High-risk aortic valve replacement: are the outcomes as bad as predicted? Ann Thorac Surg. 2008;85:102-106; discussion 107. [PMID: 18154791 DOI: 10.1016/j.athoracsur.2007.05.010]

Transapical TAVI: Survival, Hemodynamics, Devices and Machine Learning. Lessons Learned After 10-Year Experience

Aim of this single-center, retrospective study was to assess early and long-term clinical and hemodynamic results of transapical aortic valve implantation (TA-TAVI), and to identify predictors of survival at follow-up. All patients undergoing TA-TAVI for severe aortic valve stenosis at our institution were reviewed. A hybrid approach based on machine-learning techniques was employed to identify survival predictors, using a Bagging-Decision-Tree algorithm and a Random-Forest algorithm, respectively. Two-hundred-thirty-four consecutive patients underwent TA-TAVI (March 2009-May 2019). All-cause 30-day mortality was 5.1%. Device success was 95.7%. Median follow-up time was 35.2 months. Kaplan-Meier overall survival rates at 2, 5, and 8 years were 75%, 44%, and 15%, respectively. Structural-valve-deterioration occurred in 25 patients (11.3%) overall. The strongest predictors of survival at follow-up were age, body-mass-index, and ejection fraction. TA-TAVI provided valid early and long-term outcomes. These data support its choice as an optimal alternative access whenever the transfemoral route is not feasible.

Minimally-invasive cardiac surgery: a bibliometric analysis of impact and force to identify key and facilitating advanced training

Background

The number of citations an article receives is a marker of its scientific influence within a particular specialty. This bibliometric analysis intended to recognise the top 100 cited articles in minimally-invasive cardiac surgery, to determine the fundamental subject areas that have borne considerable influence upon clinical practice and academic knowledge whilst also considering bibliometric scope. This is increasingly relevant in a continually advancing specialty and one where minimally-invasive cardiac procedures have the potential for huge benefits to patient outcomes.

Methods

The Web of Science (Clarivate Analytics) data citation index database was searched with the following terms: [Minimal* AND Invasive* AND Card* AND Surg*]. Results were limited to full text English language manuscripts and ranked by citation number. Further analysis of the top 100 cited articles was carried out according to subject, author, publication year, journal, institution and country of origin.

Results

A total of 4716 eligible manuscripts were retrieved. Of the top 100 papers, the median (range) citation number was 101 (51–414). The most cited paper by Lichtenstein et al. (Circulation 114(6):591–596, 2006) published in Circulation with 414 citations focused on transapical transcatheter aortic valve implantation as a viable alternative to aortic valve replacement with cardiopulmonary bypass in selected patients with aortic stenosis. The Annals of Thoracic Surgery published the most papers and received the most citations (n = 35; 3036 citations). The United States of America had the most publications and citations (n = 52; 5303 citations), followed by Germany (n = 27; 2598 citations). Harvard Medical School, Boston, Massachusetts, published the most papers of all institutions. Minimally-invasive cardiac surgery pertaining to valve surgery (n = 42) and coronary artery bypass surgery (n = 30) were the two most frequent topics by a large margin.

Conclusions

This work establishes a comprehensive and informative analysis of the most influential publications in minimally-invasive cardiac surgery and outlines what constitutes a citable article. Undertaking a quantitative evaluation of the top 100 papers aids in recognising the contributions of key authors and institutions as well as guiding future efforts in this field to continually improve the quality of care offered to complex cardiac patients.

Preoperative frailty parameters as predictors for outcomes after transcatheter aortic valve implantation: a systematic review and meta-analysis

Guidelines suggest using frailty characteristics in the work-up for a transcatheter aortic valve implantation (TAVI). There are many frailty-screening tools with different components. The prognostic value of the individual parameters in frailty is as yet unclear. The objective of this systematic review and meta-analysis was to find and pool predictors for 1‑year mortality after TAVI. We followed a two-step approach. First, we searched for randomised controlled trials on TAVI to identify frailty parameters used in these studies. Second, we searched for publications on these frailty parameters. Articles were included for pooled analysis if the studied frailty parameters were dichotomised with clear cut-off values based on common standards or clinical practice and reported adjusted hazard ratios (HR) of 1‑year mortality after TAVI. We calculated pooled effect estimates of 49 studies based on dichotomised frailty scores (HR: 2.16, 95% CI: 1.57–3.00), chronic lung disease (HR: 1.57, 95% CI: 1.45–1.70), estimated glomerular filtration rate <30 ml/min (HR: 1.95, 95% CI: 1.68–2.29), body mass index <20 kg/m² (HR: 1.49, 95% CI: 1.09–2.03), hypoalbuminaemia (HR: 1.77, 95% CI: 1.38–2.25), anaemia (HR: 2.08, 95% CI: 0.93–4.66), low gait speed (HR: 13.33, 95% CI: 1.75–101.49) and Katz activities of daily living (ADL) score of 1 or more deficits (HR: 5.16, 95% CI: 0.77–34.47). Chronic lung disease, chronic kidney disease, underweight, hypoalbuminaemia, a low frailty score, anaemia, low gait speed and an ADL deficiency were associated with worse 1‑year outcomes after TAVI.

Risk Stratification for Transcatheter Aortic Valve Replacement

Risk assessment models developed from administrative and clinical databases are used for clinical decision making. Since these models are derived from a database, they have an inherent limitation of being as good as the data they are derived from. Many of these models under or overestimate certain clinical outcomes particularly mortality in certain group of patients. Undeniably, there is significant variability in all these models on account of patient population studied, the statistical analysis used to develop the model and the period during which these models were developed. This review aims to shed light on development and application of risk assessment models for cardiac surgery with special emphasis on risk stratification in severe aortic stenosis to select patients for transcatheter aortic valve replacement.

The impact of preoperative frailty status on outcomes after transcatheter aortic valve replacement: An update of systematic review and meta-analysis

BACKGROUND

Frailty is a syndrome of impaired physiologic reserve and decreased resistance to stressors and can often be seen in high-risk patients undergoing transcatheter aortic valve replacement (TAVR). Preoperative frailty status is thought to be related to adverse outcomes after TAVR. We conducted this systematic review and meta-analysis to determine the impact of preoperative frailty status on outcomes among patients after TAVR.

