The American Heart Hospital Journal


It is apparent that there are many techniques that are quite simple to treat the many patients with mitral valve prolapse that are appearing in valve centers throughout the US. Indeed, these patients are being referred earlier and earlier to valve centers that do valve repair, and even the asymptomatic patients who have more than a 90 % chance of getting a repair are being referred for surgery, which is a major change in the indications for valve surgery. Mitral valve repair is the treatment for more than 90 % of patients with myxomatous valve disease.9


Treatment of ischemic mitral


regurgitation or cardiomyopathic mitral regurgitation, which is really related to the extent of ventricular disease, is still in a bit of flux. The NIH is sponsoring a perspective randomized trial to evaluate repair or replacement for these patients who have primarily ventricular disease because the incidence of valve repair in this group has not proven to be as successful as those in the prolapse group.10


Although several percutaneous devices, particularly the ‘e-valve’ are being evaluated in many countries, none are as successful or as effective as the percutaneous aortic valve device. Owing to the residual mitral regurgitation that occurs with most of the devices my belief is that when approved these devices will only be used in truly non-operable cases.11


Mitral valve repair continues to be


the optimal procedure for mitral regurgitation. In a few hands, robotic mitral valve has been effective.12


Tricuspid Regurgitation. There continues to be debate about treating functional tricuspid regurgitation with leftsided valve disease, although it is clear that the patients do better in the long term if the tricuspid valve is repaired at the time of surgery. Many advocate for increased tricuspid valve repair for every patient. New bicuspidization techniques13


and many different valve


rings have been established to aid the surgeon in the repair of these valves. Primary tricuspid valve disease continues to be relatively rare in the US; however, in many countries, rheumatic disease has affected the tricuspid valve as well, requiring replacement of the valve.


Arrhythmia Surgery


Atrial fibrillation is still the most common cardiac arrhythmia in the US affecting several million people. Considerable progress has been made with catheter treatment of this, but the original Maze operations have become commonplace in many centers.14


The intraoperative


Maze procedure during mitral valve surgical repair for paroxysmal atrial fibrillation has proven to be extremely effective in the prevention of atrial fibrillation. There


Summer 2011


documented by the Society of Thoracic Surgeons database.8


Five Years On Surgery


continues to be debate about chronic atrial fibrillation in patients with an enlarged left atrium. The NIH is embarking on a prospective randomized study to determine if atrial fibrillation treatment is as effective in the interventional treatment of chronic atrial fibrillation. In a few centers there have been stand-alone operations minimally invasively performed through a small thoractomy for atrial fibrillation, but these studies are still in their infancy.15


Thoracic Aortic Disease


Huge advances in endovascular treatment of thoracic aortic disease have been made since 2006; in 2011, almost all descending thoracic aneurysms, most thoracoabdominal aneurysms, and the vast majority of abdominal aortic aneurysms have been treated by endovascular grafting.16


There have been increasing


attempts over the past year to use ascending aortic stent grafts, although not as frequently as I predicted in 2006. One of the biggest debates is who should perform these, and many peripheral vascular surgeons, interventional cardiologists, and cardiothoracic surgeons are competing in this area for these cases. Again, the hybrid operating room is the perfect place for these techniques to be employed and is a good stimulus for a team approach to these operations. Training of cardiac surgeons is changing to include endovascular and catheter techniques and, therefore, the cardiac surgical community will be able to perform these operations as well. In the next five years I predict major improvements in stent grafting combined with direct surgery to the ascending aorta and arch.


Heart Failure


Heart failure continues to be the most common indication for hospital admission in the US. There are increasing numbers of patients in whom medical therapeutics have been exhausted, but with improving left ventricular assist devices and artificial heart devices, implantation is happening increasingly in many centers worldwide and will continue to do so.17–19


Transplantation in the US


continues to be at the 2,000–2,500 cases per year mark and so left and right ventricular assist devices will continue to proliferate. Micro pumps, small pumps, restraint devices, and other operations that improve the cardiac performance of patients with heart failure will be performed. Non-transplant operations, which I predicted in 2006, have not flourished as I had thought. Again, mitral valve repair is attempted for this group, but as indicated above it is still debatable whether valve replacement with preservation of all the chordae and papillary muscles or a small ring would be better than a mitral valve repair. The Surgical treatment for ischemic heart failure (STITCH) trial, which evaluated concomitant


Future Directions in Cardiac Surgery—Part II 17


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