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Cammertoni F, Bruno P, Pavone N, Nesta M, Chiariello GA, Grandinetti M, D’Avino S, Sanesi V, D’Errico D, Massetti M. Outcomes of Minimally Invasive Aortic Valve Replacement in Obese Patients: A Propensity-Matched Study. Braz J Cardiovasc Surg 2024; 39:e20230159. [PMID: 38426432 PMCID: PMC10903361 DOI: 10.21470/1678-9741-2023-0159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 08/30/2023] [Indexed: 03/02/2024] Open
Abstract
INTRODUCTION Obese patients are at risk of complications after cardiac surgery. The aim of this study is to investigate safety and efficacy of a minimally invasive approach via upper sternotomy in this setting. METHODS We retrospectively reviewed 203 obese patients who underwent isolated, elective aortic valve replacement between January 2014 and January 2023 - 106 with minimally invasive aortic valve replacement (MIAVR) and 97 with conventional aortic valve replacement (CAVR). To account for baseline differences, a propensity-matching analysis was performed obtaining two balanced groups of 91 patients each. RESULTS The 30-day mortality rate was comparable between groups (1.1% MIAVR vs. 0% CAVR, P=0.99). MIAVR patients had faster extubation than CAVR patients (6 ± 2 vs. 9 ± 2 hours, P<0.01). Continuous positive airway pressure therapy was less common in the MIAVR than in the CAVR group (3.3% vs. 13.2%, P=0.03). Other postoperative complications did not differ significantly. Intensive care unit stay (1.8 ± 1.2 vs. 3.2 ± 1.4 days, P<0.01), but not hospital stay (6.7 ± 2.1 vs. 7.2 ± 1.9 days, P=0.09), was shorter for MIAVR than for CAVR patients. Follow-up survival was comparable (logrank P-value = 0.58). CONCLUSION MIAVR via upper sternotomy has been shown to be a safe and effective option for obese patients. Respiratory outcome was promising with shorter mechanical ventilation time and reduced need for post-extubation support. The length of stay in the intensive care unit was reduced. These advantages might be important for the obese patient to whom minimally invasive surgery should not be denied.
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Affiliation(s)
- Federico Cammertoni
- Department of Cardiovascular Sciences, Cardiac Surgery Unit,
Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Catholic University of the Sacred Heart, Rome, Italy
| | - Piergiorgio Bruno
- Department of Cardiovascular Sciences, Cardiac Surgery Unit,
Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Catholic University of the Sacred Heart, Rome, Italy
| | - Natalia Pavone
- Department of Cardiovascular Sciences, Cardiac Surgery Unit,
Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Marialisa Nesta
- Department of Cardiovascular Sciences, Cardiac Surgery Unit,
Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Giovanni Alfonso Chiariello
- Department of Cardiovascular Sciences, Cardiac Surgery Unit,
Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Catholic University of the Sacred Heart, Rome, Italy
| | - Maria Grandinetti
- Department of Cardiovascular Sciences, Cardiac Surgery Unit,
Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | | | | | - Denise D’Errico
- Department of Cardiovascular Sciences, Perfusion Unit, Fondazione
Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Massimo Massetti
- Department of Cardiovascular Sciences, Cardiac Surgery Unit,
Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Catholic University of the Sacred Heart, Rome, Italy
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Ahmed A, Awad AK, Varghese KS, Mathew J, Huda S, George J, Mathew S, Abdelnasser OA, Awad AK, Mathew DM. Minimally Invasive Versus Transcatheter Aortic Valve Replacement: An Updated Meta-Analysis and Systematic Review. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2023; 18:424-434. [PMID: 37658743 DOI: 10.1177/15569845231197224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Abstract
