be acutely successful for achieving rhythm control in this population, but the mechanisms of recurrence are ill-defined.

Objective: We hypothesized that the type and degree of recurrence would vary by the surgical technique used.

Methods: All consecutive catheter ablation procedures for dextro-transposition of the great arteries after the Mustard or Senning operation between 2004 and 2016 at a single center were reviewed. Tachycardia mechanisms were determined by complete 3-dimensional mapping in addition to a standard electrophysiological technique for all cases.

Results: Twenty-eight patients underwent 38 procedures during the study period. The most common mechanism at the index procedure was intra-atrial reentrant tachycardia using the cavotricuspid isthmus. Over a median follow-up period of 1.6 years, 9 patients experienced recurrent tachycardia (32%), all of whom underwent repeat catheter ablation. Tachycardia recurrence was more common after the Senning vs the Mustard operation (6 of 10 [60%] vs 3 of 18 [17%]; P = .034). In addition, substrates for recurrence were different from those encountered at the index procedure in 10 of 13 tachycardias (77%), with the single most common location being the posterior anastomosis after the Senning operation. Complete control was ultimately achieved in 27 patients (96%) when considering all procedures.

Conclusion: Recurrent tachycardia after catheter ablation appears to be more common after the Senning operation and to involve substrates unique to this repair. The posterior anastomosis is commonly implicated and should not be overlooked.
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http://dx.doi.org/10.1016/j.hrthm.2016.11.031DOI Listing
March 2017

Very long-term results of surgical and transcatheter ablation of long-standing persistent atrial fibrillation.

Ann Thorac Surg 2013 Oct 31;96(4):1273-1278. Epub 2013 Jul 31.

Department of Cardiac Surgery, Istituto Clinico Humanitas IRCCS, Rozzano, Italy.

Background: New hybrid approaches for atrial fibrillation (AF) ablation, combining surgical and percutaneous procedures, are emerging to enhance the long-term success rate of these 2 procedures severally considered. Recent guidelines underline the need for long-term follow-up to really assess the efficacy of AF ablation.

Methods: From 2000 to 2002, 33 patients with long-standing persistent AF and valvular heart disease underwent valve surgery and cryoablation (pulmonary veins isolation and mitral isthmus and roof line lesions). The surgically created ablation scheme was validated with electroanatomic mapping and percutaneous radiofrequency ablation was performed in case of lesion incompleteness.

Results: In 19 of 33 patients (58%) the electroanatomic mapping showed a complete lesion scheme, which increased to 79% (26 of 33) with the addition of radiofrequency ablation. At the mean follow-up of 10.7 ± 3.1 years, 73% (24 of 33) of patients were in sinus rhythm (SR), whereas 27% had permanent AF. At the end of follow-up 81% of patients with a complete lesion scheme were in SR, while 43% with an incomplete one maintained SR (p = 0.048).

Conclusions: In patients with long-standing persistent AF and valvular heart disease, the hybrid approach with surgical cryoablation consisting of pulmonary veins isolation and left atrial linear lesions combined with transcatheter radiofrequency ablation was highly effective in maintaining SR for a very long-term follow-up. Electrophysiological evaluation, to validate the transmurality of the surgical lesions and to complete the lesion scheme applying radiofrequency energy, improved the long-term efficacy.
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http://dx.doi.org/10.1016/j.athoracsur.2013.05.054DOI Listing
October 2013

Neonatal ascending aortic thrombus: successful medical treatment.

Cardiol Young 2013 Aug 3;23(4):610-2. Epub 2012 Oct 3.

Division of Pediatric Cardiothoracic Surgery, Wake Forest Baptist Health, Winston-Salem, North Carolina 27157, United States of America.

Neonatal aortic thrombosis is a potentially life-threatening condition with significant morbidity and mortality if undiagnosed and untreated. The most common location of arterial thrombosis in neonates is in the abdominal aorta and is associated with umbilical artery catheterisation. There are only a few previous reports of thrombosis in the ascending aorta. We describe a case of ascending aortic thrombosis in a neonate who underwent successful thrombolytic therapy.
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http://dx.doi.org/10.1017/S1047951112001394DOI Listing
August 2013

Use of the Valsalva graft and long-term follow-up.

