Coronary artery disease and outcomes of aortic valve replacement for severe aortic stenosis. J Am Coll Cardiol. 2013;61:837-848. [PMID: 23428216 DOI: 10.1016/j.jacc.2012.10.049]

Clinical Outcomes of Concomitant Coronary Artery Bypass Grafting During Ventricular Septal Myectomy

BACKGROUND

The clinical characteristics and survival outcomes of patients who underwent concomitant coronary artery bypass grafting during septal myectomy have not been well studied.

METHODS AND RESULTS

We reviewed patients who underwent both septal myectomy and coronary artery bypass grafting from 2009 to 2020. Causes of concomitant grafting and their impact on survival were analyzed. The median follow-up period was 5.1 years. A total of 320 patients underwent both grafting and myectomy. Of these, 69.7% and 28.1% underwent grafting attributed to atherosclerotic coronary artery disease and myocardial bridging, respectively. Patients who underwent grafting for coronary artery disease tended to be older, had a longer bypass time, and required more grafts compared with patients undergoing procedures because of myocardial bridging (all P<0.05). Postoperatively, the left ventricular outflow gradient significantly decreased from 85.4 mm Hg to 12.8 mm Hg (P<0.001) without perioperative death. The cumulative survival rates were 96.2% and 97.6% at 5 years in the coronary artery disease and myocardial bridging groups, respectively, and they were comparable to that of general myectomy cohort (hazard ratio [HR], 1.06 [95% CI, 0.47-2.36], P=0.895 and HR 0.75 [95% CI, 0.23-2.46], P=0.636, respectively). Sudden death accounted for 45.5% (5 of 11) of postoperative mortality. Analysis of composite end point events showed decreased morbidity with at least one arterial graft in the overall cohort (HR, 0.47 [95% CI, 0.23-0.94], P=0.034).

CONCLUSIONS

Concomitant grafting in septal myectomy was found to be a safe procedure. Patients who underwent such surgery experienced favorable postoperative outcomes comparable to those who underwent septal myectomy alone, with a 5-year survival rate of >95% and improved functional class of >90%.

Effect of aortic valve replacement on myocardial perfusion and exercise capacity in patients with severe aortic stenosis

Aortic valve replacement (AVR) leads to reverse cardiac remodeling in patients with aortic stenosis (AS). The aim of this secondary pooled analysis was to assess the degree and determinants of changes in myocardial perfusion post AVR, and its link with exercise capacity, in patients with severe AS. A total of 68 patients underwent same-day echocardiography and cardiac magnetic resonance imaging with adenosine stress pre and 6-12 months post-AVR. Of these, 50 had matched perfusion data available (age 67 ± 8 years, 86% male, aortic valve peak velocity 4.38 ± 0.63 m/s, aortic valve area index 0.45 ± 0.13cm2/m2). A subgroup of 34 patients underwent a symptom-limited cardiopulmonary exercise test (CPET) to assess maximal exercise capacity (peak VO2). Baseline and post-AVR parameters were compared and linear regression was used to determine associations between baseline variables and change in myocardial perfusion and exercise capacity. Following AVR, stress myocardial blood flow (MBF) increased from 1.56 ± 0.52 mL/min/g to 1.80 ± 0.62 mL/min/g (p < 0.001), with a corresponding 15% increase in myocardial perfusion reserve (MPR) (2.04 ± 0.57 to 2.34 ± 0.68; p = 0.004). Increasing severity of AS, presence of late gadolinium enhancement, lower baseline stress MBF and MPR were associated with a greater improvement in MPR post-AVR. On multivariable analysis low baseline MPR was independently associated with increased MPR post-AVR. There was no significant change in peak VO2 post-AVR, but a significant increase in exercise duration. Change in MPR was associated with change in peak VO2 post AVR (r = 0.346, p = 0.045). Those with the most impaired stress MBF and MPR at baseline demonstrate the greatest improvements in these parameters following AVR and the magnitude of change in MPR correlated with improvement in peak VO2, the gold standard measure of aerobic exercise capacity.

Coronary Artery Revascularization in Patients Undergoing Transcatheter Aortic Valve Replacement

Patients with concomitant severe aortic stenosis and significant coronary artery disease present a diagnostic and therapeutic challenge in clinical practice. There are no clear-cut guidelines as to the timing of revascularization in these patients who are referred for transcatheter aortic valve replacement (TAVR). This article aims to show that in patients without high-grade proximal coronary artery disease, revascularization after TAVR is safe, feasible, and practical. Additionally, the use of preoperative TAVR computed tomographic angiography might be used in both intermediate and high-risk patients rather than invasive coronary angiography to assess for significant proximal coronary artery disease to help guide the timing of revascularization.

Aortic valve replacement with rapid-deployment bioprosthesis in case of infective endocarditis: a literature review

Purpose

Recently, the use of rapid deployment (RD) aortic valve prostheses has been introduced for the treatment of aortic valve replacement (AVR), showing excellent hemodynamic performances.According to these data, some groups have proposed new RD valves as an alternative solution in the case of infective aortic endocarditis (IAE) to reduce the use of foreign materials, and the manipulation of the annulus.The aim of this review is to report the results of early clinical experiences with the use of RD bioprostheses in the case of IAE, in order to discuss technical and clinical aspects of this emerging strategy to better elucidate its advantages and limitations as a potential therapeutic solution.

Methods

An in-depth search of PubMed from January to March 2023 was performed. English-language articles were selected independently by authors following the criteria in order to consider all available experiences (full papers, case reports, and case series) that have investigated the use of RD in case of IAE.

Results

The use of rapid deployment bioprosthesis represents a bailout strategy in case of severe aortic valve endocarditis and should be evaluated with caution in selected cases. This review collects the first, initial, and pioneering experiences of the use of the RD prosthesis in case of infective endocarditis, particularly when the fragility of the annular tissues precludes a secure anchoring of sutured prostheses.The reduced use of foreign materials by minimizing the number of stitches, the reduced cardiopulmonary bypass (CPB) and aortic cross-clamp times, and the excellent hemodynamic performances associated with the use of RD bioprosthesis represent the most important advantages that could justify their use in the setting of aortic valve endocarditis.

Conclusion

Although there are few anecdotal experiences, surgical aortic valve replacement with the use of RD represents an emerging strategy in case of aortic valve endocarditis. Its advantages, pros, and cons are under debate, and robust clinical trials are needed to demonstrate its safety and efficacy.

Evaluation of Instantaneous Wave-Free Ratio and Fractional Flow Reserve in Severe Aortic Valve Stenosis

BACKGROUND

The optimal functional evaluation of coronary artery stenosis in patients with severe aortic stenosis (AS) has not been established. The objective of the study was to evaluate the instantaneous wave-free ratio (iFR) and fractional flow reserve (FFR) in patients with and without severe AS.

METHODS

We retrospectively investigated 395 lesions in 293 patients with severe AS and 2257 lesions in 1882 patients without severe AS between 2010 and 2022 from a subgroup of the Interventional Cardiology Research In-Cooperation Society FFR Registry. All patients had FFR values, and iFR was analyzed post hoc using dedicated software only in lesions with adequate resting pressure curves (311 lesions in patients with severe AS and 2257 lesions in patients with nonsevere AS).