OBJECTIVE Transcatheter aortic valve replacement (TAVR) has arisen as a viable alternative to surgery. Similarly, minimally invasive surgical aortic valve replacement (mini-SAVR), such as ministernotomy and minithoracotomy, have also gained interest. We conducted a pairwise meta-analysis to further investigate the efficacy of TAVR versus mini-SAVR. METHODS Medical databases were comprehensively searched for studies comparing TAVR with a mini-SAVR modality, defined as minimally invasive aortic surgery, ministernotomy, minithoracotomy, or rapid-deployment or sutureless SAVR. Random-effects meta-analysis was conducted using the generic inverse variance method. Primary outcomes included 30-day mortality, midterm mortality, 30-day stroke, acute kidney injury (AKI), paravalvular leak (PVL), new permanent pacemaker (PPM), new-onset atrial fibrillation, and postintervention mean and peak valve pressure gradients and were pooled as risk ratio (RR), mean difference (MD), or hazard ratio (HR) with 95% confidence interval (CI). RESULTS A total of 5,071 patients (2,505 mini-SAVR vs 2,566 TAVR) from 12 studies were pooled. Compared with TAVR, mini-SAVR showed significantly lower rates of both 30-day (RR = 0.63, 95% CI: 0.42 to 0.96, P = 0.03) and midterm mortality at 4 years of follow-up (HR = 0.76, 95% CI: 0.67 to 0.87, P < 0.001). Furthermore, mini-SAVR was protective against 30-day PVL (RR = 0.07, 95% CI: 0.04 to 0.13, P < 0.001) and new PPM (RR = 0.25, 95% CI: 0.11 to 0.57, P < 0.001). Conversely, TAVR was protective against 30-day AKI (RR = 1.67, 95% CI: 1.20 to 2.32, P = 0.002) and postinterventional mean gradients (MD = 1.65, 95% CI: 0.25 to 3.05, P = 0.02). No difference was observed for 30-day stroke (RR = 0.84, 95% CI: 0.56 to 1.24, P = 0.38), new-onset atrial fibrillation (RR = 1.79, 95% CI: 0.93 to 3.44, P = 0.08), or postinterventional peak gradients (MD = 3.24, 95% CI: -1.10 to 7.59, P = 0.14). CONCLUSIONS Compared with TAVR, mini-SAVR was protective against 30-day and midterm mortality, 30-day PVL, and new permanent pacemaker, while TAVR patients had lower 30-day AKI. Future randomized trials comparing the efficacy of mini-SAVR approaches with TAVR are needed.
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Affiliation(s)
- Adham Ahmed
- City University of New York School of Medicine, NY, USA
| | - Ahmed K Awad
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | | | - Joshua Mathew
- City University of New York School of Medicine, NY, USA
| | - Shayan Huda
- City University of New York School of Medicine, NY, USA
| | - Jerrin George
- City University of New York School of Medicine, NY, USA
| | - Serena Mathew
- City University of New York School of Medicine, NY, USA
| | | | - Ayman K Awad
- Faculty of Medicine, El-Galala University, Suez, Egypt
| | - Dave M Mathew
- City University of New York School of Medicine, NY, USA
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Hsieh M, Kim D, Peng D, Schisler T, Cook RC. Regional Anesthesia With Paravertebral Blockade Is Associated With Improved Outcomes in Patients Undergoing Minithoracotomy Cardiac Surgery. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2023; 18:357-364. [PMID: 37585808 PMCID: PMC10478324 DOI: 10.1177/15569845231190638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
OBJECTIVE Severe postoperative pain has been shown to affect many patients following minimally invasive cardiac surgeries (MICS). Multimodal pain management with regional anesthesia, particularly by delivery of local anesthetics using a paravertebral catheter (PVC), has been shown to reduce pain in operations involving thoracotomy incisions. However, few studies have reported high-quality safety and efficacy outcomes of PVCs following MICS. METHODS Patients who underwent MICS at Vancouver General Hospital between 2016 and 2019 (N = 123) were reviewed for perioperative opioid-narcotic use. Primary outcomes were postoperative opioid use and hospital length of stay (LOS). Statistical analyses were performed using univariate and multivariable regression models to determine independent risk factors. RESULTS A total of 54 patients received routine systemic analgesia (control), 53 patients received a paravertebral catheter (PVC), and 16 patients received another mode of regional analgesia (non-PVC). The mean hospital LOS was significantly different in patients in the PVC group at 5.8 ± 2.0 days versus 8.3 ± 7.1 days in the control and 6.6 ± 2.3 days in the non-PVC group (P = 0.033). The percentage of patients who did not require postoperative oxycodone was significantly higher in the PVC group (48.1%), compared with the control (24.5%) and non-PVC (37.5%; P = 0.043) groups. CONCLUSIONS The administration of regional anesthesia using PVCs was associated with reduced need for opioids and a shorter LOS. The reduction in postoperative opioids may reduce the risk of potential opioid dependency in this population. Future studies should involve randomized controlled trials with systematic evaluation of pain scores to verify current study results.