METHODS

PubMed, Embase, and the Cochrane Library were searched for relevant studies through January 2018. Fourteen articles (n = 7489) meeting the inclusion criteria were finally included. Possible effects were calculated using meta-analysis.

RESULTS

The pooled risk ratios (RRs) of late mortality (>6 months) and acute kidney injury after TAVR in frail group were 2.81 (95% confidence interval (CI) 1.90-4.15, P < .001, I = 84%) and 1.41 (95% CI 1.02-1.94, P = .04, I = 24%), respectively. Compared with non-frail group, significantly higher incidence of 30-day mortality (RR 2.03, 95% CI 1.63-2.54, P < .001, I = 0%) and life threatening or major bleeding after TAVR (RR 1.48, 95% CI 1.20-1.82, P < .001, I = 14%) was found in frail group. There was no significant association between frailty and incidence of stroke after TAVR (RR 0.93, 95% CI 0.53-1.63, P = .80, I = 0%).

CONCLUSION

Preoperative frailty status is proved to be significantly associated with poor outcomes after TAVR. Our findings may remind doctors in the field of a more comprehensive preoperative evaluation for TAVR candidates. More well-designed and large-sample sized prospective studies are further needed to figure out the best frailty assessment tool for patients undergoing TAVR.

Outcomes comparison of different surgical strategies for the management of severe aortic valve stenosis: study protocol of a prospective multicentre European registry (E-AVR registry)

INTRODUCTION

Traditional and transcatheter surgical treatments of severe aortic valve stenosis (SAVS) are increasing in parallel with the improved life expectancy. Recent randomised controlled trials (RCTs) reported comparable or non-inferior mortality with transcatheter treatments compared with traditional surgery. However, RCTs have the limitation of being a mirror of the predefined inclusion/exclusion criteria, without reflecting the 'real clinical world'. Technological improvements have recently allowed the development of minimally invasive surgical accesses and the use of sutureless valves, but their impact on the clinical scenario is difficult to assess because of the monocentric design of published studies and limited sample size. A prospective multicentre registry including all patients referred for a surgical treatment of SAVS (traditional, through full sternotomy; minimally invasive; or transcatheter; with both 'sutured' and 'sutureless' valves) will provide a 'real-world' picture of available results of current surgical options and will help to clarify the 'grey zones' of current guidelines.

METHODS AND ANALYSIS

European Aortic Valve Registry is a prospective observational open registry designed to collect all data from patients admitted for SAVS, with or without coronary artery disease, in 16 cardiac surgery centres located in six countries (France, Germany, Italy, Spain, Switzerland and UK). Patients will be enrolled over a 2-year period and followed up for a minimum of 5 years to a maximum of 10 years after enrolment. Outcome definitions are concordant with Valve Academic Research Consortium-2 criteria and established guidelines. Primary outcome is 5-year all-cause mortality. Secondary outcomes aim at establishing 'early' 30-day all-cause and cardiovascular mortality, as well as major morbidity, and 'late' cardiovascular mortality, major morbidity, structural and non-structural valve complications, quality of life and echocardiographic results.

ETHICS AND DISSEMINATION

The study protocol is approved by local ethics committees. Any formal presentation or publication of data will be considered as a joint publication by the participating physician(s) and will follow the recommendations of the International Committee of Medical Journal Editors for authorship.

TRIAL REGISTRATION NUMBER

NCT03143361; Pre-results.

Clinical significance of chronic obstructive pulmonary disease in patients undergoing elective total arch replacement: analysis based on the Japan Adult Cardiovascular Surgery Database

Objectives

We investigated the impact of chronic obstructive pulmonary disease (COPD) on in-hospital outcomes of patients undergoing conventional total aortic arch replacement (TAR), based on the Japan Adult Cardiovascular Surgery Database.

Methods

A total of 12 590 patients who underwent elective TAR between 2008 and 2013 were retrospectively reviewed. Patients were divided into 4 categories: normal respiratory function (control), with ratio of forced expiratory volume of air in 1 s (FEV 1 ) to forced vital capacity (FVC) of 76% or greater (TAR, n  = 10 040); mild COPD, with FEV 1 /FVC ratio 60-75% and/or use of bronchodilator (TAR, n  = 1890); moderate COPD, FEV 1 /FVC ratio 50 to 59% and/or use of steroids (TAR, n  = 504); and severe COPD, FEV 1 /FVC ratio less than 50% and/or presence of respiratory failure (TAR, n  = 156).

Results

In-hospital mortality was 5.7% (5.2% in controls, 7.0% in mild COPD, 9.3% in moderate COPD and 9.0% in severe COPD). A significant trend towards the severity of COPD was noted ( P  < 0.0001). A higher incidence of postoperative pneumonia (6.0% in control, 11.0% in mild COPD, 12.3% in moderate COPD and 15.4% in severe COPD; P  < 0.0001) and a greater need for prolonged ventilation (17.5% in control, 22.0% in mild COPD, 26.6% in moderate COPD and 29.5% in severe COPD; P  < 0.0001) were observed in cases of more severe COPD. The odds ratio of moderate/severe COPD for in-hospital mortality was 1.44 with confidence interval of 1.08-1.91 ( P  = 0.012).

Conclusions

There was a significant increase in in-hospital mortality and morbidity with increasing severity of COPD in patients who underwent TAR.

Minimally invasive aortic valve replacement in high risk patient groups

Minimally invasive aortic valve replacement (AVR) aims to preserve the sternal integrity and improve postoperative outcomes. In low risk patients, this technique can be achieved with comparable mortality to the conventional approach and there is evidence of possible reduction in intensive care and hospital length of stay, transfusion requirement, renal dysfunction, improved respiratory function and increased patient satisfaction. In this review, we aim to asses if these benefits can be transferred to the high risk patient groups. We therefore, discuss the available evidence for the following high risk groups: elderly patients, re-operative surgery, poor lung function, pulmonary hypertension, obesity, concomitant procedures and high risk score cohorts.

Association of CKD with Outcomes Among Patients Undergoing Transcatheter Aortic Valve Implantation

BACKGROUND AND OBJECTIVES

Despitethe multiple depicted associations of CKD with reduced cardiovascular and overall prognoses, the association of CKD with outcome of patients undergoing transcatheter aortic valve implantation has still not been well described.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Data from all hospitalized patients who underwent transcatheter aortic valve implantation procedures between January 1, 2010 and December 31, 2013 in Germany were evaluated regarding influence of CKD, even in the earlier stages, on morbidity, in-hospital outcomes, and costs.