RESULTS

The incidence of iFR ≤0.89 was 66.6% and 31.8% (P<0.001), while the incidence of FFR ≤0.80 was 45.3% and 43.9% (P=0.60) in the severe AS group and the nonsevere AS group, respectively. In the severe AS group, most lesions (95.2%) with iFR >0.89 had FFR >0.80, while 36.2% of lesions with iFR ≤0.89 had FFR >0.80. During a median follow-up of 2 years, FFR ≤0.80 was significantly associated with deferred lesion failure (adjusted hazard ratio, 2.71 [95% CI, 1.08-6.80]; P=0.034), while iFR ≤0.89 showed no prognostic value (adjusted hazard ratio, 1.31 [95% CI, 0.47-3.60]; P=0.60) in the severe AS group. Lesions with iFR ≤0.89 and FFR >0.80, in particular, were not associated with a higher rate of deferred lesion failure at 3 years compared with lesions with iFR >0.89 (15.4% versus 17.0%; P=0.58).

CONCLUSIONS

This study suggested that FFR appears to be less affected by the presence of severe AS and is more associated with prognosis. iFR may overestimate the functional severity of coronary artery disease without prognostic significance, yet it can be useful for excluding significant stenosis in patients with severe AS.

Coronary Artery Disease Assessment via On-Site CT Fractional Flow Reserve in Patients Undergoing Transcatheter Aortic Valve Replacement

Purpose To examine the clinical feasibility of workstation-based CT fractional flow reserve (CT-FFR) for coronary artery disease (CAD) evaluation during preprocedural planning in patients undergoing transcatheter aortic valve replacement (TAVR). Materials and Methods In this retrospective single-center study, 434 patients scheduled for TAVR between 2018 and 2020 were screened for study inclusion; a relevant proportion of patients (35.0% [152 of 434]) was not suitable for evaluation due to insufficient imaging properties. A total of 112 patients (mean age, 82.1 years ± 6.7 [SD]; 58 [52%] men) were included in the study. Invasive angiography findings, coronary CT angiography results, and Agatston score were acquired and compared with on-site CT-FFR computation for evaluation of CAD and prediction of major adverse cardiovascular events (MACE) within a 24-month follow-up. Results Hemodynamic relevant CAD, as suggested by CT-FFR of 0.80 or less, was found in 41 of 70 (59%) patients with stenosis of 50% or more. MACE occurred in 23 of 112 (20.5%) patients, from which 14 of 23 had stenoses with CT-FFR of 0.80 or less (hazard ratio [HR], 3.33; 95% CI: 1.56, 7.10; P = .002). CT-FFR remained a significant predictor of MACE after inclusion in a multivariable model with relevant covariables (HR, 2.89; 95% CI: 1.22, 6.86; P = .02). An Agatston score of 1000 Agatston units or more (HR, 2.25; 95% CI: 0.98, 5.21; P = .06) and stenoses of 50% or more determined via invasive angiography (HR, 0.94; 95% CI: 0.41, 2.17; P = .88) were not significant predictors of MACE. Conclusion Compared with conventional CAD markers, CT-FFR better predicted adverse outcomes after TAVR. A relevant portion of the screened cohort, however, was not suitable for CT-based CAD evaluation. Keywords: CT, Transcatheter Aortic Valve Implantation/Replacement (TAVI/TAVR), Cardiac, Coronary Arteries, Outcomes Analysis © RSNA, 2024 See also the commentary by Weir-McCall and Pugliese in this issue.

Aortic Stenosis With Coronary Artery Disease: SAVR or TAVR-When and How?

The growing number of candidates for transcatheter aortic valve replacement (TAVR) has increased the interest in the concomitant presence of coronary artery disease (CAD) and severe aortic stenosis (AS), prompting the need to define the appropriate revascularization strategy for each case. The reported prevalence of concurrent AS and CAD has varied over the years on the basis of the CAD definition and the population evaluated. Revascularization for treating CAD in patients with severe AS involves additional interventions that could impact outcomes. The addition of coronary artery bypass grafting (CABG) to surgical aortic valve replacement (SAVR) has demonstrated favourable effects on long-term prognosis, while the impact of adding percutaneous coronary intervention (PCI) to TAVR may depend on the CAD complexity and the feasibility of achieving complete or reasonably incomplete revascularization. Furthermore, the comparison between SAVR+CABG and TAVR+PCI in low-intermediate surgical risk and low-intermediate complex CAD patients did not reveal differences in all-cause mortality or stroke between the groups. However, there is some evidence showing a lower incidence of major cardiovascular events with the SAVR+CABG strategy for patients with complex CAD. Thus, SAVR+CABG seems to be the best option for patients with low-intermediate surgical risk and complex CAD, and TAVR+PCI for high surgical risk patients seeking complete and/or reasonable incomplete revascularization. After deciding between TAVR+PCI or SAVR+CABG, factors such as timing for PCI, low ejection fraction, coronary reaccess, and valve durability must be considered. Finally, alternative methods for assessing CAD severity are currently under evaluation to ascertain their real value for guiding revascularization in patients with severe AS with CAD.

Angina in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement

INTRODUCTION AND OBJECTIVES

To evaluate the prevalence, clinical characteristics, and outcomes of patients with angina undergoing transcatheter aortic valve replacement (TAVR) for severe aortic stenosis.

METHODS

A total of 1687 consecutive patients with severe aortic stenosis undergoing TAVR at our center were included and classified according to patient-reported angina symptoms prior to the TAVR procedure. Baseline, procedural and follow-up data were collected in a dedicated database.

RESULTS

A total of 497 patients (29%) had angina prior to the TAVR procedure. Patients with angina at baseline showed a worse New York Heart Association (NYHA) functional class (NYHA class> II: 69% vs 63%; P=.017), a higher rate of coronary artery disease (74% vs 56%; P <.001), and a lower rate of complete revascularization (70% vs 79%; P <.001). Angina at baseline had no impact on all-cause mortality (HR, 1.02; 95%CI, 0.71-1.48; P=.898) and cardiovascular mortality (HR, 1.2; 95%CI, 0.69-2.11; P=.517) at 1 year. However, persistent angina at 30 days post-TAVR was associated with increased all-cause mortality (HR, 4.86; 95%CI, 1.71-13.8; P=.003) and cardiovascular mortality (HR, 20.7; 95%CI, 3.50-122.6; P=.001) at 1-year follow-up.

CONCLUSIONS

More than one-fourth of patients with severe aortic stenosis undergoing TAVR had angina prior to the procedure. Angina at baseline did not appear to be a sign of a more advanced valvular disease and had no prognostic impact; however, persistent angina at 30 days post-TAVR was associated with worse clinical outcomes.

Five-Year Follow-Up After Transcatheter Aortic Valve Implantation in Patients with Severe Aortic Stenosis and Concomitant Coronary Artery Disease: A Single-Center Experience

INTRODUCTION

There is no consensus on the impact of coronary artery disease in patients undergoing transcatheter aortic valve implantation. Therefore, the objective of this study was, in a single-center setting, to evaluate the five-year outcome of transcatheter aortic valve implantation patients with or without coronary artery disease.

METHODS

All transcatheter aortic valve implantation patients between 2009 and 2019 were included and grouped according to the presence or absence of coronary artery disease. The primary endpoint, five-year all-cause mortality, was evaluated using Cox regression adjusted for age, sex, procedure years, and comorbidities. Comorbidities interacting with coronary artery disease were evaluated with interaction tests. In-hospital complications was the secondary endpoint.

RESULTS

In total, 176 patients had aortic stenosis and concomitant coronary artery disease, while 170 patients had aortic stenosis only. Mean follow-up was 2.2±1.6 years. There was no difference in the adjusted five-year all-cause mortality between transcatheter aortic valve implantation patients with and without coronary artery disease (hazard ratio 1.00, 95% confidence interval 0.59-1.70, P=0.99). In coronary artery disease patients, impaired renal function, peripheral arterial disease, or ejection fraction < 50% showed a significant interaction effect with higher five-year all-cause mortality. No significant differences in complications between the groups were found.

