Toronto General Hospital

201 Its man- 1,2 for the treatment of for the treatment 4 ECHO ROUNDS ECHO Adding or removing 5 E 3 - respec cm after BACE implant, Indications and contraindications 6 cases-anesthesia-analgesia.org cm to 2.9 and 2.3 The aim of the intraoperative transesophageal echo- not mandatory to guide 3D MV and TV assessments are The BACE is a new extracardiac device The BACE is a new extracardiac The patient was extubated the same day, discharged from from discharged the same day, The patient was extubated cm above the measured basal cardiac circumference. It is circumference. basal cardiac cm above the measured - coro . Previous summarized in the Table to BACE implant are contraindication tonary artery bypass grafting is an absolute isgrafting bypass artery implantation. When coronary device the device would beperformed at the time of BACE implant, performing the anastomoses. before secured examination is to confirm eligibility for the cardiography absolute contraindications, guide infla- exclude procedure, tion of the BACE ports, and detect possible complications 1, (Supplemental Digital Content 3, Supplemental Table hemody- Preoperative http://links.lww.com/AACR/A193). accurate estimation of MR namic conditions should not affect BACE chambers may become visible once inflated as severity. containing air structure a hypoechoic, ill-defined, extracardiac the midesopha- segments in bubbles adjacent to the basal LV is increments Saline solution in 2-mL geal 4-chamber view. - improve maximum a to up chambers BACE to all added in considered not is TR of degree The severity. in MR ment significant no case, our In inflation. chamber guiding MR was noted with inflation between 6 and 8 mL improvement 2, http://links.lww. (Supplemental Digital Content 2, Video com/AACR/A189). a bet- in our case, they provided BACE implant; however, and MV on BACE the of effect the of understanding ter - interven a clinical challenge and surgical agement remains tion carries a 3%–6% mortality. moderate and severe ischemic MR that may be implanted onimplanted may be that MR ischemic severe and moderate silicone banda beating heart. The device comprised a circular epi- the to it secure to loops belt chambers, inflatable 4 with chambersthe to ports connected subcutaneous and cardium, tubing (Figure 1B).silicone by 41-cmto in 21- available is It and can be oversized by (in 1-cm increments) circumferences 1 place in secured and groove atrioventricular the to advanced It wraps the base of the heart, (Figure 1C). sutures with prolene the size of the MV and TV annuli and bringingdecreasing MV leaflet segments closer to improve the basal myocardial further dilation. coaptation and prevent DISCUSSION The mechanism of ischemic MR is well described. saline into the 4 inflatable chambers adjusts the circumferential the circumferential saline into the 4 inflatable chambers adjusts by the device. applied force 4.9 and 3.2 systolic function was preserved. Biventricular tively. onhome and 2 day postoperative on unit care intensive the unchanged at and MR grade were ejection fraction day 5. LV class II. in NYHA an improvement 6-month follow-up with - cm. LV ejection cm. LV

cm (Figure 35-cm 1A). A Number 7 Number • cm in the midesophageal 4-cham- Volume 11 Volume • - (3D) MV reconstruc cm. Three-dimensional 47-year-old man in New York Heart Association Association Heart York man in New 47-year-old implant of the Basal for presented (NYHA) class III device (BACE) Externally of Cardia Annuloplasty

After a standard sternotomy, the base of the heart cir the base sternotomy, After a standard The preoperative transthoracic echocardiogram reported reported echocardiogram transthoracic The preoperative The intraoperative transesophageal echocardiography ) (Philips 3DQ software; Philips, Andover, MA), the Andover, Philips, ) (Philips 3DQ software; Figure 3 DOI: 10.1213/XAA.0000000000000789 2018 1, October Copyright © 2018 International Anesthesia Research Society Anesthesia Research Copyright © 2018 International †Division Anesthesia and Pain Management, and the *Department of From General Hospital, University Health Net- Toronto Surgery, of Cardiovascular Ontario, Canada. Toronto, work, University of Toronto, Accepted for publication January 5, 2018. Funding: None. at the end of the article. See Disclosures Conflicts of Interest: citations URL Supplemental digital content is available for this article. Direct and PDF versions in the HTML provided appear in the printed text and are of this article on the journal’s website (www.cases-anesthesia-analgesia.org). of Department FASE, MD, Meineri, Massimiliano to correspondence Address General Hospital, 200 Elizabeth Anesthesia and Pain Management, Toronto e-mail to massimil- Address ON M5G 2C4, Canada. St, EN3-400, Toronto, [email protected].