RESULTS

A total of 28,716 patients were treated with transcatheter aortic valve implantation. A total of 11,189 (39.0%) suffered from CKD. Patients with CKD were predominantly women; had higher rates of comorbidities, such as coronary artery disease, heart failure at New York Heart Association 3/4, peripheral artery disease, and diabetes; and had a 1.3-fold higher estimated logistic European System for Cardiac Operative Risk Evaluation value. In-hospital mortality was independently associated with CKD stage ≥3 (up to odds ratio, 1.71; 95% confidence interval, 1.35 to 2.17; P<0.05), bleeding was independently associated with CKD stage ≥4 (up to odds ratio, 1.82; 95% confidence interval, 1.47 to 2.24; P<0.001), and AKI was independently associated with CKD stages 3 (odds ratio, 1.83; 95% confidence interval, 1.62 to 2.06) and 4 (odds ratio, 2.33; 95% confidence interval, 1.92 to 2.83 both P<0.001). The stroke risk, in contrast, was lower for patients with CKD stages 4 (odds ratio, 0.23; 95% confidence interval, 0.16 to 0.33) and 5 (odds ratio, 0.24; 95% confidence interval, 0.15 to 0.39; both P<0.001). Lengths of hospital stay were, on average, 1.2-fold longer, whereas reimbursements were, on average, only 1.03-fold higher in patients who suffered from CKD.

CONCLUSIONS

This analysis illustrates for the first time on a nationwide basis the association of CKD with adverse outcomes in patients who underwent transcatheter aortic valve implantation. Thus, classification of CKD stages before transcatheter aortic valve implantation is important for appropriate risk stratification.

Mitral implant of the Inovare transcatheter heart valve in failed surgical bioprostheses: a novel alternative for valve-in-valve procedures

Objectives

Reoperative procedure for the treatment of a failed mitral bioprosthesis is associated with considerable risk. In some cases, mortality is high and might contraindicate the benefit of the procedure. The minimally invasive valve-in-valve (ViV) transcatheter mitral valve implant offers an alternative less-invasive approach, reducing morbidity and mortality. The objective of this paper was to evaluate the mitral ViV approach using the Braile Inovare prosthesis.

Methods

The transcatheter balloon-expandable Braile Inovare prosthesis was used in 12 cases. Procedures were performed in a hybrid operating room, under fluoroscopic and echocardiographic control. Through left minithoracotomy, the prostheses were implanted through the cardiac apex. Serial echocardiographic and clinical examinations were performed. Follow-up varied from 1 to 30 months.

Results

A total of 12 transapical mitral ViV procedures were performed. Patients had a mean age of 61.6 ± 9.9 years and 92% were women. Mean logistic EuroSCORE was 20.1%. Successful valve implantation was possible in all cases. In one case, a right lateral thoracotomy was performed for the removal of an embolized prosthesis. There was no operative mortality. Thirty-day mortality was 8.3%. Ejection fraction was preserved after the implant (66.7%; 64.8%; P  = 0.3). The mitral gradient showed a significant reduction (11 mmHg; 6 mmHg; P  < 0.001). Residual mitral regurgitation was not present. There was no left ventricular outflow tract obstruction.

Conclusions

The mitral ViV implant in a failed bioprosthesis is an effective procedure. This possibility might alter prosthesis selection in the future initial surgical prosthesis selection, favouring bioprostheses. Further large trials should explore its safety.

Prognosis after surgical replacement with a bioprosthetic aortic valve in patients with severe symptomatic aortic stenosis: systematic review of observational studies

OBJECTIVE

 To determine the frequency of survival, stroke, atrial fibrillation, structural valve deterioration, and length of hospital stay after surgical replacement of an aortic valve (SAVR) with a bioprosthetic valve in patients with severe symptomatic aortic stenosis.

DESIGN

 Systematic review and meta-analysis of observational studies.

DATA SOURCES

 Medline, Embase, PubMed (non-Medline records only), Cochrane Database of Systematic Reviews, and Cochrane CENTRAL from 2002 to June 2016.

STUDY SELECTION

 Eligible observational studies followed patients after SAVR with a bioprosthetic valve for at least two years.

METHODS

 Reviewers, independently and in duplicate, evaluated study eligibility, extracted data, and assessed risk of bias for patient important outcomes. We used the GRADE system to quantify absolute effects and quality of evidence. Published survival curves provided data for survival and freedom from structural valve deterioration, and random effect models provided the framework for estimates of pooled incidence rates of stroke, atrial fibrillation, and length of hospital stay.

RESULTS

 In patients undergoing SAVR with a bioprosthetic valve, median survival was 16 years in those aged 65 or less, 12 years in those aged 65 to 75, seven years in those aged 75 to 85, and six years in those aged more than 85. The incidence rate of stroke was 0.25 per 100 patient years (95% confidence interval 0.06 to 0.54) and atrial fibrillation 2.90 per 100 patient years (1.78 to 4.79). Post-SAVR, freedom from structural valve deterioration was 94.0% at 10 years, 81.7% at 15 years, and 52% at 20 years, and mean length of hospital stay was 12 days (95% confidence interval 9 to 15).

CONCLUSION

 Patients with severe symptomatic aortic stenosis undergoing SAVR with a bioprosthetic valve can expect only slightly lower survival than those without aortic stenosis, and a low incidence of stroke and, up to 10 years, of structural valve deterioration. The rate of deterioration increases rapidly after 10 years, and particularly after 15 years.

Long-Term Outcomes of Conventional Aortic Valve Replacement in High-Risk Patients: Where Do We Stand?

PURPOSE

The introduction of transcatheter aortic valves has focused attention on the results of conventional aortic valve surgery in high-risk patients. The aim of the study was to evaluate 5-years outcomes in this category of patients in the current surgical era.

METHODS

This is an observational retrospective study of 581 high-risk patients undergoing aortic valve replacement from 2008 to 2013, with a mean logistic EuroSCORE of 26.6% ± 14.6%. Data were prospectively collected in a database of Emilia-Romagna region (Italy).

