J. Michael DiMaio M.D.

Squiers, J. J., K. R. Hebeler, J. M. DiMaio, P. Ogbue, M. Szerlip and W. T. Brinkman (2016). “Impingement of single-tilting disc mitral prosthesis during transcatheter aortic valve replacement.” Ann Thorac Surg 102(6): e529-e531.

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An 80-year-old woman with a medical history of mitral valve replacement with single-tilting disc prosthesis underwent transcatheter aortic valve replacement (TAVR). The tilting disc was noted to have abnormal motion after re-ballooning of the TAVR valve. Cardiopulmonary bypass was initiated, and the procedure was converted to surgical aortic valve replacement. After removal of the TAVR valve, the tilting disc moved freely. Although TAVR in patients with mitral prostheses is technically feasible, particular caution is necessary, and postdeployment dilation should be avoided.

Baumgarten, H., J. J. Squiers, W. T. Brinkman, J. M. DiMaio, A. Gopal, M. J. Mack and R. L. Smith (2016). “Implantation of transcatheter aortic prosthesis in 3 patients with mitral annular calcification.” Ann Thorac Surg 102(5): e433-e435.

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Mitral annular calcification (MAC) is a chronic degenerative process at the fibrous base of the mitral valve. It is a feared diagnosis in the context of mitral valve operations because of the risk of severe adverse events such as atrioventricular disruption, injury to the circumflex artery during debridement, and difficult placement of annular sutures. We report a series of 3 consecutive female patients with severe circular MAC who underwent successful mitral valve replacement through a lateral minithoracotomy with use of an inverted transcatheter aortic valve.

Gayed, B. A., R. Youssef, O. Darwish, P. Kapur, A. Bagrodia, J. Brugarolas, G. Raj, J. M. DiMaio, A. Sagalowsky and V. Margulis (2016). “Multi-disciplinary surgical approach to the management of patients with renal cell carcinoma with venous tumor thrombus: 15 year experience and lessons learned.” BMC Urol 16(1): 43.

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BACKGROUND: The management of patients with renal cell carcinoma (RCC) with venous tumor thrombus (VTT) is challenging. We report our 15 year experience in the management of patients with RCC with VTT utilizing a multidisciplinary team approach, highlighting improved total and specifically Clavien III-V complication rates. METHODS: We reviewed the records of 146 consecutive patients who underwent radical nephrectomy with venous thrombectomy between 1998 and 2012. Data on patient history, staging, surgical techniques, morbidity, and survival were analyzed. Additionally, complication rates between two surgical eras, 1998-2006 and 2006-2012, were assessed. RESULTS: The study included 146 patients, 97 males (66 %), and a median age of 61 years (range, 24-83). Overall complications rate was 53 %, high grade complications (Clavien III -V) occurred in 10 % of patients. Most importantly, there was a lower incidence of overall and high grade complications (45 % and 8 %, respectively) in the last 6 years compared to the earlier surgeries included in the study (67 % and 13 % respectively) [p = .008 and .03, respectively). 30 day postoperative mortality was 2.7 %. 5 year overall survival (5Y- OS) and 5 year cancer specific survival (5Y- CSS) were 51 % and 40 %, respectively. Metastasis was the only independent predictor factor for CSS (HR 3.8, CI 1.9-7.6 and p < .001) and OS (HR 2.6, CI 1.5-4.7 and p = .001) in all patients. CONCLUSIONS: Our data suggest that patients with RCC and VTT can be treated safely utilizing a multidisciplinary team approach leading to a decrease in complication rates.

Squiers, J. J., B. Lima and J. M. DiMaio (2016). “Contemporary extracorporeal membrane oxygenation therapy in adults: Fundamental principles and systematic review of the evidence.” J Thorac Cardiovasc Surg 152(1): 20-32.

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Extracorporeal membrane oxygenation (ECMO) provides days to weeks of support for patients with respiratory, cardiac, or combined cardiopulmonary failure. Since ECMO was first reported in 1974, nearly 70,000 runs of ECMO have been implemented, and the use of ECMO in adults increased by more than 400% from 2006 to 2011 in the United States. A variety of factors, including the 2009 influenza A epidemic, results from recent clinical trials, and improvements in ECMO technology, have motivated this increased use in adults. Because ECMO is increasingly becoming available to a diverse population of critically ill patients, we provide an overview of its fundamental principles and a systematic review of the evidence basis of this treatment modality for a variety of indications in adults.

Baumgarten, H., J. J. Squiers, M. Arsalan, M. John and M. J. Dimaio (2016). “Defining the clinical need and indications: Who are the right patients for transcatheter mitral valve replacement.” J Cardiovasc Surg (Torino) 57(3): 352-359.

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Mitral regurgitation (MR) can be divided into two major etiologies, primary and secondary MR. Primary MR, also termed degenerative or organic MR, is a disease of the valve itself and is treated routinely by surgical repair in all but prohibitive risk patients. In these patients, transcatheter repair techniques, including edge to edge repair with the MitraClip device have been largely successful and widely adopted. Transcatheter placement of artificial chords has also been performed. The potential role for transcatheter mitral valve replacement (TMVR) in primary MR will likely be quite limited. Secondary or functional MR is due to a disease of the left ventricle and not the valve itself. The MR is a result of dilation of the left ventricle causing distraction of the papillary muscles with tethering of the mitral leaflets and lack of leaflet coaptation. Medical therapy is the mainstay treatment, with resynchronization used in appropriate patients. Surgical repair, usually with an undersized annuloplasty, is used in a limited number of patients. Transcatheter edge to edge repair is used extensively outside the US in secondary MR and is the subject of a pivotal trial in the US. However, it is in this group of patients with secondary MR that there is the largest clinical unmet need and, hence, the greatest potential opportunity for TMVR. At least ten TMVR platforms are in early feasibility, first in human, or preclinical trial stages. Four devices have cumulative early human experience in <100 patients. In this article, we discuss those patients most likely to benefit from TMVR and detail lessons learned from the first human studies regarding patient selection.