J Thorac Cardiovasc Surg 2010 Dec;140(6 Suppl):S23-7; discussion S45-51

Department of Cardiac Surgery, European Hospital, Rome, Italy.

Objective: The Valsalva graft is a specifically designed Dacron graft that, on implantation and pressurization, generates pseudosinuses of Valsalva. We reviewed a multicenter experience of the reimplantation procedure with the Valsalva graft in patients with aneurysms involving the aortic root.

Methods: A total of 278 patients underwent valve-sparing aortic root replacement using the Valsalva graft at 4 different Italian cardiac surgery centers and were studied by clinical assessment and echocardiography. Of the 278 patients, 220 were men (79%), with a mean age of 56 ± 15 years. Of the patients, 42 (15%) had Marfan syndrome, 31 (11%) had a bicuspid aortic valve, 13 (5%) had acute aortic dissection, and 136 (49%) had grade 3 or 4+ aortic insufficiency. Concomitant cardiac procedures were performed in 78 patients (28%). Additional aortic leaflet repair was necessary in 25 patients (9%). The mean crossclamp time was 120 ± 27 minutes.

Results: There were 5 (1.8%) operative and 5 (1.8%) late deaths. The mean follow-up was 52 ± 28 months (range, 2-112 months) and was 100% complete. The cumulative actuarial survival was 95.2% (268 patients). A total of 32 patients (11%) had grade 3 to 4+ aortic insufficiency, and 17 of these required late aortic valve replacement (range, 3-78 months). At 10 years of follow-up, the freedom from aortic valve reoperation rate was 91%, and the rate of freedom from residual aortic insufficiency not needing reoperation was 88%.

Conclusions: The reimplantation type of valve-sparing procedure can be facilitated by the use of the Valsalva graft and can be performed with satisfactory perioperative and midterm results. How an optimal root reconstruction will affect the second decade of follow-up has yet to be determined.
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http://dx.doi.org/10.1016/j.jtcvs.2010.07.060DOI Listing
December 2010

Reimplantation valve-sparing aortic root replacement with the Valsalva graft: what have we learnt after 100 cases?

Interact Cardiovasc Thorac Surg 2009 Jul 28;9(1):113-6. Epub 2009 Apr 28.

Department of Cardiac Surgery, Istituto Clinico Humanitas, Via Manzoni 56, cap: 20089, Rozzano (MI), Italy.

Objectives: Reimplantation valve-sparing aortic root replacement has been increasingly performed with improving perioperative and mid-term results. The success of this operation primarily depends on preserving the highly sophisticated dynamic function of the aortic valve by recreating an anatomical three-dimensional configuration similar to the normal aortic root, thus minimizing the mechanical stress and strain on the cusps. Over the years several techniques have been proposed to reproduce the sinuses of Valsalva. We reviewed our experience with aortic valve reimplantation by means of a modified Dacron graft that incorporates sinuses of Valsalva, in a series of 100 consecutive patients.

Methods: During a 60-month period, 100 patients with aortic root aneurysm underwent aortic valve reimplantation using the Gelweave Valsalva prosthesis. There were 74 males and the mean age was 60+/-12 years (range 28-83 years). Five patients had the Marfan's syndrome, 15 had a bicuspid aortic valve. Cusp repair was performed in five patients. The mean follow-up time was 28.6 months (range 1-60). Transesophageal echocardiogram was performed at the end of each procedure to assess the aortic valve in terms of competence, dynamic motion and level of coaptation within the graft.

Results: There was one hospital death and two late deaths. Overall survival at 60 months was 91.7+/-5.1%. Five patients developed severe aortic incompetence (AI) during follow-up requiring aortic valve replacement (AVR). The 60 months freedom from re-operation due to AI was 90.9+/-4.4%. One patient had moderate AI at latest echocardiographic study. The 60 months freedom from AI>2+ was 91.6+/-7.9%. Cox regression identified cusp's repair as independent risk factor (P=0.001) for late reimplantation failure (AVR or AI>2+). There were no episodes of endocarditis and the majority of the patients (88%) were in New York Heart Association functional class I.

