Transcatheter Aortic Valve Replacement After Prior Mitral Valve Surgery: Results From the Transcatheter Valve Therapy Registry

BACKGROUND

Due to perceived technical challenges, patients with previous surgical mitral valve repair or replacement (SMVR) have been excluded from most transcatheter aortic valve replacement (TAVR) trials. Our objective was to compare the 30-day and 1-year outcomes of TAVR for patients with and without prior SMVR.

METHODS

In a retrospective review of The Society of Thoracic Surgeons (STS) and American College of Cardiology (ACC) Transcatheter Valve Therapy (TVT) Registry, we compared 1097 patients with prior SMVR to 46,327 patients without prior SMVR who underwent TAVR between November 2011 and September 2015 at 394 US centers. Preoperative characteristics, procedural details, and clinical outcomes were analyzed.

RESULTS

Patients with previous SMVR were younger, more often female, and had higher STS predicted risk of mortality (8.6% vs 6.8%, P < .001). However, there was no difference in 30-day mortality (4.6% vs 5.5%, P = .293), myocardial infarction, stroke, reintervention, new dialysis, or readmission. Moderate/severe paravalvular leak at discharge was also similar (5.8% vs 4.9%, P = .343). At 1 year, morbidity was similar with slightly higher mortality among patients with prior SMVR (20% vs 17.5%, P = .087) that was significant after adjustment (hazard ratio 1.18, P = .043). The type of prior SMVR (repair, bioprosthetic replacement, or mechanical replacement) had no impact on 30-day or 1-year survival.

CONCLUSIONS

Patients with prior SMVR undergoing TAVR had similar 30-day outcomes, slightly higher 1-year mortality, and no increase in early paravalvular leak compared with patients who did not have previous SMVR. Prior SMVR should not preclude TAVR for appropriately selected patients.

P5608Acute respiratory failure after type A aortic dissection repair: data from the International Registry of Aortic Dissection (IRAD)

Background

Acute Respiratory Failure (ARF) has been noted in up to 20% of patients undergoing cardiac surgery and is associated with increased mortality. Cardiopulmonary bypass (CPB) is often followed by pulmonary dysfunction, although literature on the subject in the setting of Type A acute aortic dissection (TAAAD) is limited.

Methods

This study identified the incidence of ARF after TAAAD, associated risk factors, and the impact of ARF on early and late outcomes. All data have been derived from the International Registry of Acute Aortic Dissection (IRAD).

Results

Postoperative ARF (defined as ventilator support for ≥3 days, tracheostomy, and/or pneumonia) occurred in 434 (24.6%) of 1764 surgically managed TAAAD patients (mean age 60.1±14.2 years) from November 2001 until November 2017. Peripheral vessel procedures (6.4% v 2.8%, p=0.002), cerebral perfusion (89.2% v 82.3%, p<0.001), use of hypothermic circulatory arrest (93% v 87.7%), longer arrest time (median 39 (Q1-Q3 27–128 minutes) v 31 (Q1-Q3 22.0–52.9 minutes)), and lower extremity ischemia (18.8% v 6.7%, p<0.001) were more common in ARF patients.

On multivariable logistic regression analysis, age ≥70 years (OR 1.019, 95% CI 1.005–1.034, p=0.008), current smoking (OR 1.744, 95% CI 1.184–2.570, p=0.005), peripheral vessel procedures (OR 2.457, 95% CI 1.132–5.334, p=0.023), presenting hypotension/shock (OR 2.036, 95% CI 1.336–3.102, p=0.001), lower extremity ischemia at surgery (OR 2.77, 95% CI 1.574–4.875, p<0.001), concomitant coronary artery bypass graft (CABG) (OR 2.982, 95% CI 1.597–5.568, p=0.001), pre-operative acute renal failure (OR 2.532, 95% CI 1.350–4.749, p=0.004), and prolonged circulatory arrest time in minutes (OR 1.005, 95% CI 1.003–1.007, p<0.001) were independently associated with ARF development. Patients with aortic valve replacement (AVR) were less likely to develop ARF (OR 0.497, 95% CI 0.308–0.802, p=0.004).

Post-operative complications were more common in ARF patients. In-hospital mortality was higher in the ARF cohort (16.4% v 4.7%, p<0.001). Multivariable logistic regression identified ARF (OR 2.686, 95% CI 1.647–4.381, p<0.001) as well as pre-operative hypotension (OR 1.89, 95% CI 1.130–3.159, p=0.015), lower extremity ischemia (OR 2.77, 95% CI 1.545–4.998, p=0.001), pre-operative myocardial infarction (OR 3.141, 95% CI 1.058–9.33, p=0.039), and CABG (OR 1.988, 95% CI 1.011–3.909, p-value 0.047) as independent predictors of death.

Conclusions

Post-operative ARF is common after TAAAD repair; in-hospital complications and death are higher in this cohort.