RESULTS

Overall 30-day mortality was 9.3%. Stroke rate was 1.5%. At 1-, 3-, and 5-years overall mortality was 18.2%, 30.4%, and 42.2%, cardiac death rate was 3.9%, 9.2%, and 12.9%, stroke rate 2.5%, 7.7%, and 10.2%, re-operation occurrence 0.2%, 0.9% and 1.3%, and new pacemaker implantation was 2.3%, 5.1% and 7.8%. At multivariate analysis, urgency, hemodynamic instability, LVEF ≤30%, NYHA III-IV, severe chronic obstructive pulmonary disease (COPD), extra-cardiac arteriopathy, cerebrovascular disease, and creatinine >2.0 mg/dL remained independent predictors of 5-year mortality.

CONCLUSION

The results of the current study add weight to the evidence that traditional aortic valve replacement can be performed in high-risk patients with satisfactory 5-year mortality and morbidity. Our study may help to improve decision-making in this category of high-risk patients with aortic valve disease.

New Braile Inovare transcatheter aortic prosthesis: clinical results and follow-up

AIMS

Transcatheter aortic valve implantation has emerged as an alternative to conventional aortic valve replacement in high-risk patients. Diverse prostheses are currently under investigation. The aim of this study was the clinical, safety and efficacy assessment of Braile Inovare Transcatheter Aortic Prosthesis usage.

METHODS AND RESULTS

Ninety high-risk or inoperable patients underwent transcatheter aortic valve implantation. The mean logistic EuroSCORE was 39.3%. All patients presented calcified aortic stenosis. The procedures were performed under fluoroscopic and echocardiographic guidance. Prostheses were implanted through the transapical approach under rapid ventricular pacing. Echocardiographic and angiographic controls were included. Implantation was feasible in 87 cases. There was only one case of operative mortality, and 30-day mortality was 13.3%. The median transvalvular aortic gradient was reduced from 44.8±15.3 to 14.1±8.0 mmHg. Left ventricular function improved in the first seven postoperative days. Paravalvular aortic regurgitation was present in 29.7% of cases, mostly trace. One case presented a major vascular complication, and there were two cases of permanent pacemaker implantation. Two cases of major stroke occurred.

CONCLUSIONS

Transcatheter aortic valve replacement using the Braile Inovare prosthesis is able to provide encouraging results with significant functional and structural cardiac improvement. It is mandatory to continue follow-up to measure the benefits of this device as well as to improve selection criteria of patients.

Impact of lung diseases on morbidity and mortality after transcatheter aortic valve implantation: insights from spirometry and body plethysmography

BACKGROUND

The study aims to determine the impact of different lung diseases on morbidity and mortality after transcatheter aortic valve implantation (TAVI).

METHODS

Transcatheter aortic valve implantation was performed transfemoral or transaxillary with CoreValve prosthesis or Edwards SAPIEN prosthesis in patients with symptomatic severe aortic valve stenosis and high surgical risk. Examinations comprised spirometry, body plethysmography echocardiography, and x-ray before TAVI. The primary study end point was death from any cause after TAVI.

RESULTS

During follow-up of 750 ± 538 days, 63 of 212 patients died. Logistic European System for Cardiac Operative Risk Evaluation (hazard risk [HR] 1.032, P < .001), aortic mean gradient (HR 0.96, P < .001), chronic obstructive pulmonary disease (COPD; each degree of COPD: HR 1.436, P = .001), restrictive ventilatory disease (HR 2.252, P = .002), oxygen dependency (HR 3.291, P = .004), and noninvasive ventilation (HR 3.799, P = .005) were independent predictors of long-term mortality. Restrictive ventilatory disease was associated with lower left ventricular ejection fraction, higher B-type natriuretic peptide levels, and pulmonary edema.

CONCLUSION

In patients undergoing TAVI, lung diseases are an independent predictor of all-cause mortality. In particular, oxygen dependency patients and patients with severe COPD and noninvasive ventilation indicate a dismal prognosis. Transcatheter aortic valve implantation seems to have a dubious prognostic benefit in these patients.

Short-term and medium-term outcomes of transapical aortic valve implantation as a single-strategy approach: one center's experience

INTRODUCTION

Transcatheter aortic valve replacement has been developed as an alternative option for surgical high-risk or inoperable patients with severe symptomatic aortic stenosis.

AIM OF THE STUDY

Aim of the study was to evaluate the outcomes of patients undergoing transapical aortic valve replacement as a single-strategy option by a single-center multidisciplinary heart team.

MATERIAL AND METHODS

Between June 2009 and December 2014, 41 patients underwent transapical transcatheter aortic valve implantation (TA-TAVI) at our institution. All patients received Edwards SAPIEN balloon expandable pericardial valves (Edwards Lifesciences, Irvine, CA, USA). Our center followed a "clear transapical strategy" for all patients.

RESULTS

The mean age of the patients was 79.6 years, and the mean logistic EuroSCORE was 21.06 ± 12.82%. Fifteen patients (36.6%) underwent redo operations. Complications included stroke (n = 1), re-exploration for bleeding or cardiac tamponade (n = 4), renal failure requiring temporary hemodialysis (n = 4) and permanent pacemaker implantation (n = 3). There were no myocardial infarctions or coronary obstruction. The total 30-day mortality rate was 17.1% (7 patients). Postoperative intensive care unit stay was 4.6 ± 5.7 days, and mean hospitalization was 11.6 ± 7.2 days.

CONCLUSIONS

The TA-TAVI approach provides good results in terms of early and midterm outcomes. This approach is feasible and safe for patients who have high surgical risk.

A comparison of conventional surgery, transcatheter aortic valve replacement, and sutureless valves in "real-world" patients with aortic stenosis and intermediate- to high-risk profile

OBJECTIVE

We sought to investigate the clinical outcomes of patients with isolated severe aortic stenosis and an intermediate- to high-risk profile treated by means of conventional surgery (surgical aortic valve replacement), sutureless valve implantation, or transcatheter aortic valve replacement in a multicenter evaluation.

METHODS

Among 991 consecutive patients with isolated severe aortic stenosis and an intermediate- to high-risk profile (Society of Thoracic Surgeons score >4 and logistic European System for Cardiac Operative Risk Evaluation I >10), a propensity score analysis was performed on the basis of the therapeutic strategy: surgical aortic valve replacement (n = 204), sutureless valve implantation (n = 204), and transcatheter aortic valve replacement (n = 204). Primary end points were 30-day mortality and overall survival at 24-month follow-up; the secondary end point was survival free from a composite end point of major adverse cardiac events (defined as cardiac-related mortality, myocardial infarction, cerebrovascular accidents, and major hemorrhagic events) and periprosthetic regurgitation greater than 2.