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Affiliation(s)
- Monica Hsieh
- Department of Anesthesiology, Pharmacology, and Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - Diane Kim
- University of British Columbia, Vancouver, BC, Canada
| | - Defen Peng
- Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, BC, Canada
| | - Travis Schisler
- Department of Anesthesiology, Pharmacology, and Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - Richard C. Cook
- Division of Cardiovascular Surgery, University of British Columbia, Vancouver, BC, Canada
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Mistiaen W. Referral of Patients for Surgical Aortic Valve Replacement before and after Introduction of the Transcatheter Aortic Valve Implantation-Changing Patterns of Preoperative Characteristics and Volume and Postoperative Outcome. J Cardiovasc Dev Dis 2023; 10:223. [PMID: 37233190 PMCID: PMC10219067 DOI: 10.3390/jcdd10050223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 05/15/2023] [Accepted: 05/20/2023] [Indexed: 05/27/2023] Open
Abstract
Transcatheter aortic valve implantation (TAVI) was first presented in 2002 as a case report. Randomized controlled trials showed that TAVI could serve as an alternative for surgical aortic valve replacement (SAVR) in high-risk patients. While the indications for TAVI have expanded into low-risk groups, favorable results of SAVR in elderly showed an increase in application of surgical treatment in this age category. This review aims to explore the effect of the introduction of TAVI in the referral for SAVR with respect to volume, patient profile, early outcome, and use of mechanical heart valves. Results show that the volume of SAVR has increased in several cardiac centers. In a small minority of series, age and risk score of the referred patients also increased. In most of the series, early mortality rate reduced. These findings, however are not universal. Different management policies could be responsible for this observation. Moreover, some patients in whom aortic valve replacement in whatever form is indicated still do not receive adequate treatment. This can be due to several reasons. Heart teams consisting of interventional cardiologists and cardiac surgeons should become a universal approach in order to minimize the number of untreated patients.
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Affiliation(s)
- Wilhelm Mistiaen
- Faculty of Medicine & Health Sciences, University of Antwerp, 2610 Antwerp, Belgium; ; Tel.: +32-38305002
- Department of Health and Sciences, Artesis-Plantijn University of Applied Sciences, 2000 Antwerp, Belgium
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Fong KY, Yap JJL, Chan YH, Ewe SH, Chao VTT, Amanullah MR, Govindasamy SP, Aziz ZA, Tan VH, Ho KW. Network Meta-Analysis Comparing Transcatheter, Minimally Invasive, and Conventional Surgical Aortic Valve Replacement. Am J Cardiol 2023; 195:45-56. [PMID: 37011554 DOI: 10.1016/j.amjcard.2023.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 02/11/2023] [Accepted: 02/14/2023] [Indexed: 04/05/2023]
Abstract
The landscape of aortic valve replacement (AVR) has evolved dramatically over the years, but time-varying outcomes have yet to be comprehensively explored. This study aimed to compare the all-cause mortality among 3 AVR techniques: transcatheter (TAVI), minimally invasive (MIAVR), and conventional AVR (CAVR). An electronic literature search was performed for randomized controlled trials (RCTs) comparing TAVI with CAVR and RCTs or propensity score-matched (PSM) studies comparing MIAVR with CAVR or MIAVR to TAVI. Individual patient data for all-cause mortality were derived from graphical reconstruction of Kaplan-Meier curves. Pairwise comparisons and network meta-analysis were conducted. Sensitivity analyses were performed in the TAVI arm for high risk and low/intermediate risk, as well as patients who underwent transfemoral (TF) TAVI. A total of 27 studies with 16,554 patients were included. In the pairwise comparisons, TAVI showed superior mortality to CAVR until 37.5 months, beyond which there was no significant difference. When restricted to TF TAVI versus CAVR, a consistent mortality benefit favoring TF TAVI was seen (shared frailty hazard ratio [HR] = 0.86, 95% confidence interval [CI] = 0.76 to 0.98, p = 0.024). In the network meta-analysis involving majority PSM data, MIAVR demonstrated significantly lower mortality than TAVI (HR = 0.70, 95% CI = 0.59 to 0.82) and CAVR (HR = 0.69, 95% CI = 0.59 to 0.80); this association remained compared with TF TAVI but with a lower extent of benefit (HR = 0.80, 95% CI = 0.65 to 0.99). In conclusion, the initial short- to medium-term mortality benefit for TAVI over CAVR was attenuated over the longer term. In the subset of patients who underwent TF TAVI, a consistent benefit was found. Among majority PSM data, MIAVR showed improved mortality compared with TAVI and CAVR but less than the TF TAVI subset, which requires validation by robust RCTs.