Acknowledgement/Funding

W.L. Gore & Associates, Inc.; Medtronic; Varbedian Aortic Fund; Hewlett Foundation; Mardigian Foundation; UM Faculty Group Practice; Ann & Bob Aikens

The Role of Thoracic Endovascular Repair in Chronic Type B Aortic Dissection

Continued device improvements along with refined implantation techniques have revolutionize the use of thoracic endovascular repair for both aortic dissections and aneurysms. This is now considered standard of care for acute, complicated type B aortic dissection in patients with appropriate anatomy. However, the treatment of chronic, uncomplicated type B dissection continues to present challenges for the aortic surgeon, as the long-held dogma of medical management and surveillance for aneurysm degeneration has recently come into questions. We present evidence for a more thoughtful approach to management and intervention with thoracic endovascular repair in select patients with chronic, type B dissection.

Two different geometric orientations for aortic neoroot creation in bicuspid aortic valve repair with root reimplantation

OBJECTIVE

Bicuspid aortic valve (BAV) represents 2 cusps oriented along a spectrum of equal (180°/180°) or unequal (150°/210°) leaflet surface area distribution along the aortic annular plane. We have taken the approach of respecting the native geometric orientation of the repaired BAV leaflets when creating the aortic neoroot during valve-sparing root reimplantation (VSRR) procedures. We investigated midterm outcomes with this 2-prong approach for VSRR in BAV syndrome.

METHODS

Of 72 patients in a prospectively maintained BAV repair database, 68 met inclusion criteria: 36 patients had 180°/180° neoroot geometry, and 32 patients had 150°/210° orientation. A multivariate ordinal logistic mixed effects model was performed to study parameters associated with recurrent AI greater than 2+.

RESULTS

Preoperative parameters were similar between 180°/180° and 150°/210° groups, except for greater incidence of AI 4+ in the latter (50.0% [n = 16] vs 8.3% [n = 3]; P < .001). Postoperatively, stroke, renal failure, reoperation for bleeding, and pacemaker rates were 0 in the entire cohort. In-hospital/30-day mortality in the entire cohort was 1.5% (n = 1). Multivariate ordinal logistic mixed effects model showed that preoperative AI greater than 3+ (odds ratio, 0.4; P = .46) and geometric orientation of the aortic neoroot (odds ratio, 3.8; P = .25) were not significantly associated with recurrence of AI greater than 2+.

CONCLUSIONS

Respecting BAV geometry for VSRR neoroot creation yields excellent midterm outcomes and may minimize conjoint cusp leaflet stress that may occur in "forcing" a 150°/210° type I BAV into a 180°/180° neoroot.

Procedural Volume and Outcomes for Transcatheter Aortic-Valve Replacement

BACKGROUND

During the introduction of transcatheter aortic-valve replacement (TAVR) in the United States, requirements regarding procedural volume were mandated by the Centers for Medicare and Medicaid Services as a condition of reimbursement. A better understanding of the relationship between hospital volume of TAVR procedures and patient outcomes could inform policy decisions.

METHODS

We analyzed data from the Transcatheter Valve Therapy Registry regarding procedural volumes and outcomes from 2015 through 2017. The primary analyses examined the association between hospital procedural volume as a continuous variable and risk-adjusted mortality at 30 days after transfemoral TAVR. Secondary analysis included risk-adjusted mortality according to quartile of hospital procedural volume. A sensitivity analysis was performed after exclusion of the first 12 months of transfemoral TAVR procedures at each hospital.

RESULTS

Of 113,662 TAVR procedures performed at 555 hospitals by 2960 operators, 96,256 (84.7%) involved a transfemoral approach. There was a significant inverse association between annualized volume of transfemoral TAVR procedures and mortality. Adjusted 30-day mortality was higher and more variable at hospitals in the lowest-volume quartile (3.19%; 95% confidence interval [CI], 2.78 to 3.67) than at hospitals in the highest-volume quartile (2.66%; 95% CI, 2.48 to 2.85) (odds ratio, 1.21; P = 0.02). The difference in adjusted mortality between a mean annualized volume of 27 procedures in the lowest-volume quartile and 143 procedures in the highest-volume quartile was a relative reduction of 19.45% (95% CI, 8.63 to 30.26). After the exclusion of the first 12 months of TAVR procedures at each hospital, 30-day mortality remained higher in the lowest-volume quartile than in the highest-volume quartile (3.10% vs. 2.61%; odds ratio, 1.19; 95% CI, 1.01 to 1.40).

CONCLUSIONS

An inverse volume-mortality association was observed for transfemoral TAVR procedures from 2015 through 2017. Mortality at 30 days was higher and more variable at hospitals with a low procedural volume than at hospitals with a high procedural volume. (Funded by the American College of Cardiology Foundation National Cardiovascular Data Registry and the Society of Thoracic Surgeons.).

Factors associated with acute stroke after type A aortic dissection repair: An analysis of the Society of Thoracic Surgeons National Adult Cardiac Surgery Database

OBJECTIVES

Data from the Society of Thoracic Surgeons Adult Cardiac Surgery Database was used to examine the incidence and factors associated with acute stroke following type A repair.