RESULTS

Thirty-day mortality was significantly higher in the transcatheter aortic valve replacement group (surgical aortic valve replacement = 3.4% vs sutureless = 5.8% vs transcatheter aortic valve replacement = 9.8%; P = .005). The incidence of postprocedural was 3.9% in asurgical aortic valve replacement vs 9.8% in sutureless vs 14.7% in transcatheter aortic valve replacement (P< .001) and peripheral vascular complications occurred in 0% of surgicalaortic valve replacement vs 0% of sutureless vs 9.8% transcatheter aortic valve replacement (P< .001). At 24-month follow-up, overall survival (surgical aortic valve replacement = 91.3% ± 2.4% vs sutureless = 94.9% ± 2.1% vs transcatheter aortic valve replacement = 79.5% ± 4.3%; P < .001) and survival free from the composite end point of major adverse cardiovascular events and periprosthetic regurgitation were significantly better in patients undergoing surgical aortic valve replacement and sutureless valve implantation than in patients undergoing transcatheter aortic valve replacement (surgical aortic valve replacement = 92.6% ± 2.3% vs sutureless = 96% ± 1.8% vs transcatheter aortic valve replacement = 77.1% ± 4.2%; P < .001). Multivariate Cox regression analysis identified transcatheter aortic valve replacement as an independent risk factor for overall mortality hazard ratio (hazard ratio, 2.5; confidence interval, 1.1-4.2; P = .018).

CONCLUSIONS

The use of transcatheter aortic valve replacement in patients with an intermediate- to high-risk profile was associated with a significantly higher incidence of perioperative complications and decreased survival at short- and mid-term when compared with conventional surgery and sutureless valve implantation.

Outcomes in Nonagenarians Undergoing Transcatheter Aortic Valve Replacement in the PARTNER-I Trial

BACKGROUND

This study describes short-term and mid-term outcomes of nonagenarian patients undergoing transfemoral or transapical transcatheter aortic valve replacement (TAVR) in the Placement of Aortic Transcatheter Valve (PARTNER)-I trial.

METHODS

From April 2007 to February 2012, 531 nonagenarians, mean age 93 ± 2.1 years, underwent TAVR with a balloon-expandable prosthesis in the PARTNER-I trial: 329 through transfemoral (TF-TAVR) and 202 transapical (TA-TAVR) access. Clinical events were adjudicated and echocardiographic results analyzed in a core laboratory. Quality of life (QoL) data were obtained up to 1 year post-TAVR. Time-varying all-cause mortality was referenced to that of an age-sex-race-matched US population.

RESULTS

For TF-TAVR, post-procedure 30-day stroke risk was 3.6%; major adverse events occurred in 35% of patients; 30-day paravalvular leak was greater than moderate in 1.4%; median post-procedure length of stay (LOS) was 5 days. Thirty-day mortality was 4.0% and 3-year mortality 48% (44% for the matched population). By 6 months, most QoL measures had stabilized at a level considerably better than baseline, with Kansas City Cardiomyopathy Questionnaire (KCCQ) 72 ± 21. For TA-TAVR, post-procedure 30-day stroke risk was 2.0%; major adverse events 32%; 30-day paravalvular leak was greater than moderate in 0.61%; and median post-procedure LOS was 8 days. Thirty-day mortality was 12% and 3-year mortality 54% (42% for the matched population); KCCQ was 73 ± 23.

CONCLUSIONS

A TAVR can be performed in nonagenarians with acceptable short- and mid-term outcomes. Although TF- and TA-TAVR outcomes are not directly comparable, TA-TAVR appears to carry a higher risk of early death without a difference in intermediate-term mortality. Age alone should not preclude referral for TAVR in nonagenarians.

Transcatheter aortic valve implantation in patients with pre-existing chronic kidney disease

BACKGROUND

We investigated the effect of chronic kidney disease (CKD) on morbidity and mortality following transcatheter aortic valve implantation (TAVI) including patients on haemodialysis, often excluded from randomised trials.

METHODS AND RESULTS

We performed a retrospective post hoc analysis of all patients undergoing TAVI at our centre between 2008 and 2012. 118 consecutive patients underwent TAVI; 63 were considered as having (CKD) and 55 not having (No-CKD) significant pre-existing CKD, (defined as estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m²). Chronic haemodialysis patients (n = 4) were excluded from acute kidney injury (AKI) analysis. Following TAVI, in CKD and No-CKD patients respectively, AKI occurred in 23.7% and 14.5% (p = 0.455) and renal replacement therapy (RRT) was necessary in 8.5% and 3.6% (relative risk (RR) [95% CI] = 2.33 [0.47-11.5], p = 0.440); 30-day mortality rates were 6.3% and 1.8% (p = 0.370); and 1-year mortality rates were 17.5% and 18.2% (p = 0.919). Patients who developed AKI had a significantly increased risk of 30-day (12.5% vs. 1.1%, p = 0.029) mortality. We found the presence of diabetes (odds ratio (OR) [95% CI] = 4.58 [1.58-13.3], p = 0.005) and elevated baseline serum creatinine (OR [95% CI] = 1.02 [1.00-1.03], p = 0.026) to independently predict AKI to statistical significance by multivariate analysis.

CONCLUSION

TAVI is a safe, acceptable treatment for patients with pre-existing CKD, however caution must be exercised, particularly in patients with pre-existing diabetes mellitus and elevated pre-operative serum creatinine levels as this confers a greater risk of AKI development, which is associated with increased short-term post-operative mortality.

Nontransfemoral Approaches to Transcatheter Aortic Valve Replacement

Transcatheter aortic valve replacement (TAVR) is noninferior to surgical aortic valve replacement in patients with high operative risk and superior to medical treatment in patients deemed unsuitable for surgical intervention. However, up to 30% to 50% of patients screened for this intervention are not candidates for TAVR via the preferred transfemoral route because of severe peripheral arterial disease. Alternative access routes must be considered and include the transapical, transaortic, transsubclavian, and transcarotid approaches. The use of alternative access is predicated on appropriate patient selection as determined by a dedicated multispecialty heart valve team and can lead to excellent outcomes.