Conclusions: The aortic valve reimplantation with the Gelweave Valsalva prosthesis provided satisfactory mid-term results. An accurate assessment of the level of coaptation of the aortic cusps in respect to the lower rim of the Dacron graft by means of intraoperative transesophageal echocardiogram at the end of each procedure is mandatory in order to avoid early reimplantation failure. Cusp's repair may play an important role in the development of late AI. However, long-term results are needed in order to define the durability of this technique.
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http://dx.doi.org/10.1510/icvts.2009.202622DOI Listing
July 2009

Reimplantation valve-sparing aortic root replacement for aortic root aneurysm in the elderly: are we pushing the limits?

J Card Surg 2010 Jan-Feb;25(1):56-61. Epub 2009 Mar 23.

Cardiac Surgery Department, Istituto Clinico Humanitas, Rozzano, Italy.

Objectives: Reimplantation valve-sparing aortic root replacement has been increasingly performed with improving perioperative and midterm results. However, extending the age criterion in patient selection remains a debate. This study reviews the results of reimplantation valve-sparing aortic replacement in patients greater than 60 years of age.

Methods: During a 51-month period, 63 patients with aortic root aneurysms underwent reimplantation valve-sparing aortic root replacement. The Gelweave Valsalva prosthesis (TERUMO CardioVascular Systems Corp., Ann Arbor, MI, USA) was used in all but one case. The patients were predominantly male, and the mean age was 67 years (range, 61-83 years). Four patients had congenital bicuspid aortic valves, and cusp repair was required in one patient. The mean follow-up was 25 months (range, 1-51 months).

Results: There were one hospital and two late deaths. Overall survival at 51 months was 84 +/- 9.9%. During follow-up, one patient developed severe aortic incompetence (AI) requiring an aortic valve replacement (AVR). Freedom from reoperation at 51 months was 92.8 +/- 6.8%. Moderate AI was present at latest echocardiogram in one patient. Freedom from moderate or severe AI at 51 months was 90 +/- 9.4%. There was no episode of endocarditis on follow-up. Univariate analysis demonstrated that no preoperative or intraoperative factor was a predictor for late reimplantation failure.

Conclusions: Reimplantation valve-sparing aortic root replacement in patients greater than 60 years old can be performed with satisfactory perioperative and midterm results. Long-term results are needed to define the durability of this technique and its role in this subset of patients.
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http://dx.doi.org/10.1111/j.1540-8191.2008.00782.xDOI Listing
June 2011

Reoperation for aortic false aneurysms: our experience and strategy for safe resternotomy.

J Card Surg 2008 May-Jun;23(3):216-20

Department of Cardiac Surgery, Istituto Clinico Humanitas, Rozzano, Italy.

Background And Aim Of The Study: To review our experience with reoperation for aortic false aneurysms (FA) and to present an analysis of the relevant surgical approaches and risks.

Methods: From May 1999 to June 2006, 11 patients underwent a total of 13 reoperations due to aortic false aneurysms, with an incidence of 3% of all thoracic aortic cases. Cardiopulmonary bypass (CPB) and cooling were started before sternotomy in all cases. Three different strategies were adopted for patients depending on the position of the FA in the mediastinum as indicated by a preoperative CT scan. These included: deep hypothermic circulatory arrest (18 degrees C), moderate hypothermia (28 degrees C), and mild hypothermia (32 degrees C). In two patients, the sternotomy ruptured the FA causing profuse hemorrhaging. In all the other cases sternotomy was performed without complication. The repair consisted in simple repair by direct suture (10 cases) or extensive repair by refashioning the anastomosis (three cases).

Results: Two hospital deaths occurred with a hospital mortality rate of 16.7%. Permanent neurological deficit developed in one patient. Transient neurological deficit in the form of left lower limb weakness was observed in one patient. False aneurysm recurrence developed in two cases. Among patients present at follow-up (nine survivors), four are in NYHA class I and five in class II.