CONCLUSION

Five-year mortality did not differ between transcatheter aortic valve implantation patients with or without coronary artery disease. However, in patients with coronary artery disease and impaired renal function, peripheral arterial disease, or ejection fraction < 50%, we found significantly higher five-year all-cause mortality.

Management of coronary artery disease in patients with aortic stenosis in the era of transcatheter aortic valve replacement

Aortic stenosis (AS) is a common valve disorder among the elderly, and these patients frequently have concomitant coronary artery disease (CAD). Risk factors for calcific AS are similar to those for CAD. Historically, the treatment of these conditions involved simultaneous surgical replacement of the aortic valve (AV) with coronary artery bypass grafting. Since the advancement of transcatheter AV therapies, there have been tremendous advancements in the safety, efficacy, and feasibility of this procedure with expanding indications. This has led to a paradigm shift in our approach to the patient with AS and concomitant CAD. Data regarding the management of CAD in patients with AS are largely limited to single-center studies or retrospective analyses. This article aims to review available literature around the management of CAD in patients with AS and assist in the current understanding in approaches toward management.

Beyond Aortic Stenosis: Addressing the Challenges of Multivalvular Disease Assessment

Aortic stenosis (AS) can often coexist with other valvular diseases or be combined with aortic regurgitation (AR), leading to unique pathophysiological conditions. The combination of affected valves can vary widely, resulting in a lack of standardized diagnostic or therapeutic approaches. Echocardiography is crucial in assessing patients with valvular heart disease (VHD), but careful consideration of the hemodynamic interactions between combined valvular defects is necessary. This is important as it may affect the reliability of commonly used echocardiographic parameters, making the diagnosis challenging. Therefore, a multimodality imaging approach, including computed tomography or cardiac magnetic resonance, is often not just beneficial but crucial. It represents the future of diagnostics in this intricate field due to its unprecedented capacity to quantify and comprehend valvular pathology. The absence of definitive data and guidelines for the therapeutic management of AS in the context of multiple valve lesions makes this condition particularly challenging. As a result, an individualized, case-by-case approach is necessary, guided primarily by the recommendations for the predominant valve lesion. This review aims to summarize the pathophysiology of AS in the context of multiple and mixed valve disease, with a focus on the hemodynamic implications, diagnostic challenges, and therapeutic options.

Catheter versus surgical approach for the management of concomitant aortic stenosis and coronary artery disease: An inverse probability treatment weighting analysis

BACKGROUND

Two therapeutic strategies are available when aortic stenosis and coronary artery disease coexist: a transcatheter approach, with percutaneous coronary intervention followed by transcatheter aortic valve replacement; and a surgical approach, consisting of surgical aortic valve replacement combined with coronary artery bypass graft.

AIM

We sought to compare the outcomes of these two strategies.

METHODS

The study population consisted of 241 patients who benefited from aortic valve replacement and coronary revascularization (transcatheter, n=150; surgery, n=91).

RESULTS

Patients in the transcatheter population were older (83.5 vs. 71.8years; P<0.001) and had a higher Logistic EuroSCORE (11.1% vs. 5.7%; P<0.001). At 30days postprocedure, patients who had surgery exhibited more life-threatening bleedings (12.1% vs 4.5%; P=0.034), acute kidney injury (12.1% vs. 1.3%; P<0.001) and atrial fibrillation (55.6% vs. 8.7%; P<0.001). After a median follow-up of 27months, the risk of major adverse cardiovascular or cerebrovascular events did not differ significantly between the two strategies (hazard ratio [HR] 1.41, 95% confidence interval [CI] 0.97-2.04; P=0.07), whereas estimated glomerular filtration rate<60mL/min (HR 2.22, 95% CI 1.58-3.12; P<0.001), peripheral artery disease (HR 2.00, 95% CI 1.37-2.91; P<0.001) and left ventricular ejection fraction<50% (HR 1.69, 95% CI 1.12-2.55; P=0.012) were associated with a negative prognosis.

CONCLUSIONS

In our study, patients with aortic stenosis and coronary artery disease treated by catheter were older and had a higher co-morbidity burden than those treated by surgery. The surgical strategy was associated with a higher rate of 30-day complications, but long-term outcomes were similar between the two strategies.

Unravelling the Fate of Coronary Artery Disease in Patients Undergoing Valve Replacement for Severe Aortic Valve Stenosis

Severe aortic valve stenosis is the most frequent valve pathology in the western world and approximately 50% of these patients have concomitant coronary artery disease (CAD). Revascularization of proximal obstructive CAD in patients undergoing surgical aortic valve replacement (SAVR) is common practice considered appropriate. However, the management of patients with CAD undergoing transcatheter aortic valve implantation (TAVI) is more controversial. Nevertheless, performing percutaneous coronary intervention (PCI) of significant ( > 70%) proximal coronary lesions is a widely adopted strategy, but robust supporting scientific evidence is missing. Some studies suggest that complex CAD with incomplete revascularization negatively impacts outcomes post-TAVI. As increasingly younger patients are undergoing TAVI, optimizing the long-term outcomes will become more important. Although PCI in TAVI patients is safe, no benefit on outcomes has been demonstrated, possibly due to an inadequate selection of prognostically important lesions for revascularization. A possible solution might be the use of coronary physiological indices, but these have their own limitations and more data is needed to support widespread adoption. In this review we provide an overview of current evidence on the outcomes after aortic valve replacement (AVR) and the evidence regarding revascularization in this population.

Right ventricle to pulmonary artery coupling after transcatheter aortic valve implantation-Determinant factors and prognostic impact

Introduction

Right ventricular (RV) dysfunction and pulmonary hypertension (PH) have been previously associated with unfavorable outcomes in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI), but little is known about the effect of right ventricle (RV) to pulmonary artery (PA) coupling. Our study aimed to evaluate the determinant factors and the prognostic value of RV-PA coupling in patients undergoing TAVI.

Methods

One hundred sixty consecutive patients with severe AS were prospectively enrolled, between September 2018 and May 2020. They underwent a comprehensive echocardiogram before and 30 days after TAVI, including speckle tracking echocardiography (STE) for myocardial deformation analysis of the left ventricle (LV), left atrium (LA), and RV function. Complete data on myocardial deformation was available in 132 patients (76.6 ± 7.5 years, 52.5% men) who formed the final study population. The ratio of RV free wall longitudinal strain (RV-FWLS) to PA systolic pressure (PASP) was used as an estimate of RV-PA coupling. Patients were analyzed according to baseline RV-FWLS/PASP cut-off point, determined through time-dependent ROC curve analysis, as follows: normal RV-PA coupling group (RV-FWLS/PASP ≥0.63, n = 65) and impaired RV-PA coupling group (RV-FWLS/PASP < 0.63, n = 67).

Results

A significant improvement of RV-PA coupling was observed early after TAVI (0.75 ± 0.3 vs. 0.64 ± 0.3 before TAVI, p < 0.001), mainly due to PASP decrease (p < 0.001). LA global longitudinal strain (LA-GLS) is an independent predictor of RV-PA coupling impairment before and after TAVI (OR = 0.837, p < 0.001, OR = 0.848, p < 0.001, respectively), while RV diameter is an independent predictor of persistent RV-PA coupling impairment after TAVI (OR = 1.174, p = 0.002). Impaired RV-PA coupling was associated with a worse survival rate (66.3% vs. 94.9%, p-value < 0.001) and emerged as an independent predictor of mortality (HR = 5.97, CI = 1.44-24.8, p = 0.014) and of the composite endpoint of death and rehospitalization (HR = 4.14, CI = 1.37-12.5, p = 0.012).