[Impact of transcatheter aortic valve implantation in the treatment of aortic valve disease after previous coronary artery bypass]

INTRODUCTION

Patients with a history of coronary artery bypass and aortic valve disease constitute a high-risk group for conventional redo surgery. The transcatheter aortic valve implantation (TAVI) may be an alternative for high-risk patients. The purpose of this study is to evaluate the impact of TAVI in the treatment of aortic valve disease after previous surgical coronary artery revascularization.

PATIENTS AND METHODS

This is a single-center retrospective, observational study, including 87 patients undergoing surgery for surgical heart valve replacement or TAVI from January 2007 to December 2013.

RESULTS

The introduction of transcatheter aortic valve implantation techniques has doubled the number of redo patients treated for aortic valve disease. From 2010 to 2013, the patients treated by conventional surgery diminished by 30%, with improved postoperative outcomes. This study allowed us to notice differences in patient's in terms of operative risk factors. For the same reasons no comparison was possible between 2 subgroup of patients. Hospital mortality was 6.4% for conventional aortic surgery and 20% for transcatheter aortic valve treatment.

CONCLUSION

Surgery remains the standard treatment for aortic valve disease even in redo patients, but TAVI becomes a very interesting tool as it may represent a tailored approach for our patients.

Does treatment assignment influence the prognosis of patients with symptomatic severe aortic stenosis?

Objective

Aortic valve replacement (AVR) is the standard therapy in patients with symptomatic aortic stenosis (AS). In high surgical risk patients, alternative therapeutic options to medical treatment (MT) such as trans-catheter aortic valve implantation (TAVI) or balloon aortic valvuloplasty (BAV) have been proposed. In this study we evaluated whether treatment assignment influences per se the prognosis of these subjects.

Patients and methods

Criteria for treatment assignment were based on patient’s clinical conditions, Logistic EuroSCORE and other co-morbidities ignored by EuroSCORE. Due to baseline clinical differences between patients with diverse treatment assignment, we used propensity score matching to achieve balance.

Results

368 patients were studied: 141 underwent AVR, 127 TAVI, 49 BAV and 51 MT. 84 events (deaths for all causes) occurred during 14 months of follow-up: 11 AVR (8%), 26 TAVI (20%), 18 MT (35%), 29 BAV group (59%). Traditional Cox analysis identified treatment assignment as independent predictor of events (HR 1.82 [CI 1.10-3.25]) together with lower left ventricular ejection fraction, impaired renal function and history of heart failure. Matched Cox analysis by propensity score confirmed treatment assignment as an independent prognosticator of events (HR 1.90 [CI 1.27-2.85]), and showed similar rate events in TAVI and AVR patients, while it was significantly increased in BAV and MT patients.

Conclusions

Treatment assignment may influence outcome of symptomatic patients with AS.

Aortic valve replacement via right minithoracotomy versus median sternotomy: a propensity score analysis

OBJECTIVE

The aim of this study was to define the relative role of a right minithoracotomy (RT) versus standard median sternotomy (ST) for open aortic valve replacement (AVR).

METHODS

A retrospective analysis was performed of all 1348 patients undergoing isolated, open AVR at a single institution during a 14-year period. Because relatively few patients were technically suitable for redo AVR with the RT approach (n = 20), all redo patients (n = 209) were excluded, leaving 1139 patients available for analysis. Patients converting from RT to ST approach (n = 15) were analyzed separately.

RESULTS

Relative to ST (n = 672), the RT patients (n = 452) were older with more stenosis but with more recent operation year, lower rate of congestive heart failure, higher ejection fraction, lower rate of endocarditis, and lower rate of renal disease than the ST AVR patients (all P < 0.0001). Right minithoracotomy AVR was associated with longer cardiopulmonary bypass times [157 (25) vs 131 (38), P = 0.0004] and clamp times [103 (20) vs 85 (27), P < 0.0001] but less transfusion (1.4 vs 3.4 U, P = 0.0003), less chest tube output (405 vs 950 mL, P < 0.0001), fewer reoperations for bleeding (0.4% vs 4%, P < 0.0001), shorter length of stay (6 vs 8 days, P = 0.03), and lower rate of atrial fibrillation (15% vs 20%, P = 0.03). Stroke, operative mortality, and survival were not significantly different between the groups.

CONCLUSIONS

Given the biases of retrospective propensity-adjusted analysis, these data suggest that RT AVR is a safe alternative to ST AVR in selected patients, with advantages of avoiding sternotomy with associated bleeding, transfusion, and delayed wound healing, at the expense of longer pump and clamp times.

The association of chronic lung disease with early mortality and respiratory adverse events after aortic valve replacement

BACKGROUND

We studied the association between components of chronic lung disease (CLD) assessment and operative outcomes in patients undergoing aortic valve replacement (AVR) for aortic stenosis.

METHODS

From 2011 to 2012, 9,177 patients included in The Society of Thoracic Surgeons (STS) Cardiac Surgery Database underwent AVR for aortic stenosis with complete pulmonary function tests (PFT) and CLD data (31% of AVRs). We evaluated markers of CLD and their association with operative mortality, pulmonary morbidity, and length of hospital stay using multivariable logistic regression analysis.

RESULTS

In a selected population of AVR patients with PFTs, CLD was prevalent in 50% (mild, 25.6%; moderate, 13.2%; severe, 11.2%). Predicted forced expiratory volume in 1 second (FEV1) was obtained in all patients and diffusion capacity of the lung for carbon monoxide (DLCO), arterial oxygen tension (PaO2), and arterial carbon dioxide tension (PaCO2) in 31%. The STS predicted risk of operative mortality, mortality, pulmonary morbidity, and hospital stay increased with severity of CLD and with low FEV1, DLCO, and PaO2. Moderate and severe CLD were independently associated with operative mortality (odds ratio [OR] 2.88, 95% confidence interval [CI]: 2.0-4.5), pulmonary morbidity (OR 2.33, 95% CI: 1.93-2.8), and prolonged hospital stay (OR 2.73, 95% CI: 2.17-3.45). Low FEV1 was independently associated with pulmonary morbidity and prolonged hospital stay. Low PaO2 and DLCO were independently associated with a combined mortality and pulmonary morbidity endpoint.