Conclusions: Aortic false aneurysms carry a high mortality and morbidity rate. Nevertheless, we believe that selecting the right strategy according to the position of the FA in the chest can reduce surgical risk, thus permitting relatively safe resternotomy.
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http://dx.doi.org/10.1111/j.1540-8191.2008.00597.xDOI Listing
August 2008

Aortic root replacement with the Carboseal composite valve graft: analysis of risk factors.

Interact Cardiovasc Thorac Surg 2005 Aug 9;4(4):360-4. Epub 2005 May 9.

Department of Cardiac Surgery, Istituto Clinico Humanitas, Via Manzoni 56, cap:20089, Rozzano (MI), Italy.

This retrospective analysis of a selected series of Bentall-De Bono procedures was carried out in order to evaluate the performance of the Carboseal composite valve graft (Sulzer Carbomedics Inc, Austin, TX, USA). Between October 1997 and April 2004, 120 patients underwent aortic root replacement with the Carboseal Composite Valve Graft. The mean age of patients was 59.7+/-13.4 years (range, 21-83 years); 96 patients (80%) were male. Eighty-nine patients (74.2%) had annulaortic ectasia, 10 patients (8.3%) post-stenotic dilatation, 3 (2.5%) post dissection aneurysm, 2 (1.7%) acute type A dissection and 1 (0.8%) endocarditis. The average follow-up duration was 29.2 months (range 2-82 months). Hospital mortality was 1.7% (2 of 120 patients). The actuarial survival rate (including hospital mortality) was 97.2+/-1.5% at 1 year, 91.6+/-3.5% at 3 years and 84.0+/-8.0% at 5 years. Chronic renal failure was an independent risk factor for late mortality (P=0.02). The actuarial freedom from pseudoaneurysms at 3 years was higher among patients without Marfan syndrome (94.7+/-3.2% vs. 75.0+/-21.6% at 3 years, P<0.003). In our recent series, the Bentall-De Bono operation provided good results with low incidence of prosthetic related complications. Pseudoaneurysms requiring re-operation have a higher incidence among patients with Marfan syndrome.
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http://dx.doi.org/10.1510/icvts.2004.103846DOI Listing
August 2005

Aortic valve-sparing operations in patients with aneurysms of the aortic root or ascending aorta: preliminary results.

Interact Cardiovasc Thorac Surg 2005 Apr 16;4(2):137-9. Epub 2005 Feb 16.

Department of Cardiac Surgery, Istituto Clinico Humanitas, Via Manzoni 56, cap: 20089, Rozzano (MI), Italy.

Objective: Aortic valve-sparing operations were developed to preserve the native aortic valve in patients with aneurysms of the aortic root or ascending aorta and normal aortic valve leaflets. This paper describes our initial experience with valve-sparing operations and early clinical and echocardiographic results obtained.

Methods: From October 2002 to March 2004, 32 consecutive patients underwent aortic valve-sparing operations at the Istituto Clinico Humanitas, Rozzano, Italy. Preoperative transesophageal echocardiography showed moderate or severe aortic incompetence (AI) in 15 patients (47%). Twenty-nine patients underwent reimplantation of the aortic valve and 3 patients remodeling of one sinus. In 2 cases prolapsing cusp repair was carried out.

Results: There were no intraoperative deaths. At discharge, two-dimensional echocardiogram showed no or trivial aortic incompetence (AI) in 17 (52%) patients and mild AI in 13 (42%); 2 (6%) patients had severe AI requiring reoperation, respectively 4 and 6 weeks later.

Conclusions: The valve-sparing procedures showed good preliminary results, thus encouraging further use of this type of repair. However, further larger studies and long-term results are needed in order to define the durability of these techniques.
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http://dx.doi.org/10.1510/icvts.2004.095422DOI Listing
April 2005

Reimplantation valve-sparing aortic root replacement in Marfan syndrome using the Valsalva conduit: an intercontinental multicenter study.