Conclusion

Our results confirm that relief of aortic valve obstruction has beneficial effects on the baseline RV-PA coupling, and they occur early after TAVI. Despite significant improvement in LV, LA, and RV function after TAVI, RV-PA coupling remains impaired in some patients, it is mainly related to persistent pulmonary hypertension and is associated with adverse outcomes.

Perioperative management of P2Y12 inhibitors in patients undergoing cardiac surgery within 1 year of PCI

AIMS

To evaluate the impact of perioperative P2Y12 receptor inhibitor therapy among patients undergoing cardiac surgery within 1 year of percutaneous coronary intervention (PCI).

METHODS AND RESULTS

Patients undergoing cardiac surgery in the year post-PCI at three tertiary care centres between 2011 and 2018 were stratified into those who had received at least one dose of P2Y12 inhibitor prior to surgery (within 5 days for clopidogrel or prasugrel, or within 3 days for ticagrelor) and those who had not. The outcomes of interest were major adverse cardiac and cerebrovascular events (MACCEs) and bleeding. Among 20 279 PCI patients, 359 (1.8%) underwent cardiac surgery in the ensuing year, 76.3% of whom received coronary artery bypass grafts. Overall, 33 (9.2%) MACCEs and 85 (23.7%) bleeding events occurred within 30 days post-cardiac surgery. Perioperative P2Y12 inhibition (N = 133, 37%) was not associated with the risk of MACCEs or bleeding, despite numerically lower rates of myocardial infarction or stent thrombosis (0.0% vs. 2.6%; P = 0.089). Patients who continued the P2Y12 inhibitor until the day of surgery (N = 60, 17%) had significantly higher bleeding risk [adjusted odds ratio 2.93, 95% confidence interval 1.53-5.59)]. Predictors of MACCEs included a time interval from PCI to cardiac surgery of ≤30 days and reduced ejection fraction, whereas urgent/emergent surgery predicted bleeding. Chronic kidney disease and myocardial infarction as indication for PCI predicted both MACCEs and bleeding.

CONCLUSION

Among patients undergoing cardiac surgery in the year after PCI, the perioperative risk of ischaemic and bleeding events might be influenced by P2Y12 inhibitor therapy in addition to other risk parameters, including the timing and urgency of the procedure.

Contemporary prevalence of coronary artery disease in patients referred for heart valve surgery

BACKGROUND

Patients undergoing heart valve surgery are routinely evaluated for the presence of coronary artery disease (CAD). Currently, concomitant valve intervention and surgical revascularization is recommended when there is obstructive CAD. The aim of our study was to evaluate the prevalence of CAD, its treatment strategies, and their prognostic implications in a contemporary population of patients with valvular heart disease (VHD) referred for valve surgery (HVS).

METHODS

In a multicenter registry, consecutive patients with formal indication for HVS referred for a preoperative routine invasive coronary angiogram (ICA) were analyzed. Baseline characteristics, CAD prevalence and revascularization patterns, as well as their impact on short and mid-term all-cause mortality, were assessed.

RESULTS

Overall, 1133 patients were included; most had aortic stenosis (69%) and obstructive CAD was present in 307 (27.1%). HVS was ultimately performed in 82.3%. In patients with CAD, 53.4% were revascularized. After a mean follow-up time of 29.06±18.46 months, all-cause mortality rate was 12.9%. In multivariate analysis, not having HVS (HR 6.845, 95% CI=4.281-10.947, P<0.001), obstructive CAD (HR 2.762, 95% CI=1.764-4.326, P<0.01), COPD (HR 2.043, 95% CI=1.014-4.197, P=0.022), and age (HR 1.030, 95% CI=1.009-1.063, P=0.047), were independent predictors of all-cause mortality. In patients with obstructive CAD who underwent HVS, revascularization was not significantly associated with survival (HR 2.127, 95% CI=0.0-4.494, P=0.048; log rank P=0.042).

CONCLUSIONS

In a contemporary cohort of patients with VHD and surgical indication, overall obstructive CAD prevalence was 27%. CAD presence and severity were associated with higher mortality. However, revascularization was not associated with a survival benefit, except in patients with left anterior descending artery disease.

Theaflavin-3,3′-Digallate from Black Tea Inhibits Neointima Formation Through Suppression of the PDGFRβ Pathway in Vascular Smooth Muscle Cells

The abnormal neointima formation caused by the phenotypic switching of vascular smooth cells (VSMCs) into a synthetic state plays a key role in the pathogenesis of various vascular diseases, including atherosclerosis and postangioplasty restenosis. Theaflavin-3,3′-digallate (TF3) in black tea has been reported to exert antiinflammatory and anticancer effects, but its role in neointima formation remains unclear. Here, we delineated a remarkable effect of TF3 in suppressing neointima formation of VSMCs in vivo as well as the ability of primary rat aortic smooth cells (RASMCs) to proliferate and migrate in vitro. Further study confirmed that the effects of TF3 on PDGF-BB–induced RASMCs were due to reduced phosphorylation of PDGFRβ, which led to the repression of downstream pathways. We concluded that TF3 may act as a repressor in the progression of neointima formation and serve as a potential therapeutic candidate for excessive phenotypic switching of VSMCs.

Challenges in Diagnosis and Functional Assessment of Coronary Artery Disease in Patients With Severe Aortic Stenosis

More than half of patients with severe aortic stenosis (AS) over 70 years old have coronary artery disease (CAD). Exertional angina is often present in AS-patients, even in the absence of significant CAD, as a result of oxygen supply/demand mismatch and exercise-induced myocardial ischemia. Moreover, persistent myocardial ischemia leads to extensive myocardial fibrosis and subsequent coronary microvascular dysfunction (CMD) which is defined as reduced coronary vasodilatory capacity below ischemic threshold. Therefore, angina, as well as noninvasive stress tests, have a low specificity and positive predictive value (PPV) for the assessment of epicardial coronary stenosis severity in AS-patients. Moreover, in symptomatic patients with severe AS exercise testing is even contraindicated. Given the limitations of noninvasive stress tests, coronary angiography remains the standard examination for determining the presence and severity of CAD in AS-patients, although angiography alone has poor accuracy in the evaluation of its functional severity. To overcome this limitation, the well-established invasive indices for the assessment of coronary stenosis severity, such as fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR), are now in focus, especially in the contemporary era with the rapid increment of transcatheter aortic valve replacement (TAVR) for the treatment of AS-patients. TAVR induces an immediate decrease in hyperemic microcirculatory resistance and a concomitant increase in hyperemic flow velocity, whereas resting coronary hemodynamics remain unaltered. These findings suggest that FFR may underestimate coronary stenosis severity in AS-patients, whereas iFR as the non-hyperemic index is independent of the AS severity. However, because resting coronary hemodynamics do not improve immediately after TAVR, the coronary vasodilatory capacity in AS-patients treated by TAVR remain impaired, and thus the iFR may overestimate coronary stenosis severity in these patients. The optimal method for evaluating myocardial ischemia in patients with AS and co-existing CAD has not yet been fully established, and this important issue is under further investigation. This review is focused on challenges, limitations, and future perspectives in the functional assessment of coronary stenosis severity in these patients, bearing in mind the complexity of coronary physiology in the presence of this valvular heart disease.