CONCLUSIONS

CLD is associated with adverse operative outcomes in selected patients with aortic stenosis undergoing AVR. FEV1, DLCO, and PaO2 may add important information to current risk adjustment models beyond the broad CLD classification.

Assessing the risk of aortic valve replacement for severe aortic stenosis in the transcatheter valve era

Surgical aortic valve replacement had been the only definitive treatment of severe aortic stenosis before the availability of transcatheter valve technology. Historically, many patients with severe aortic stenosis had not been offered surgery, largely related to professional and patient perception regarding the risks of operation relative to anticipated benefits. Such patients have been labeled as "high risk" or "inoperable" with respect to their suitability for surgery. The availability of transcatheter aortic valve replacement affords a new treatment option for patients previously not felt to be optimal candidates for surgical valve replacement and allows for the opportunity to reexamine the methods for assessing operative risk in the context of more than 1 available treatment. Standardized risk assessment can be challenging because of both the imprecision of current risk scoring methods and the variability in ascertaining risk related to operator experience as well as local factors and practice patterns at treating facilities. Operative risk in actuality is not an absolute but represents a spectrum from very low to extreme, and the conventional labels of high risk and inoperable are incomplete with respect to their utility in clinical decision making. Moving forward, the emphasis should be on developing an individual assessment that takes into account procedure risk as well as long-term outcomes evaluated in a multidisciplinary fashion, and incorporating patient preferences and goals in a model of shared decision making.

Aortic valve replacement in octogenarians

BACKGROUND

With improved life expectancy more octogenarians now present with aortic valve disease. Cardiac surgery in this group of patients has previously been considered high risk due to co-morbidities and challenges of rehabilitation. This study seeks to challenge the concept of octogenarian cardiac surgery "unsuitability" by analysing operative outcomes and long term survival following aortic valve replacement.

METHODS

Eighty-seven consecutive patients undergoing aortic valve replacement between 2000 and 2009 at St Vincent's Hospital were retrospectively identified. Statistical analysis was performed using SPSS (version 15 and 19).

RESULTS

The average age was 82.7 ± 2.4 years. The mean logistic EuroSCORE was 18.86 ± 14.11. Post-operatively, four patients required insertion of a permanent pacemaker (4.6%) and five patients had a myocardial infarction (5.8%). In-hospital mortality was 3.4%. Follow-up was 93.1% complete. One-year survival was 92.9%, three-year survival was 86.7% and five-year survival was 75.0%. At follow-up 98.1% of patients were New York Heart Association (NYHA) Class I or II.

CONCLUSIONS

Results were excellent despite reasonable co-morbidities and Euroscore risk. Survival was impressive and the NYHA class reflected the success of the surgery in relieving the pathological aortic valve process. Patient age should not be the primary exclusion for cardiac surgery for aortic valve disease.

Integrating a palliative approach in a transcatheter heart valve program: bridging innovations in the management of severe aortic stenosis and best end-of-life practice

Severe aortic stenosis (AS) is the most prevalent structural heart disease and affects primarily older adults in their last decade of life. If the risk for surgery is high, transcatheter aortic valve implantation (TAVI) is the treatment of choice for many patients with suitable anatomy who are likely to derive significant benefit from this innovative and minimally invasive approach. In a large transcatheter heart valve (THV) centre that offers TAVI as one of the treatment options, of 565 consecutive referrals for the assessment of eligibility for TAVI over 18 months, 78 (14%) were deemed unsuitable candidates for TAVI or higher risk surgery by the interdisciplinary Heart Team because of their advanced disease, excessive frailty or comorbid burden. Concerns were raised for patients for whom TAVI is not an option. The integration of a palliative approach in a THV program offers opportunities to adopt best end-of-life practices while promoting innovative approaches for treatment. An integrated palliative approach to care focuses on meeting a patient's full range of physical, psychosocial and spiritual needs at all stages of a life-limiting illness, and is well suited for the severe AS and TAVI population. A series of interventions that reflect best practices and current evidence were adopted in collaboration with the Palliative Care Team and are currently under evaluation in a large TAVI centre. Changes include the introduction of a palliative approach in patient assessment and education, the measurement of symptoms, improved clarity about responsibility for communication and follow-up, and triggering referrals to palliative care services.

Simple bedside clinical evaluation versus established scores in the estimation of operative risk in valve replacement for severe aortic stenosis

BACKGROUND

The operative risk of cardiac surgery is ascertained preoperatively on the basis of scores validated in multinational studies. However, the value they add to a simple bedside clinical evaluation (CE) remains controversial.

AIMS

To compare operative mortality (defined as death from all causes before the 31st postoperative day) predicted by CE with that predicted by additive and logistic EuroSCOREs, EuroSCORE II and Society of Thoracic Surgeons (STS), Ambler and age-creatinine-ejection fraction (ACEF) scores in patients undergoing aortic valve replacement (AVR) for severe aortic stenosis.

METHODS

Overall, 314 consecutive patients were included who underwent AVR between October 2009 and November 2011 (22% with coronary artery bypass graft); mean age 73.4 ± 9.7 years (29% aged>80 years). Based on CE, patients were divided into four predefined groups of increasing estimated mortality risk: I ≤ 3.9%; II 4-6.9%; III 7-9.9%; IV ≥ 10%. The positive and negative predictive values of the six scores and CE were compared.

RESULTS

The observed overall operative mortality was 5.7%. The distribution of the four predicted mortality groups by each score was highly variable. The positive predictive value, calculated for the 64 patients classified at highest risk by CE (groups III or IV) or each score, was 17.2% for EuroSCORE II, 14.1% for CE and STS scores, 10.9% for additive and logistic EuroSCOREs, 10.6% for ACEF and 10.2% for Ambler. The positive predictive value of each score in the low-risk groups (I and II) ranged from 2.8% to 4.4%.

CONCLUSION

A simple bedside CE appears as reliable as the various established scores for predicting operative risk in patients undergoing surgical aortic valve replacement. The development and validation of more comprehensive risk stratification tools, including risk factors thus far neglected, seems warranted.

Transapical aortic valve implantation in patients with previous cardiac surgery

BACKGROUND

This study compared surgical outcomes of patients with previous cardiac surgery undergoing transapical transcatheter aortic valve implantation (PCS-TA-TAVI) with those of patients undergoing transapical transcatheter aortic valve implantation as an initial procedure (initial TA-TAVI) by using propensity analysis.