* † * ExternallyMitral Regurgitation for Ischemic Device FASE MD, Meineri, and Massimiliano PhD, MD, Vivek Rao, MD, Carla Andrea Luzzi, After Implantation of Basal Annuloplasty of Cardia of Cardia Annuloplasty of Basal Implantation After Echocardiography Assessment of Valvular Geometry of Valvular Assessment Echocardiography Intraoperative 3-Dimensional Transesophageal Transesophageal 3-Dimensional Intraoperative cumference was measured 34 was measured cumference BACE device (Figure heart the 1B) was inserted around (Figure 1C). at the atrioventricular groove and secured The solution with- saline filled with 4 mL BACE chambers were milliliters were more out a significant change in MR. Four (Supplementalgrade MR in changes further without added 2, http://links.lww.com/AACR/ Digital Content 2, Video slightly MV diameter increased A189). The anteroposterior diameter to anterolateral to 3.1 cm, and the posteromedial to 3.7 decreased analysis On 3D TV multiplanar reconstruction ber view. ( from annular maximum and minimum diameters decreased tion by semiautomated Mitral Valve Navigation software Navigation software tion by semiautomated Mitral Valve in the MA) demonstrated a reduction Andover, (Philips, a to change with a annulus area volume, height, and tenting valve (TV) annulus ). Tricuspid (Figure 2 shape circular more to 2.9 4.2 from was reduced fraction was 23%. Trace TR was noted. fraction was 23%. Trace (Phoenix Cardiac Devices, Cary, NC), as part of a clini- Cary, Devices, (Phoenix Cardiac for ischemic mitral regurgitation cal trial (NCT02701972) consent for publication of this case. (MR). The patient gave fraction of 30%, moderate MR ejection a left ventricular (LV) - valve regurgita (Carpentier type IIIb), and mild tricuspid tion (TR). systolic to due MR moderate to mild functional confirmed Video 1, (Supplemental Digital Content restriction bileaflet - /AACR/A188). The anteropos 1, http://links.lww.com 3 cm, and the pos- terior mitral valve (MV) diameter was diameter was 4.2 to anterolateral teromedial A

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Figure 1. View of the heart (median sternotomy): (A) measuring tape positioned below the atrioventricular groove; (B) schematic diagram of BACE device: circular silicone band, inflatable chambers (1–4), silicone tubing connected to subcutaneous ports ( ) corresponding to chambers (1–4); and (C) BACE in place. BACE indicates Basal Annuloplasty of Cardia Externally. *

Figure 2. Three-dimensional MV reconstruction using the semiautomated Mitral Valve Navigation software (Philips) before (A) and after (B) the implantation of the BACE device. The tenting volume was reduced from 4.9 to 3.1 mL and the tenting height from 9.7 to 7.2 mm. The MV annulus area was decreased from 1215 to 986 mm2 with a reduction of the posteromedial to anterolateral (from 42.5 to 37.1 mm) and increase in anteroposterior (30.1–31.2 mm) MV diameters. BACE indicates Basal Annuloplasty of Cardia Externally; MV, mitral valve.