Psoas muscle size, possible sarcopenia and frailty, and long-term survival in elderly patients after isolated surgical aortic valve replacement for aortic stenosis

Purpose

This study investigated the use of psoas muscle area index (PAI) as an indicator of mortality risk in relation to survival in elderly patients after isolated surgical aortic valve replacement (SAVR) for aortic valve stenosis (AS).

Methods

Between January 2005 and March 2015, 140 patients with AS, aged ≥ 70 years, and with preoperative abdominal computed tomography scans, underwent elective, primary, isolated SAVR. PAI showed the ratio of the psoas muscle cross-sectional area at the fourth lumbar vertebral level to body surface area, and PAI less than the gender-specific lowest 20th percentile we called “low PAI” for the purposes of this study. Patients were classified as low PAI (n = 29) or normal PAI (n = 111).

Results

The mean age in the low-PAI group was significantly older than in the normal-PAI group (81.0 vs. 77.3 years; p = 0.001). The mean follow-up was 4.25 years. The low-PAI group had a lower survival rate than the normal-PAI group at 1 year (89.7 ± 5.7% vs. 96.3 ± 1.8%), at 3 years (71.6 ± 9.3% vs. 91.5 ± 2.7%), and overall (53.0 ± 13.4% vs. 76.0 ± 5.6%; p = 0.039). The prognostic factors of mortality included low PAI (hazard ratio 2.95; 95% confidence interval 1.084–8.079; p = 0.034).

Conclusions

PAI was associated with reduced overall survival after isolated SAVR in elderly people. PAI measurement may help to predict patient risks.

2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The guideline for coronary artery revascularization replaces the 2011 coronary artery bypass graft surgery and the 2011 and 2015 percutaneous coronary intervention guidelines, providing a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization as well as the supporting documentation to encourage their use.

METHODS

A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered.

STRUCTURE

Coronary artery disease remains a leading cause of morbidity and mortality globally. Coronary revascularization is an important therapeutic option when managing patients with coronary artery disease. The 2021 coronary artery revascularization guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with coronary artery disease who are being considered for coronary revascularization, with the intent to improve quality of care and align with patients' interests.

Impact of extent of coronary artery disease and percutaneous revascularization assessed by the SYNTAX score on outcomes following transcatheter aortic valve replacement

OBJECTIVES

The aim of the study was to analyze the impact of concomitant coronary artery disease (CAD) assessed by the SYNTAX score (SS) and periprocedural percutaneous coronary intervention (PCI) on outcomes after transcatheter aortic valve replacement (TAVR).

BACKGROUND

Due to controversial data regarding the effect of CAD on outcomes after TAVR, proper revascularization strategies remain a matter of debate.

METHODS

553 patients with severe aortic stenosis undergoing TAVR were included in this study. SS was calculated for each patient at baseline and after PCI. Primary outcome was one-year all-cause mortality.

RESULTS

60.2% of patients (N = 333) exhibited CAD with a mean SS of 10.8 ± 8.8. Of those, 120 patients (36.0%) received periprocedural PCI. In the treatment group, mean SS was decreased from 14.9 ± 9.1 to 6.3 ± 6.7. Patients with concomitant CAD suffered more frequently from myocardial infarction (MI) post TAVR compared to those without CAD (2.1% vs. 0.0%; P < 0.01). In the CAD cohort, MI rates were comparable between patients with and without PCI (2.2% vs. 2.5%; P = 0.71). Regarding SS, patients with a residual SS < 8 showed significant lower rates of one-year mortality (9.0% vs. 18.2%; P = 0.016) and MACCE (16.5% vs. 32.2%; P = 0.001). Besides left bundle brunch, predictors for an increased one-year mortality were a residual SS ≥ 8 in the CAD group (OR = 3.17; P = 0.011) and a EuroSCORE ≥ 4% in the entire study population (OR = 2.18; P = 0.017).

CONCLUSION

Our results suggest that a residual SS-guided revascularization strategy may improve prognosis after TAVR in patients with concomitant CAD. PCI aiming for a residual SS < 8 was associated with improved one-year clinical outcomes.

Factors Influencing Cardiac Sympathetic Nervous Function in Patients With Severe Aortic Stenosis: Assessment by 123I-Metaiodobenzylguanidine Myocardial Scintigraphy

BACKGROUND

Numerous studies have shown that 123I-metaiodobenzylguanidine (MIBG) scintigraphy, an index of cardiac sympathetic nervous (CSN) activity, is useful for predicting prognosis in patients with heart failure. However, the factors influencing the CSN activity of patients with severe aortic stenosis (AS) remain unclear.

METHODS

We enrolled 91 patients with severe AS who underwent 123I-MIBG scintigraphy, coronary computed tomography (CCT), and transthoracic echocardiography. When CCT angiography (CCTA) showed an obstructive epicardial artery, invasive coronary angiography was performed within 1 week of CCTA.

RESULTS

There were 21 male and 70 female patients with a mean age of 84±5 years. Eighty-five (85) patients (93%) had hypertension and 13 patients (14%) had diabetes. Two (2) patients (2%) had previous myocardial infarction and eight (9%) had a previous coronary intervention. All patients had severe AS: aortic valve area was 0.63±0.18 cm² and the mean pressure gradient was 56±19 mmHg. Regarding 123I-MIBG parameters, early heart-to-mediastinum (H/M) ratio was 3.1±0.5, delayed H/M ratio was 2.8±0.6, and the washout rate (WR) was 35%±13%. Multivariable linear regression analysis showed that coronary artery disease (β=-0.30, p=0.002) was an independent predictor of delayed H/M ratio, and that aortic valve area (β=-0.20, p=0.048) was an independent predictor of WR.

CONCLUSIONS

Our findings suggest that coronary artery disease is an independent predictor of delayed H/M ratio, and aortic valve area is an independent predictor of WR in patients with severe AS.

Coronary Revascularization in Patients Undergoing Aortic Valve Replacement for Severe Aortic Stenosis

Aortic stenosis (AS) and coronary artery disease (CAD) frequently coexist, with up to two thirds of patients with AS having significant CAD. Given the challenges when both disease states are present, these patients require a tailored approach diagnostically and therapeutically. In this review the authors address the impact of AS and aortic valve replacement (AVR) on coronary hemodynamic status and discuss the assessment of CAD and the role of revascularization in patients with concomitant AS and CAD. Remodeling in AS increases the susceptibility of myocardial ischemia, which can be compounded by concomitant CAD. AVR can improve coronary hemodynamic status and reduce ischemia. Assessment of the significance of coexisting CAD can be done using noninvasive and invasive metrics. Revascularization in patients undergoing AVR can benefit certain patients in whom CAD is either prognostically or symptomatically important. Identifying this cohort of patients is challenging and as yet incomplete. Patients with dual pathology present a diagnostic and therapeutic challenge; both AS and CAD affect coronary hemodynamic status, they provoke similar symptoms, and their respective treatments can have an impact on both diseases. Decisions regarding coronary revascularization should be based on understanding this complex relationship, using appropriate coronary assessment and consensus within a multidisciplinary team.

Revascularization in the Transcatheter Aortic Valve Replacement Population

Transcatheter aortic valve replacement (TAVR) is a standard treatment option for patients with severe aortic stenosis. Management of concomitant coronary artery disease (CAD) in these patients remains controversial with no randomized clinical trials to guide decision making in this cohort. The role of CAD in TAVR has been difficult to evaluate given the current heterogeneity in defining CAD, and the used methods to assess CAD. Subsequently, the role of coronary revascularization remains individualized and assessed on a case-by-case basis by the heart team. In this article, the authors discuss the rationale and prognostic role of CAD in patients undergoing TAVR.