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Affiliation(s)
- Khi Yung Fong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Yiong Huak Chan
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Victor T T Chao
- Department of Cardiothoracic Surgery, National Heart Center Singapore, Singapore
| | | | | | - Zameer Abdul Aziz
- Department of Cardiothoracic Surgery, National Heart Center Singapore, Singapore
| | - Vern Hsen Tan
- Department of Cardiology, Changi General Hospital, Singapore
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Gempel S, Cohen M, Milian E, Vidret M, Smith A, Jones I, Orozco Y, Kirk-Sanchez N, Cahalin LP. Inspiratory Muscle and Functional Performance of Patients Entering Cardiac Rehabilitation after Cardiac Valve Replacement. J Cardiovasc Dev Dis 2023; 10:142. [PMID: 37103021 PMCID: PMC10141801 DOI: 10.3390/jcdd10040142] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 03/25/2023] [Accepted: 03/26/2023] [Indexed: 03/30/2023] Open
Abstract
Limited research has examined inspiratory muscle performance (IMP) and functional performance (FP) of patients after valve replacement surgery (VRS). The purpose of this study was to examine IMP as well as several measures of FP in patients post-VRS. The study results of 27 patients revealed that patients undergoing transcatheter VRS were significantly (p = 0.01) older than patients undergoing minimally invasive or median sternotomy VRS with the median sternotomy VRS group performing significantly (p < 0.05) better than the transcatheter VRS group in the 6-min walk test, 5x sit-to-stand test, and sustained maximal inspiratory pressure. The 6-min walk test and IMP measures in all groups were significantly (p < 0.001) lower than predicted values. Significant (p < 0.05) relationships were found between IMP and FP with greater IMP being associated with greater FP. Pre-operative and early post-operative rehabilitation may improve IMP and FP post-VRS.
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Affiliation(s)
- Sabine Gempel
- Department of Physical Therapy, University of Miami, Miller School of Medicine, Coral Gables, FL 33146, USA
- Department of Cardiac Rehabilitation, University of Miami Hospital, Miami, FL 33136, USA
| | - Meryl Cohen
- Department of Physical Therapy, University of Miami, Miller School of Medicine, Coral Gables, FL 33146, USA
| | - Eryn Milian
- Department of Physical Therapy, University of Miami, Miller School of Medicine, Coral Gables, FL 33146, USA
| | - Melany Vidret
- UF Health Cardiac & Pulmonary Rehab Gym, Gainesville, FL 32608, USA
| | - Andrew Smith
- San Diego Gulls Hockey Club, Poway, CA 92064, USA
| | - Ian Jones
- Empowerme Wellness in Wickshire, Fort Lauderdale, FL 33309, USA
| | - Yessenia Orozco
- Department of Cardiac Rehabilitation, University of Miami Hospital, Miami, FL 33136, USA
| | - Neva Kirk-Sanchez
- Department of Physical Therapy, University of Miami, Miller School of Medicine, Coral Gables, FL 33146, USA
| | - Lawrence P. Cahalin
- Department of Physical Therapy, University of Miami, Miller School of Medicine, Coral Gables, FL 33146, USA
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Abd Al Jawad M, Mourad F. Measurement of health-related quality of life post aortic valve replacement via minimally invasive incisions. J Cardiothorac Surg 2022; 17:208. [PMID: 36028838 PMCID: PMC9414161 DOI: 10.1186/s13019-022-01964-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 08/14/2022] [Indexed: 11/17/2022] Open
Abstract