METHODS

Acute type A aortic dissection repairs performed from 2014 to 2017 were identified from the Society of Thoracic Surgeons Adult Cardiac Surgery Database. The effect of cannulation strategy (eg, axillary, femoral, direct, or innominate), lowest temperature, cerebral protection techniques (antegrade cerebral profusion, retrograde cerebral perfusion, both, or none), repair technique, and institutional volume on postoperative stroke was investigated.

RESULTS

Acute type A repair was performed on 8937 patients at 772 centers, of which 7353 met inclusion criteria. Operative mortality was 17% and incidence of postoperative stroke was 13%. Axillary cannulation was associated with lower risk of stroke versus femoral (odds ratio, 0.60; P < .001). Retrograde cerebral perfusion was associated with reduced risk for stroke compared with no cerebral perfusion (odds ratio, 0.75; P = .008) or antegrade cerebral perfusion (odds ratio, 0.75; P = .007). Total arch replacement was associated with greater risk for stroke versus hemiarch technique (odds ratio, 1.30; P = .013). Longer circulatory arrest time, cerebral perfusion time, and cardiopulmonary bypass time were all related to higher risk of postoperative stroke.

CONCLUSIONS

Stroke is a common complication after type A repair. Axillary cannulation was associated with lower incidence of stroke, whereas femoral cannulation significantly increased the risk of stroke regardless of the cerebral perfusion strategy or the degree of hypothermia. Retrograde cerebral profusion was found to have reduced risk for postoperative stroke. Degree of hypothermia and center volume were not related to stroke incidence.

Association of Overnight Extubation With Outcomes After Cardiac Surgery in the Intensive Care Unit

BACKGROUND

The frequency and safety of overnight extubation (OE) after cardiac surgery across intensive care units (ICUs) is unknown.

METHODS

We performed a retrospective study of adults (≥ 18 years) in US ICUs after coronary artery bypass grafting (CABG) or aortic valve replacement (AVR) or both, using The Society of Thoracic Surgery Adult Cardiac Surgery Database (July 2014 to June 2017); our primary cohort was elective CABGs. We assessed OE (7:00 pm to 6:59 am) frequency and used multilevel regression modelling to identify factors associated with OE. Within mechanical ventilation (MV) duration strata, we used propensity score matching to evaluate associations of OE with reintubations (primary outcome), mortality, and complications.

RESULTS

Among 142,225 patients with elective CABG, 42.2% had OEs. MV duration, cardiopulmonary bypass time, distal anastomosis number, and hospital of admission (median odds ratio [OR] 1.82, 95% confidence interval [CI]: 1.76 to 1.89) were independently associated with OE. After propensity matching, OE was associated with increased reintubation for patients with MV duration of 6 to 8 hours (2.2% vs 1.7%, OR 1.27, 95% CI: 1.04 to 1.56) and decreased reintubation for patients with MV duration of 15 to 17 hours (3.0% vs 4.2%, OR 0.70, 95% CI: 0.50 to 0.97) and 18 to 20 hours (2.3% vs 5.7%, OR 0.39, 95% CI: 0.21 to 0.72); OE was associated with increased ICU length of stay for patients with MV duration of 6 to 8 hours, but reduced length of stay for patients with MV duration of 9 to 20 hours. OE was not associated with increased mortality (hospital, 30-day). Other groups had similar OE rates (nonelective CABGs, 47.6%; elective AVR, 36.0%; elective CABG + AVRs, 51.0%) and outcomes.

CONCLUSIONS

OE is prevalent after cardiac surgery. OE is associated with little risk and reduces ICU length of stay for patients who require MV for more than 8 hours.

Bicuspid aortic valve repair: systematic review on long-term outcomes

Background

Many patients with bicuspid aortic valve (BAV) develop aortic regurgitation but are not considered for valve repair. This is partly due to limited long term data regarding repair durability. The purpose of the review is to summarize the long-term (1 year) outcomes of BAV repair.

Methods

A systematic review was performed to evaluate durability and survival following BAV repair. OVID SP versions of MEDLINE and Embase were searched using 'aortic valve', 'bicuspid', 'repair', 'David' 'Yacoub', 'reimplantation' and 'remodeling'.

Results

Initial search produced 770 abstracts, reduced to 92 full papers for review after excluding duplications and abstract review for relevance. Twenty-six studies met full inclusion criteria. BAV repair revealed low operative mortality, with excellent 5-year survival, and low freedom from reoperation. Differences in surgical technique between reimplantation and remodeling do not appear to confer protection against reintervention. Systematic assessment of cusp height and annular stabilization in some form do appear to favor improved long term durability. Leaflet calcification is associated with higher rates of reintervention.

Conclusions

BAV repair is associated with acceptable long term survival. Ongoing standardized outcome assessments will further refine surgical techniques associated with excellent repair durability.