The Common Combination of Aortic Stenosis with Mitral Regurgitation: Diagnostic Insight and Therapeutic Implications in the Modern Era of Advanced Echocardiography and Percutaneous Intervention

The combination of aortic stenosis (AS) and mitral regurgitation (MR) is common in patients with degenerative valvular disease. It is characterized by having complex pathophysiology, leading to potential diagnostic pitfalls. Evidence is scarce in the literature to direct the diagnostic framework and treatment of patients with this particular combination of multiple valvular diseases. In this complex scenario, the appropriate use of advanced echocardiography and multimodality imaging methods plays a central role. Transcatheter mitral valve replacement or repair and transcatheter aortic valve replacement widen the surgical options for valve diseases. Therefore, there is an increasing need to reconsider the function, timing, and mode intervention for patients with a combination of AS with MR towards more personalized treatment.

Role of coronary angiogram before transcatheter aortic valve implantation

BACKGROUND

Coexistent coronary artery disease is commonly seen in patients undergoing transcatheter aortic valve implantation (TAVI). Previous studies showed that pre-TAVI coronary revascularisation was not associated with improved outcomes, challenging the clinical value of routine coronary angiogram (CA).

AIM

To assess whether a selective approach to perform pre-TAVI CA is safe and feasible.

METHODS

This was a retrospective non-randomised single-centre analysis of consecutive patients undergoing TAVI. A selective approach for performing CA tailored to patient clinical need was developed. Clinical outcomes were compared based on whether patients underwent CA. The primary endpoint was a composite of all-cause mortality, myocardial infraction, repeat CA, and re-admission with heart failure.

RESULTS

Of 348 patients (average age 81 ± 7 and 57% male) were included with a median follow up of 19 (9-31) mo. One hundred and fifty-four (44%) patients, underwent CA before TAVI procedure. Patients who underwent CA were more likely to have previous myocardial infarction (MI) and previous percutaneous revascularisation. The primary endpoint was comparable between the two group (22.6% vs 22.2%; hazard ratio 1.05, 95%CI: 0.67-1.64, P = 0.82). Patients who had CA were less likely to be readmitted with heart failure (P = 0.022), but more likely to have repeat CA (P = 0.002) and MI (P = 0.007). In those who underwent CA, the presence of flow limiting lesions did not affect the incidence of primary endpoint, or its components, except for increased rate of repeat CA.

CONCLUSION

Selective CA is a feasible and safe approach. The clinical value of routine CA should be challenged in future randomised trials

Coronary Evaluation Before Heart Valvular Surgery by Using Coronary Computed Tomographic Angiography Versus Invasive Coronary Angiography

Background

Coronary computed tomography angiography (CCTA) is a noninvasive, less expensive, low‐radiation alternative to invasive coronary angiography (ICA). ICA is recommended for coronary evaluation before heart valvular surgery, and the supporting evidence for CCTA is insufficient. Our study is a single‐center, prospective cohort study designed to evaluate the feasibility of CCTA instead of ICA in detection of coronary artery disease before surgery.

Methods and Results

Heart valvular surgery candidates were consecutively enrolled between April 2017 and December 2018. Nine hundred fifty‐eight patients in the CCTA group underwent CCTA primarily, and those with ≥50% coronary stenosis or uncertain diagnosis underwent subsequent ICA. One thousand five hundred twenty‐five patients in the ICA group underwent ICA directly before surgery. Coronary artery bypass grafting decision was made by surgeons according to CCTA or ICA results. Most of the patients (78.8%) in the CCTA group avoided invasive angiography. Thirty‐day mortality (0.7% versus 0.9%, P=0.821), myocardial infarction (6.4% versus 6.9%, P=0.680 ), and low cardiac output syndrome (4.2% versus 2.8%, P=0.085) were similar in the CCTA and ICA groups. Median duration of follow‐up was 19.3 months (interquartile range, 14.2–30.0 months), cumulative rates of mortality (2.6% versus 2.6%, P=0.882) and major adverse cardiac events (9.6% versus 9.0%, P=0.607) showed no difference between the 2 groups. Coronary evaluation expense was lower in the CCTA group ($149.6 versus $636.0, P<0.001).

Conclusions

The strategy of using CCTA as a doorkeeper in coronary evaluation before heart valvular surgery showed noninferiority in identification of candidates for coronary artery bypass grafting and postoperative safety.

The need for future coronary access following surgical or transcatheter aortic valve replacement

The aim of the study was to estimate the percentage of Medicare patients needing coronary access for percutaneous coronary intervention (PCI) or coronary angiography following aortic valve replacement (AVR). Indications for TAVR have expanded to include younger and low-risk patients, raising the question of coronary access for future procedures. Medicare patients <80 years old with an AVR between 2011 and 2018 were included. Time-to-event analyses were conducted using Cox hazard models to estimate risk of coronary access up to 7 years after AVR. Model adjustments included age, sex, race, region, comorbidity, concomitant CABG, and smoking. A total of 13,469 Medicare patients (mean age 70.6) met inclusion criteria. Models estimated that 2.5% of patients at 1-year post-index and 17% at over 7 years would need coronary access. For patients who had SAVR (with or without CABG), estimates for coronary access were similar and over 15% after 6.5 years. For TAVR patients, with a previous PCI, 28% at 4.5 years required coronary access, which was higher than TAVR patients without a previous PCI. SAVR patients with and without CAD at baseline were similar; however, TAVR patients with CAD had a 22% rate of coronary access versus 7% for those without at 3 years. Approximately half of patients who needed coronary access returned to the same hospital as their initial AVR. Coronary access is required in a substantial portion of AVR patients especially those with PCI or a history of CAD undergoing TAVR. The need for coronary access may increase as transcatheter AVR becomes accessible to younger patients with a longer life expectancy.

Role of Concomitant Coronary Artery Bypass Grafting in Valve Surgery for Infective Endocarditis

BACKGROUND

It is current practice to perform concomitant coronary artery bypass grafting (CABG) in patients with infective endocarditis (IE) who have relevant coronary artery disease (CAD). However, CABG may add complexity to the operation. We aimed to investigate the impact of concomitant CABG on perioperative outcomes in patients undergoing surgery for IE.

METHODS

We retrospectively used data of surgically treated IE patients between 1994 and 2018 in six German cardiac surgery centers. We performed inverse probability weighting (IPW), multivariable adjustment, chi-square analysis, and Kaplan-Meier survival estimates.

RESULTS

CAD was reported in 1242/4917 (25%) patients. Among them, 527 received concomitant CABG. After adjustment for basal characteristics between CABG and no-CABG patients using IPW, concomitant CABG was associated with higher postoperative stroke (26% vs. 21%, p = 0.003) and a trend towards higher postoperative hemodialysis (29% vs. 25%, p = 0.052). Thirty-day mortality was similar in both groups (24% vs. 23%, p = 0.370). Multivariate Cox regression analysis after IPW showed that CABG was not associated with better long-term survival (HR: 1.00, 95% CI: 0.82-1.23, p = 0.998).

CONCLUSION

In endocarditis patients with CAD, adding CABG to valve surgery may be associated with a higher likelihood of postoperative stroke without adding long-term survival benefits. Therefore, in the absence of critical CAD, concomitant CABG may be omitted without impacting outcome. The results are limited due to a lack of data on the severity of CAD, and therefore there is a need for a randomized trial.