Background Minimally invasive aortic surgery is growing in popularity among surgeons. Although many clinical reports have proven both the safety and efficacy from a surgical point of view, there are few data regarding its impact on patients’ quality of life and whether there is a difference between ministernotomy and minithoracotomy from the patient perspective. Methods This prospective, questionnaire-based, nonrandomized study included 189 patients who underwent aortic valve replacement via a minimally invasive incision between May 2014 and December 2020 and completed at least 1 year of follow-up. The study uses the RAND SF 36-Item Health Survey 1.0 to assess and compare health-related quality of life between ministernotomy and minithoracotomy. Results There was a statistically significant improvement in the minithoracotomy group with regard to physical functioning, role limitation due to a physical problem, and social functioning (79.69 ± 20.72, 75.28 ± 26.52, 87.91 ± 16.98) compared to the ministernotomy group (70.31 ± 22.88, 58.59 ± 31.17, 66.15 ± 27.32) with p values (0.0036, 0.0001, < 0.0001), respectively. Conclusions Both minimally invasive aortic valve incisions positively impacted patient quality of life. The minithoracotomy incision showed significant improvements in physical capacity and successful patient re-engagement in daily physical and social activities. This, in turn, positively improved their general health status compared to the 1-year preoperative status. Trial registration: This study was approved by the Research Ethics Committee (REC) at the Faculty of Medicine, Ain Shams University, under the number code (FWA 000017585, FAMSU R 91 /2021).
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Affiliation(s)
- Mohammed Abd Al Jawad
- Department of Cardiothoracic Surgery, Ain Shams University, Abbaseya Square, Cairo, Egypt.
| | - Faisal Mourad
- Department of Cardiothoracic Surgery, Ain Shams University, Abbaseya Square, Cairo, Egypt
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van Bakel PAJ, Ahmed Y, Hou H, Sukul D, Likosky DS, van Herwaarden JA, Patel HJ, Thompson MP. Trends in Medicare Payments for Beneficiaries With Aortic Stenosis. J Am Heart Assoc 2022; 11:e026102. [PMID: 35861820 PMCID: PMC9707827 DOI: 10.1161/jaha.122.026102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background
Aortic stenosis (AS) is the most common form of valvular heart disease with an increasing prevalence. Management of AS has changed dramatically with the introduction of transcatheter aortic valve replacement (AVR). The shift in management of AS, combined with an aging population, may increase the cost of patients with AS in the US health care system.
Methods and Results
We performed a retrospective cohort study, using inpatient, carrier, and outpatient data from a 20% Medicare fee‐for‐service beneficiaries' sample from 2008 to 2019 and included beneficiaries, aged ≥65 years. We identified beneficiaries with a diagnosis of AS and stratified the sample into 3 age groups: 66 to 74, 75 to 84, and ≥85 years. We evaluated the crude and adjusted changes in annual Medicare payments (total and component) per beneficiary. We identified 1 887 340 (1.6%) Medicare beneficiaries diagnosed with AS. The average annual spending for Medicare beneficiaries with AS was $19 241 in 2010 and increased annually by $301 to $23 174 in 2019 (
P
<0.0001). Annual Medicare payments on patients with AS increased from $2 894 995 131 in 2010 to $4 619 077 182 in 2019, a difference of >1.7 billion dollars. Inpatient spending increased 1.1% per year, with the highest increase in patients aged ≥85 years (1.9%). The percentage of beneficiaries undergoing surgical AVR decreased from 3.7% to 1.6%, and annual spending on surgical AVR decreased an average of 7.2% per year. The percentage of beneficiaries undergoing transcatheter AVR increased from 0% in 2010 to 3.8% in 2019, and annual spending for transcatheter AVR increased by 458.7% per year.