Clinician’s Key Teaching Points By Nikolaos J. Skubas, MD •Ischemic mitral regurgitation (MR) results from left ventricular remodeling. Its management is challenging, and surgical repair or replacement is fraught by significant mortality. Nonstandard interventions include percutane- ous, transcatheter clipping of redundant leaflets, transapical introduction of artificial neochords, and external restriction of the mitral annulus. •Diagnosis and etiology of MR and baseline measurements of mitral valve diastolic orifice, as well as the degree of MR reduction and adequacy of mitral valve orifice postproce- dure are performed with conventional 2-dimensional echocardiography. Characteristic anatomic features related to ischemic MR, such as the depth of leaflet coaptation inside the left ventricle, are also recorded. •In this case of a 47-year-old man with ischemic MR and reduced left ventricular systolic function, an external ring with inflatable chambers (Basal Annuloplasty of Cardia Externally) was surgically secured around the atrioventricular groove. The chambers were gradually inflated with saline under real-time transesophageal echocardiography. Although the degree of MR was not decreased, the coapta- Figure 3. Multiplanar reconstruction of the tricuspid valve annulus from a 3D TEE data set acquired using full-volume ECG-gated acquisition tion depth and mitral valve annular dimensions decreased. from a modified midesophageal 4-chamber view. The blue plane was positioned to intersect the TV annulus. Maximum and minimum TV annu- •Less invasive interventions for MR require real-time echo- lar diameters were measured in the short-axis TV view (blue panel) before (A) and after (B) the BACE device implantation assuming a flat TV cardiographic observation of critical anatomic features. The annulus. BACE, Basal Annuloplasty of Cardia Externally; TV, tricuspid valve; ECG, electrocardiography; TEE, transesophageal echocardiography; extracardiac device may cause iatrogenic mitral or tricus- 3D, 3-dimensional. pid stenosis and the sudden increase of afterload after MR reduction may lead to acute left ventricular failure. Three- residual MR in the operating room or improved cardiac dimensional echocardiography may complement conven- Table. Indications and Contraindications to BACE function due to altered interventricular coupling. Implant E tional transesophageal echocardiography and facilitate Indications DISCLOSURES accurate measurement of mitral annular diameters and ori- Moderate to severe ischemic mitral regurgitation Name: Carla Andrea Luzzi, MD. fice, among others. NYHA class II to IV Contribution: This author helped create the outline, and write the Normal MV leaflets manuscript. Contraindications Conflicts of Interest: None. Rheumatic heart disease Name: Vivek Rao, MD, PhD. ANY structural mitral valve abnormality Contribution: This author helped review the manuscript. Moderate or severe tricuspid stenosis Conflicts of Interest: Vivek Rao is the principal investigator for Severe pulmonary hypertension (systolic pulmonary artery pressure NCT02701972 trial of Basal Annuloplasty of Cardia Externally. >60 mm Hg) Name: Massimiliano Meineri, MD, FASE. Contribution: This author helped conceive this review paper, cre- ST-elevation myocardial infarction within 30 d or non-ST segment ate the outline, provide and edit all images and videos, and edit the elevation myocardial infarction within 7 d manuscript. Previous mitral valve surgery Conflicts of Interest: None. Prior coronary artery bypass graft surgery This manuscript was handled by: Nikolaos J. Skubas, MD, DSc, History of IV drug abuse FACC, FASE. Chronic renal failure requiring hemodialysis Abbreviations: BACE, Basal Annuloplasty of Cardia Externally; IV, intravenous; REFERENCES MV, mitral valve; NYHA, New York Heart Association. 1. Badiwala MV, Verma S, Rao V. Surgical management of ischemic mitral regurgitation. Circulation. 2009;120:1287–1293. TV valvular geometry. On 3D analysis, the MV annulus 2. Carpentier A. Cardiac valve surgery–the “French correction.” J became less elliptic with a reduction in tenting volume. Thorac Cardiovasc Surg. 1983;86:323–337. 3. Goldstein D, Moskowitz AJ, Gelijns AC, et al; CTSN. Two-year We also observed an incidental decrease in TV annular outcomes of surgical treatment of severe ischemic mitral regur- diameters. gitation. N Engl J Med. 2016;374:344–353. Possible complications mandating chamber deflation 4. Padmanabhan C, Jagannathan R, Talluri K, Raman J. Extracardiac include LV failure due to abrupt resolution of MR, iatro- approach to functional mitral regurgitation: a cost-effective approach to addressing heart failure. BMJ Innovations. 2017;24:1–7. genic mitral or tricuspid stenosis, and right ventricular out- 5. Raman J, Hare D, Storer M, Hata M. Epicardial cardiac basal flow tract compression. annuloplasty: preliminary findings on extra-cardiac mitral In our case, despite a lack of improvement of MR grade valve repair. Heart Lung Circ. 2009;18:401–406. 6. Raman J, Jagannathan R, Chandrashekar P, Sugeng L. Can we after BACE positioning, the patient NYHA status improved repair the mitral valve from outside the heart? A novel extra- at 6 months postimplant without progression of ischemic cardiac approach to functional mitral regurgitation. Heart Lung MR. This may be explained by either underestimation of Circ. 2011;20:157–162.