Association between a genetic variant in scavenger receptor class B type 1 and its role on codon usage bias with increased risk of developing coronary artery disease

OBJECTIVE

Coronary artery disease (CAD) as an important cause of morbidity and mortality globally. The scavenger receptor class B type 1 (SCARB1) plays an essential role in the reverse cholesterol transport. We have explored the association between a genetic variant, rs5888, in the SCARB1 gene with CAD and serum HDL-C levels.

METHODS

Patients were categorized into two groups' angiogram positive (>50% coronary stenosis) and angiogram negative (<50% coronary stenosis). Genotyping was carried out using polymerase chain reaction-amplification refractory mutation system. The association between the SNP rs5888 and serum HDL-C was analyzed using a logistic regression model.

RESULTS

The results showed that the subjects carrying a T allele was associated with a decreased serum HDL-C levels compared to the C allele in total population (p < 0.001). The risk of angiogram positivity in subjects carrying a T allele was 3.1-fold higher than for the control group (p < 0.001).

CONCLUSION

CVD patients carrying the T allele of rs5888 variant in the SCARB1 gene was associated with decreased serum level of HDL.

2020 update of the Austrian Society of Cardiology (ÖKG) and the Austrian Society of Cardiac Surgery (ÖGHTG) on the position statement of the ÖKG and ÖGHTG for transcatheter aortic valve implantation 2011

This position statement is an update to the 2011 consensus statement of the Austrian Society of Cardiology (ÖKG) and the Austrian Society of Cardiac Surgery (ÖGTHG) for transfemoral transcatheter aortic valve implantation.Due to a number of recently published studies, broadening of indications and recommendations of medical societies and our own national developments, the ÖKG and the ÖGHTG wish to combine the 2017 ESC/EACTS guidelines for the management of valvular heart disease with a national position paper and to focus on certain details for the application in Austria. Thus, this position statement serves as a supplement and further interpretation of the international guidelines.

High thoracic epidural decreases perioperative myocardial ischemia and improves left ventricle function in aortic valve replacement alone or in addition to cabg surgery even with increased left ventricle mass index

Introduction:

High thoracic epidural (HTE) may reduce perioperative tachyarrhythmias, respiratory complications and myocardial ischemia (MI) and it may increase coronary perfusion and myocardial oxygen balance through sympatholysis and pain control. The aim of this study is to investigate the benefit of HTE in patients undergoing aortic valve replacement (AVR) alone or in addition to coronary artery bypass graft (CABG).

Methods:

This prospective randomized controlled study was conducted on 80 patients (40 with increased left ventricular mass index (LVMI) and 40 with normal LVMI) who were equally randomised (n = 40) to receive either GA with HTE (HTE group) or GA alone (GA group). Heart rate (HR), mean arterial blood pressure (MAP) and the incidence of ischemic ECG changes were recorded. LV functions (preoperative and postoperative by transthoracic echocardiography and intraoperative by transoesophageal echocardiography) were measured preoperative, intraoperative and till 48 H postoperative.

Results:

There was no significant difference in the baseline values of all measurements. HR and MAP were lower, and LV functions were improved in HTE group intraoperatively and postoperatively. Ischemic ECG changes were significantly lower in HTE group; with 42.9% intraoperative risk reduction (95% CI: 0.195-0.943) and 46.6% postoperative risk reduction (95% CI 0.227-0.952) as compared to GA group. The risk of ischemia was significantly higher in patients with increased LVMI in GA group (2.25 times compared to normal LVMI patients with 95% CI: 1.195-4.236), but it wasn't increased in HTE group. LV functions were significantly improved from the induction to 48 H postoperative in HTE group as compared to GA group.

Conclusion:

HTE reduced the incidence of MI and improved the LV function, even with increased LVM, in patients undergoing AVR alone or in addition to CABG.

Simultaneous transaortic transcatheter aortic valve implantation and off-pump coronary artery bypass: An effective hybrid approach

INTRODUCTION

Transcatheter aortic valve implantation (TAVI) techniques are increasingly being adopted into clinical routine for various risk groups. Coronary artery disease (CAD) is seen in up to 75% of patients with severe aortic valve stenosis (AS) presenting with typical angina pectoris. Due to high mortality rates and procedural complications in these patients, a hybrid concept of simultaneous transaortic TAVI and off-pump coronary artery bypass (OPCAB) can be a feasible treatment option.

METHODS

Between April 2014 and July 2020, 10 consecutive high-risk patients underwent concomitant transaortic TAVI and OPCAB at our institution. All indications were discussed in Heart Team and decisions were made based on patients' comorbidities and complexity of CAD. The study endpoints were 30-day mortality, device success, and development of postoperative adverse events defined by the Valve Academic Research Consorium.

RESULTS

The mean age of the patients was 77.9 ± 7.1 years old. All patients presented with multiple comorbidities (mean logistic EuroSCORE 26.5 ± 12.3%, median EuroSCORE II 5.13% [interquartile range 4.2-9.5], mean STS-Score 6.04 ± 1.6%). Five patients (50%) presented with porcelain aorta. No conversion to conventional procedures was needed. 30-day mortality occurred in one patient (10%). Complete revascularization was achieved in seven (70%) of the patients. Device success rate was 100%. No paravalvular leakage was detected. No stroke, myocardial infarction or vascular complications were observed.

CONCLUSIONS

A hybrid approach combining transaortic TAVI and OPCAB might be a safe and feasible method of treatment in high-risk patients presenting with severe AS and CAD who are not eligible for conventional surgical or interventional solutions.

[Current problems of simultaneous surgery of the aortic valve and ischaemic heart disease]

Surgical policy in treatment of patients suffering from concomitant valvular pathology and ischaemic heart disease is an extremely important problem of contemporary cardiac surgery. With the advent of advanced techniques and due to the improvement of old ones, there have over the last decades appeared new approaches to treatment of this cohort of patients. Presented in the article is a review of current publications regarding the problem of surgical treatment of patients with a combination of pronounced valvular pathology requiring surgical correction and ischaemic heart disease necessitating the need for myocardial revascularization. This is followed by providing the data concerning contemporary strategies of treatment of patients with concomitant pathology, as well as the comparison of various approaches and the effect of the chosen technique on the outcome.

Factors Associated With Early Extubation After Cardiac Surgery: A Retrospective Single-Center Experience

OBJECTIVES

To identify factors associated with early extubation in cardiac surgery patients.

DESIGN

Single center, retrospective.

SETTING

Tertiary university hospital.

PARTICIPANTS

The study comprised 8,872 adult patients who underwent cardiothoracic surgery from 2011-2019.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of the 8,872 patients, 2,950 (33%) were extubated within six hours after surgery. Early extubated patients were younger, had a higher body mass index (BMI), were more likely to be male, and were fast-track designated. These patients more frequently underwent isolated coronary artery bypass graft, isolated valve, or adult congenital surgeries than did late extubated patients. Early extubated patients had a greater incidence of coronary artery disease (CAD) and anxiety and a higher left ventricular ejection fraction. They also were less likely to have difficult intubation or require mechanical circulatory support, reintubation, or readmission. Analysis of the 8,872 patients showed that male sex (odds ratio [OR] 1.222, 95% confidence interval [CI] 1.096-1.363), a BMI >30 kg/m² (OR 1.702, 95% CI 1.475-1.965), undergoing isolated valve surgery (OR 1.187, 95% CI 1.060-1.328), and having a fast-track designation (OR 1.455, 95% CI 1.208-1.751) and CAD (OR 1.122, 95% CI 1.005-1.253) were associated with early extubation. Data on intensive care unit (ICU) admission after surgery were available only from 2014-2018. Within this subgroup of 5,977 patients, variables associated with early extubation included male sex (OR 1.356, 95% CI 1.193-1.541), BMI >30 kg/m² (OR 1.267, 95% CI 1.084-1.480), daytime admission to the ICU (OR 1.712, 95% CI 1.527-1.919), and fast-track designation (OR 1.423, 95% CI 1.123-1.802).