Conclusions
Although average annual Medicare spending per beneficiary modestly increased over the study period, the increase in the prevalence of AS and the proportion of beneficiaries undergoing (transcatheter) interventions for AS led to a substantial increase in overall Medicare spending among patients with AS.
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Affiliation(s)
- Pieter A. J. van Bakel
- Department of Cardiac Surgery University of Michigan Ann Arbor MI
- Department of Vascular Surgery University Medical Center Utrecht Utrecht the Netherlands
| | - Yunus Ahmed
- Department of Cardiac Surgery University of Michigan Ann Arbor MI
- Department of Vascular Surgery University Medical Center Utrecht Utrecht the Netherlands
| | - Hechuan Hou
- Department of Cardiac Surgery University of Michigan Ann Arbor MI
| | - Devraj Sukul
- Division of Cardiology, Department of Internal Medicine University of Michigan Ann Arbor MI
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Pozzoli A, Torre T, Toto F, Theologou T, Ferrari E, Demertzis S. Percutaneous Venous Cannulation for Minimally Invasive Cardiac Surgery: The Safest and Effective Technique Described Step-by-Step. Front Surg 2022; 9:828772. [PMID: 35392055 PMCID: PMC8980230 DOI: 10.3389/fsurg.2022.828772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 02/25/2022] [Indexed: 11/13/2022] Open
Abstract
The current cardiac surgical landscape, with the expansion of minimally invasive operations, ECMO, and some interventional therapies, requires a thorough knowledge of peripheral cannulation techniques. In particular, venous cannulation may appear trivial and complication-free, but this does not reflect the reality. A venous cannulation which is not perfectly performed can lead to serious life-threatening complications in several steps. The technique we describe step by step is the current gold standard in terms of safety and efficacy: from the use of ultrasound for ultrasound-guided puncture to safe advancement of super stiff guidewires by means of a sentinel catheter, and concluding with smooth insertion of the venous cannula over the stiff guidewire up to the SVC. Moreover, a list of bailout maneuvers to solve complications is presented along with a report of institutional clinical experience since the adoption of this technique.
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Affiliation(s)
- Alberto Pozzoli
- Division of Cardiac Surgery, Cardiocentro Ticino Institute, EOC, Lugano, Switzerland
- *Correspondence: Alberto Pozzoli
| | - Tiziano Torre
- Division of Cardiac Surgery, Cardiocentro Ticino Institute, EOC, Lugano, Switzerland
| | - Francesca Toto
- Division of Cardiac Surgery, Cardiocentro Ticino Institute, EOC, Lugano, Switzerland
| | - Thomas Theologou
- Division of Cardiac Surgery, Cardiocentro Ticino Institute, EOC, Lugano, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana (USI), Lugano, Switzerland
| | - Enrico Ferrari
- Division of Cardiac Surgery, Cardiocentro Ticino Institute, EOC, Lugano, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana (USI), Lugano, Switzerland
| | - Stefanos Demertzis
- Division of Cardiac Surgery, Cardiocentro Ticino Institute, EOC, Lugano, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana (USI), Lugano, Switzerland
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Minimally invasive approach: is this the future of aortic surgery? Indian J Thorac Cardiovasc Surg 2021; 38:171-182. [PMID: 35463712 PMCID: PMC8980970 DOI: 10.1007/s12055-021-01258-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 08/17/2021] [Accepted: 08/18/2021] [Indexed: 12/03/2022] Open
Abstract
Median sternotomy incision has shown to be a safe and efficacious approach in patients who require thoracic aortic interventions and still represents the gold-standard access. Nevertheless, over the last decade, less invasive techniques have gained wider clinical application in cardiac surgery becoming the first-choice approach to treat heart valve diseases, in experienced centers. The popularization of less invasive techniques coupled with an increased patient demand for less invasive therapies has motivated aortic surgeons to apply minimally invasive approaches to more challenging procedures, such as aortic root replacement and arch repair. However, technical demands and the paucity of available clinical data have still limited the widespread adoption of minimally invasive thoracic aortic interventions. This review aimed to assess and comment on the surgical techniques and the current evidence on mini thoracic aortic surgery.