Ann Thorac Surg 2007 Feb;83(2):S769-73; discussion S785-90

Cardiac Surgery Department, Istituto Clinico Humanitas, Rozzano, Italy.

Background: Introduced by DePaulis in 2000, the Gelweave Valsalva graft (Sulzer Vascutek, Refrewshire, Scotland) is a modified Dacron conduit (DuPont, Wilmington, DE), with prefashioned sinuses of Valsalva. The aim of this study was to evaluate the mid-term results of the reimplantation valve-sparing aortic root replacement using the Gelweave Valsalva prosthesis in Marfan syndrome patients.

Methods: A retrospective review was performed of 35 patients with Marfan syndrome in four centers who underwent the reimplantation valve-sparing aortic root replacement using the Gelweave Valsalva prosthesis.

Results: The patients were predominantly men, with a mean age of 36.5 +/- 12.6 years (range, 14 to 62 years). Two patients presented with acute type A dissections and underwent emergent operations. Elective hemiarch reconstruction using hypothermic circulatory arrest was required in 11 patients. Aortic valve cusp repair was performed in 2 patients. There were no operative or hospital deaths, and no patients died during follow-up. The mean follow-up was 19 months (range, 1 to 60 months). Significant (>2+) aortic insufficiency (AI), requiring aortic valve replacement, developed in 3 patients during follow-up that requiring aortic valve replacement. The 5-year freedom from reoperation owing to structural valve deterioration was 88.9% +/- 8.1%. There were no episodes of clinically significant thromboembolism.

Conclusions: Reimplantation valve-sparing aortic root replacement with the Gelweave Valsalva prosthesis in Marfan patients provides satisfactory mid-term results, thus encouraging further use of this type of repair. However, long-term results are needed in order to define the durability of this technique.
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http://dx.doi.org/10.1016/j.athoracsur.2006.10.084DOI Listing
February 2007

Early results of valve-sparing reimplantation procedure using the Valsalva conduit: a multicenter study.

Ann Thorac Surg 2006 Sep;82(3):865-71; discussion 871-2

Cardiac Surgery Department, S. Orsola-Malpighi Hospital, University of Bologna, Bologna.

Background: This study evaluates the midterm clinical results of valve-preserving aortic root reconstruction by means of a modified conduit incorporating sinuses of Valsalva.

Methods: During a 5-year period, 151 patients with aneurysm of the aortic root underwent a reimplantation type of valve-sparing procedure using the Gelweave Valsalva prosthesis that incorporates sinuses of Valsalva. There were 121 males (80.1%), and the mean age was 56.4 +/- 14.4 years (range, 14 to 83). Fourteen percent of the patients had Marfan syndrome and 8.6% had bicuspid aortic valve. Seven patients (4.6%) suffered from acute aortic dissection. Aortic replacement was extended to the arch in 14 patients (9.3%). Sixteen patients (10.6%) had associated cusp repair.

Results: In-hospital mortality was 3.3%, and it was significantly higher among patients operated on for acute dissection (p = 0.001) and in symptomatic patients (III-IV New York Heart Association class; p = 0.021). Follow-up (mean, 18 months; range, 1 to 60) was 100% complete. There were 2 late deaths. Ten patients (6.8%) had 3 to 4+ aortic regurgitation, and 8 of these required late aortic valve replacement. Cusp repair was associated with a high incidence of late aortic valve replacement (p = 0.005). At 5 years, freedom from aortic valve replacement and freedom from grade 3 to 4 aortic insufficiency was 90.8% +/- 3.3% and 88.7% +/- 3.6%, respectively.

Conclusions: The reimplantation valve-sparing procedure with the Gelweave Valsalva prosthesis provides satisfactory results for patients with aortic root aneurysm. Aortic cusp repair may lead to late aortic insufficiency. Proper leaflet evaluation is of paramount importance in preventing residual valve regurgitation.
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http://dx.doi.org/10.1016/j.athoracsur.2006.04.018DOI Listing
September 2006

Aspergillus left ventricular assist device endocarditis.

Ital Heart J 2004 Nov;5(11):876-80

Cardiac Surgery, Istituto Clinico Humanitas, Rozzano (MI), Italy.