CONCLUSIONS

Male sex; a BMI >30 kg/m²; undergoing isolated valve surgery; and having a fast-track designation, CAD, and daytime admission to the ICU are associated with early extubation.

Ultrastructural Pathology of Atherosclerosis, Calcific Aortic Valve Disease, and Bioprosthetic Heart Valve Degeneration: Commonalities and Differences

Atherosclerosis, calcific aortic valve disease (CAVD), and bioprosthetic heart valve degeneration (alternatively termed structural valve deterioration, SVD) represent three diseases affecting distinct components of the circulatory system and their substitutes, yet sharing multiple risk factors and commonly leading to the extraskeletal calcification. Whereas the histopathology of the mentioned disorders is well-described, their ultrastructural pathology is largely obscure due to the lack of appropriate investigation techniques. Employing an original method for sample preparation and the electron microscopy visualisation of calcified cardiovascular tissues, here we revisited the ultrastructural features of lipid retention, macrophage infiltration, intraplaque/intraleaflet haemorrhage, and calcification which are common or unique for the indicated types of cardiovascular disease. Atherosclerotic plaques were notable for the massive accumulation of lipids in the extracellular matrix (ECM), abundant macrophage content, and pronounced neovascularisation associated with blood leakage and calcium deposition. In contrast, CAVD and SVD generally did not require vasculo- or angiogenesis to occur, instead relying on fatigue-induced ECM degradation and the concurrent migration of immune cells. Unlike native tissues, bioprosthetic heart valves contained numerous specialised macrophages and were not capable of the regeneration that underscores ECM integrity as a pivotal factor for SVD prevention. While atherosclerosis, CAVD, and SVD show similar pathogenesis patterns, these disorders demonstrate considerable ultrastructural differences.

Impact of Incomplete Coronary Revascularization on Late Ischemic and Bleeding Events after Transcatheter Aortic Valve Replacement

BACKGROUND

The impact of coronary artery disease (CAD) and revascularization by percutaneous coronary intervention (PCI) on prognosis in patients undergoing transcatheter aortic valve replacement (TAVR) remain debated. A dismal prognosis in patients undergoing PCI has been associated with elevated baseline SYNTAX score (bSS) and residual SYNTAX score (rSS). The objective was to investigate whether the degree of bSS and rSS impacted ischemic and bleeding events after TAVR.

METHODS

bSS and rSS were calculated in 311 patients admitted for TAVR. The primary outcome was the occurrence of major adverse cardiac events (MACE), a composite endpoint of myocardial infarction, stroke, cardiovascular death, or rehospitalization for heart failure. The occurrence of late major/life-threatening bleeding complications (MLBCs) and each primary endpoint individually were the secondary endpoints.

RESULTS

bSS > 22 was associated with higher occurrence of MACE (p = 0.013). rSS > 8 and bSS > 22 had no impact on overall cardiovascular mortality. rSS > 8 and bSS > 22 were associated with higher rates of myocardial infarction (p = 0.001 and p = 0.004) and late occurrence of MLBCs. Multivariate analysis showed that bSS > 22 (sHR 2.48) and rSS > 8 (sHR 2.35) remained predictors of MLBCs but not of myocardial infarction.

CONCLUSIONS

Incomplete coronary revascularization and CAD burden did not impact overall and cardiac mortality but constitute predictors of late MLBCs in TAVR patients.

Transcatheter aortic valve replacement and percutaneous coronary intervention versus surgical aortic valve replacement and coronary artery bypass grafting in patients with severe aortic stenosis and concomitant coronary artery disease: A systematic review and meta-analysis

OBJECTIVES

We performed a systematic review and meta-analysis to evaluate the early and midterm outcomes of patients who underwent surgical aortic valve replacement (SAVR) and coronary artery bypass grafting (CABG) against patients who had transcatheter aortic valve replacement (TAVR) and percutaneous coronary intervention (PCI).

BACKGROUND

Contemporary guidelines suggest that surgical or percutaneous revascularization of significant coronary artery disease (CAD) in patients with severe aortic stenosis (AS) is a reasonable strategy.

METHODS

We conducted a comprehensive search of Medline and Embase to identify studies comparing a percutaneous transcatheter versus a surgical approach. Random effects meta-analyses using the Mantel-Haenszel method were performed to estimate the effect of percutaneous compared surgical strategies using aggregate data.

RESULTS

Six studies reporting on 1770 participants were included in the meta-analysis. There were no significant differences in effect estimates for early and midterm mortality (OR: 0.78; 95% CI, 0.50-1.20 and OR: 1.09; 95% CI, 0.80-1.49, respectively) or myocardial infarction (OR: 0.52; 95% CI, 0.20-1.33 and OR: 1.34; 95% CI, 0.67-2.65, respectively). No significant difference was shown for peri-procedural stroke (OR: 0.80; 95% CI, 0.35-1.87). A transcatheter approach had a higher rate of major vascular complications (OR: 14.44; 95% CI, 4.42-47.16), but a lower rate of acute kidney injury (OR: 0.41; 95% CI, 0.19-0.91).

CONCLUSION

Our analysis suggests that a percutaneous transcatheter approach confers similar outcomes compared to a surgical approach in patients with severe AS and CAD. However, our findings are based on low quality studies and should serve as hypothesis generating. In the absence of adequately powered studies yielding high level evidence, individualized decision making should be based on surgical risk assessment.

Effect of Concomitant Coronary Artery Bypass Grafting on Outcomes of Ascending Aorta Replacement

BACKGROUND

Ascending aorta replacement can be performed safely in high-volume centers. What remains unknown is whether concomitant coronary revascularization with bypass grafting affects postoperative outcomes.

METHODS

This study retrospectively reviewed a prospectively maintained institutional database for patients who underwent ascending aorta replacement (AAR) during the period from 1997 to 2018. Patients were stratified into AAR alone (AAR) vs AAR and coronary artery bypass graft (AAR with CABG), further categorized as 1 or more than 1 CABG. Aortic dissection and root replacement cases were excluded. The primary end point consisted of major adverse events (MAE), including operative mortality, perioperative myocardial infarction, stroke, need for tracheostomy, and need for dialysis. Secondary end points were operative mortality, each MAE component, and late survival.

RESULTS

A total of 951 patients were included in the analysis; 725 (76.2%) underwent isolated AAR, and 226 (23.8%) underwent AAR with CABG. Operative mortality was similar across the 2 groups (1.8% for AAR with CABG and 0.8% for AAR; P = .40). The unadjusted incidence of MAE was higher in the AAR with CABG group (5.8% vs 1.9%; P = .005).). On multivariable analysis, the performance of 1 CABG (odds ratio [OR], 1.90; 95% confidence interval [CI], 0.67 to 5.33; P = .23) and more than 1 CABG (OR, 2.65; 95% CI, 0.93 to 7.53; P = .07) was not associated with higher rates of MAE. Preoperative pulmonary dysfunction (OR, 2.51; 95% CI, 1.07 to 5.85; P = .03) was the only independent predictor of MAE.

CONCLUSIONS

In patients undergoing concomitant CABG with AAR, the performance of concomitant CABG is not associated with an increased risk of MAE.