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Maranta F, Cianfanelli L, Grippo R, Alfieri O, Cianflone D, Imazio M. Post-pericardiotomy syndrome: insights into neglected postoperative issues. Eur J Cardiothorac Surg 2021; 61:505-514. [PMID: 34672331 DOI: 10.1093/ejcts/ezab449] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 07/01/2021] [Accepted: 07/27/2021] [Indexed: 12/20/2022] Open
Abstract
ABSTRACT OBJECTIVES Pericardial effusion is a common complication after cardiac surgery, both isolated and in post-pericardiotomy syndrome (PPS), a condition in which pleuropericardial damage triggers both a local and a systemic inflammatory/immune response. The goal of this review was to present a complete picture of PPS and pericardial complications after cardiac surgery, highlighting available evidence and gaps in knowledge. METHODS A literature review was performed that included relevant prospective and retrospective studies on the subject. RESULTS PPS occurs frequently and is associated with elevated morbidity and significantly increased hospital stays and costs. Nevertheless, PPS is often underestimated in clinical practice, and knowledge of its pathogenesis and epidemiology is limited. Several anti-inflammatory drugs have been investigated for treatment but with conflicting evidence. Colchicine demonstrated encouraging results for prevention. CONCLUSIONS Wider adoption of standardized diagnostic criteria to correctly define PPS and start early treatment is needed. Larger studies are necessary to better identify high-risk patients who might benefit from preventive strategies.
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Affiliation(s)
- Francesco Maranta
- Cardiac Rehabilitation Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Lorenzo Cianfanelli
- Cardiac Rehabilitation Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Rocco Grippo
- Cardiac Rehabilitation Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Ottavio Alfieri
- Cardiac Surgery Department, San Raffaele Scientific Institute, Milan, Italy
| | - Domenico Cianflone
- Cardiac Rehabilitation Unit, San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Massimo Imazio
- Cardiology, Cardiothoracic Department, University Hospital "Santa Maria della Misericordia", Udine, Italy
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Poschner T, Werner P, Kocher A, Laufer G, Musumeci F, Andreas M, Russo M. The JenaValve pericardial transcatheter aortic valve replacement system to treat aortic valve disease. Future Cardiol 2021; 18:101-113. [PMID: 34647465 DOI: 10.2217/fca-2021-0065] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Transcatheter aortic valve replacement is a valuable alternative technique to surgery and the spectrum of therapy continues to evolve. The JenaValve Pericaridal transcatheter aortic valve replacement System allows prosthesis fixation in a native, noncalcified aortic annulus with a unique paper clip-like anchorage mechanism. The low rate of paravalvular leakage and permanent pacemaker implantation emphasizes the further widespread use of the JenaValve - despite the limited data available. In May 2021, a CE mark for the transfemoral implantation in both aortic regurgitation and aortic stenosis was granted. However, no data have been published so far. The ongoing ALIGN trials are expected to provide the pending long-term data.