METHODS

From January 2005 through January 2013, 267 consecutive high-risk patients underwent transapical transcatheter aortic valve implantation using a pericardial xenograft fixed within a stainless steel, balloon-expandable stent (Edwards SAPIEN). Of these, 59 patients underwent PCS-TA-TAVI (coronary artery bypass grafting: n = 31; valve surgery: n = 28), and the remaining 208 had an initial TA-TAVI procedure. Logistic regression analysis was used to identify covariates among 10 baseline patient variables. Using the significant regression coefficients, each patient's propensity score was calculated, allowing selectively matched subgroups of 45 patients in the two groups. Operative outcomes were analyzed for differences. Follow-up was 4 ± 2 years and 100% complete.

RESULTS

There was no significant difference between PCS-TA-TAVI and initial TA-TAVI patients in operative time, postoperative bleeding, 30-day survival (91% versus 93%), and survival at late follow-up (63% versus 68%; p ≥ 0.28). Overall incidence of early stroke was low with 0% for the PCS-TA-TAVI and 4% for initial TA-TAVI group (p = 0.56). Transapical transcatheter aortic valve implantation was successfully performed in all but 1 patient from the initial TA-TAVI group who required conversion to sternotomy.

CONCLUSIONS

Transapical transcatheter aortic valve implantation has simplified surgical treatment of high-risk patients with previous cardiac surgery and severe aortic valve stenosis and is associated with minimal risk of stroke. Furthermore, current data suggest that the presence of previous cardiac surgery does not impair outcomes after transapical transcatheter aortic valve implantation, making this subset of patients particularly applicable for this evolving approach.

Type of Valvular Heart Disease Requiring Surgery in the 21st Century: Mortality and Length-of-Stay Related to Surgery

Aim:

While the incidence of rheumatic heart disease has declined dramatically over the last half-century, the number of valve surgeries has not changed. This study was undertaken to define the most common type of valvular heart disease requiring surgery today, and determine in-hospital surgical mortality and length-of-stay (LOS) for isolated aortic or mitral valve surgery in a United States tertiary-care hospital.

Methods:

Patients with valve surgery between January 2002 to June 2008 at The Ohio State University Medical Center were studied. Patients only with isolated aortic or mitral valve surgery were analyzed.

Results:

From 915 patients undergoing at least aortic or mitral valve surgery, the majority had concomitant cardiac proce-dures mostly coronary artery bypass grafting (CABG); only 340 patients had isolated aortic (n=204) or mitral (n=136) valve surgery. In-hospital surgical mortality for mitral regurgitation (n=119), aortic stenosis (n=151), aortic insufficiency (n=53) and mitral stenosis (n=17) was 2.5% (replacement 3.4%; repair 1.6%), 3.9%, 5.6% and 5.8%, respectively (p=NS). Median LOS for aortic insufficiency, aortic stenosis, mitral regurgitation, and mitral stenosis was 7, 8, 9 (replacement 11.5; repair 7) and 11 days, respectively (p<0.05 for group). In-hospital surgical mortality for single valve surgery plus CABG was 10.2% (p<0.005 compared to single valve surgery).

Conclusions:

Aortic stenosis and mitral regurgitation are the most common valvular lesions requiring surgery today. Surgery for isolated aortic or mitral valve disease has low in-hospital mortality with modest LOS. Concomitant CABG with valve surgery increases mortality substantially. Hospital analysis is needed to monitor quality and stimulate improvement among Institutions.

The past, present and future of minimally invasive therapy in endovascular interventions: a review and speculative outlook

Cardiovascular disease is a leading cause of death in all developed countries. In response to this need, endovascular management techniques have been developed across a large range of medical specialties. Minimally invasive percutaneous interventions were initially complex and challenging, but with the continued development of equipment and expertise their use has become routine in many fields. With routine use, it has become important to establish the safety and efficacy of endovascular treatments against the respective "gold standard" procedures, especially in light of their initial intended use for the management of patients at unacceptably high risk for standard therapy only. Such evaluation has to take into account the variety and diversity of devices and techniques, as well as the effects of operator dependability. Endovascular techniques are increasingly recognised as valid alternative management options for a variety of conditions, and it is anticipated that the current trend towards minimally invasive techniques will continue in the future, with moves towards increasingly complex endovascular techniques and hybrid interventions.

German Aortic Valve Score: a new scoring system for prediction of mortality related to aortic valve procedures in adults

OBJECTIVES

The aim of the study was to establish a scoring system to predict mortality in aortic valve procedures in adults [German Aortic Valve Score (German AV Score)] based upon the comprehensive data pool mandatory by law in Germany.

METHODS

In 2008, 11 794 cases were documented who had either open aortic valve surgery or transcatheter aortic valve implantation (TAVI). In-hospital mortality was chosen as a binary outcome measure. Potential risk factors were identified on the basis of published scoring systems and clinical knowledge. First, each of these risk factors was tested in an univariate manner by Fisher's exact test for significant influence on mortality. Then, a multiple logistic regression model with backward and forward selection was used. Calibration was ascertained by the Hosmer-Lemeshow method. In order to define the quality of discrimination, the area under the receiver operating characteristic (ROC) curve was calculated.

RESULTS

In 11 147 of 11 794 cases (94.5%), a complete data set was available. In-hospital mortality was 3.7% for all patients, 3.4% in the surgical group (95% confidence interval 3.0-3.7%, n = 10 574) and 10.6% in the TAVI group (95% confidence interval 8.2-13.5%, n = 573). Based on multiple logistic regression, 15 risk factors with an influence on mortality were identified. Among them, age, body mass index and left ventricular function were categorized in three (body mass index, left ventricular dysfunction) or 6 subgroups (age). The Hosmer-Lemeshow method corroborated a valid concordance of predicted and observed mortality in 10 different risk groups. The area under the ROC curve with a value of 0.808 affirmed the quality of discrimination of the established scoring model.

CONCLUSIONS

It is well known that a predictive model works best in the setting where it was developed; therefore, the German AV Score fits well to the patient population in Germany. It was designed for fair and reliable outcome evaluation. It allows comparison of predicted and observed mortality for conventional aortic valve surgery and transcatheter aortic valve implantation in low-, moderate- and high-risk groups. Thus, it enables primarily a risk-adjusted benchmark of outcome and fosters the efforts for continuous improvement of quality in aortic valve procedures.