Left ventricular assist device (LVAD) support is an established therapy for patients with end-stage heart failure as a bridge to transplant; its usage as an alternative for those patients not eligible for transplant is not an established therapy yet. A 68-year-old male had a Thoratec-Heartmate LVAD implanted as destination therapy. After an uneventful (apart from early fever) recovery in the intensive care unit, the patient developed an intractable high temperature, and generalized sepsis and died 21 days following implant. The white cell blood count never exceeded the guard limits, and the patient succumbed with severe LVAD valve malfunction. At post-mortem examination friable material consisting of fungal hyphae was found on the inflow and outflow valves. According to published clinical trials, infection accounts for more than 40% of mortality in LVAD supported patients. Fungal LVAD endocarditis is a particularly deadly disease. Successful management requires a high level of suspicion and timely institution of antifungal therapy to control the infection. This has led some authors to recommend empiric antifungal therapy in LVAD recipients with culture-negative sepsis unresponsive to broad-spectrum antibiotics.
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November 2004

Linear cryoablation of the left atrium versus pulmonary vein cryoisolation in patients with permanent atrial fibrillation and valvular heart disease: correlation of electroanatomic mapping and long-term clinical results.

Circulation 2005 Jan 27;111(2):136-42. Epub 2004 Dec 27.

Division of Cardiology, Department of Cardiology, Civil Hospital Asti, Via Botallo, 4, 14100 Asti, Italy.

Background: The aim of this study was to clarify the role of pulmonary vein isolation (PVI) alone versus left atrial linear lesions in the treatment of permanent atrial fibrillation (AF) in patients with left atrial dilatation and valvular disease. The primary end point was to assess the persistence of sinus rhythm (SR) off antiarrhythmic drugs (AADs) at 2-year follow-up and to correlate clinical outcome with surgical results validated with electroanatomic mapping (EAM).

Methods And Results: A total of 105 patients with permanent AF undergoing valve surgery were assigned to 3 different groups: in groups "U" and "7," left atrial linear cryoablation was performed, whereas in group "PV" patients, anatomic cryoisolation of pulmonary veins only was performed. In groups U and 7, SR was achieved in 57% of patients, whereas it was achieved in 20% of PV patients during 2-year follow-up. In the first 51 patients, the ablation schemes were validated with EAM. The EAM showed that the U lesion was never obtained: in 59% of these patients, a complete 7 lesion was achieved instead; in the 7 group, a complete 7 lesion was present in 65% of patients, whereas a complete PVI was obtained in 71% of patients. Considering patients in whom a complete 7 lesion was demonstrated with the EAM, SR without AADs was achieved in 86% of patients, whereas only 25% of patients with complete PVI were in SR without AADs.

Conclusions: In patients with permanent AF, left atrial dilatation and valvular heart disease linear lesions in the posterior region of the left atrium are more effective than PVI alone. With cryoablation, the surgical intent is fulfilled in only approximately 65% of the cases. Knowing the real anatomic and electrophysiological effects of surgical ablation is necessary to correctly interpret the clinical outcome.
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http://dx.doi.org/10.1161/01.CIR.0000151310.00337.FADOI Listing
January 2005

Surgical treatment of atrial fibrillation in the beating heart: a novel approach.

Ital Heart J 2003 Dec;4(12):872-4

Division of Cardiac Surgery, Istituto Clinico Humanitas, Rozzano, MI, Italy.

Up to 50% of patients undergoing mitral valve surgery have concomitant atrial fibrillation. An epicardial approach may offer the benefit of reducing the aortic cross-clamping time and avoiding an undue left atriotomy. During the last year we have been developing a simple technique to reproduce epicardially the same lesion pattern we had previously achieved endocardially. Two patients with chronic atrial fibrillation received atrial ablation using a microwave energy probe (Flex-10, AFx Inc., Fremont, CA, USA) immediately before undergoing a concomitant cardiac procedure. The procedure is relatively quick to perform and with appropriate care can be conducted with a low risk of perioperative adverse events.
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December 2003
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