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Affiliation(s)
- Thomas Poschner
- Department of Cardiac Surgery, Medical University Vienna, Vienna, Austria
| | - Paul Werner
- Department of Cardiac Surgery, Medical University Vienna, Vienna, Austria
| | - Alfred Kocher
- Department of Cardiac Surgery, Medical University Vienna, Vienna, Austria
| | - Guenther Laufer
- Department of Cardiac Surgery, Medical University Vienna, Vienna, Austria
| | - Francesco Musumeci
- Department of Cardiac Surgery & Heart Transplantation, San Camillo Forlanini Hospital of Rome, Rome, Italy
| | - Martin Andreas
- Department of Cardiac Surgery, Medical University Vienna, Vienna, Austria
| | - Marco Russo
- Department of Cardiac Surgery, Medical University Vienna, Vienna, Austria.,Department of Cardiac Surgery & Heart Transplantation, San Camillo Forlanini Hospital of Rome, Rome, Italy
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13
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Berretta P, Cefarelli M, Montecchiani L, Alfonsi J, Vessella W, Zahedi MH, Carozza R, Munch C, Di Eusanio M. Minimally invasive versus standard extracorporeal circulation system in minimally invasive aortic valve surgery: a propensity score-matched study. Eur J Cardiothorac Surg 2021; 57:717-723. [PMID: 31746980 DOI: 10.1093/ejcts/ezz318] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 10/15/2019] [Accepted: 10/21/2019] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVES The impact of minimally invasive extracorporeal circulation (MiECC) systems on the clinical outcomes of patients undergoing minimally invasive aortic valve replacement (MI-AVR) has still to be defined. This study compared in-hospital and 1 year outcomes of MI-AVR interventions using MiECC systems versus conventional extracorporeal circulation (c-ECC). METHODS Data from 288 consecutive patients undergoing primary isolated MI-AVR using MiECC (n = 102) or c-ECC (n = 186) were prospectively collected. Treatment selection bias was addressed by the use of propensity score matching (MiECC vs c-ECC). After propensity score matching, 2 groups of 93 patients each were created. RESULTS Compared with c-ECC, MiECC was associated with a higher rate of autologous priming (82.4% vs 0%; P < 0.001) and a greater nadir haemoglobin (9.3 vs 8.7 g/dl; P = 0.021) level and haematocrit (27.9% vs 26.4%; P = 0.023). Patients who had MiECC were more likely to receive ultra-fast-track management (60.8% vs 26.9%; P < 0.001) and less likely to receive blood transfusions (32.7% vs 44%; P = 0.04). The in-hospital mortality rate was 1.1% in the MiECC group and 0% in the c-ECC group (P = 0.5). Those in the MiECC group had reduced rates of bleeding requiring revision (0% vs 5.3%; P = 0.031) and postoperative atrial fibrillation (AF) (30.1% vs 44.1%; P = 0.034). The 1-year survival rate was 96.8% and 97.5% for MiECC and c-ECC patients, respectively (P = 0.4). CONCLUSIONS MiECC systems were a safe and effective tool in patients who had MI-AVR. Compared with c-ECC, MiECC promotes ultra-fast-track management and provides better clinical outcomes as regards bleeding, blood transfusions and postoperative AF. Thus, by reducing surgical injury and promoting faster recovery, MiECC may further validate MI-AVR interventions.
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Affiliation(s)
- Paolo Berretta
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy
| | - Mariano Cefarelli
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy
| | - Luca Montecchiani
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy
| | - Jacopo Alfonsi
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy
| | - Walter Vessella
- Cardiac Anaesthesia and Intensive Care Unit, Lancisi Cardiovascular Center, Ancona, Italy
| | | | - Roberto Carozza
- Perfusion Unit, Lancisi Cardiovascular Center, Ancona, Italy
| | - Christopher Munch
- Cardiac Anaesthesia and Intensive Care Unit, Lancisi Cardiovascular Center, Ancona, Italy
| | - Marco Di Eusanio
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy
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14
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Cammertoni F, Bruno P, Pavone N, Farina P, Mazza A, Iafrancesco M, Nesta M, Chiariello GA, Spalletta C, Cavaliere F, Calabrese M, D'Angelo GA, Sanesi V, Conti F, D'Errico D, Massetti M. Influence of cardiopulmonary bypass set-up and management on clinical outcomes after minimally invasive aortic valve surgery. Perfusion 2021; 36:679-687. [PMID: 34080484 DOI: 10.1177/02676591211023301] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Minimally invasive aortic valve replacement (MIAVR) requires changes in cannulation strategy and cardiopulmonary bypass (CPB) management when compared to the conventional approach (CAVR). We aimed at evaluating if these differences could influence perfusion-related quality parameters and impair postoperative outcomes. METHODS Overall, 339 consecutive patients underwent MIAVR or CAVR between 2014 and 2020 and were analyzed retrospectively. To account for baseline differences, a propensity-matching analysis was performed, obtaining two groups of 97 patients each. RESULTS MIAVR group had longer CPB time [107 (95-120) vs 95 (86-105) min, p = .003] than CAVR group. Of note, average pump flow rate index [2.4 (2.2-2.5) vs 2.7 (2.4-2.8) l/min/m2, p = .004] was lower in the MIAVR group. Mean arterial pressure was 73 = 9 mmHg vs 62 = 11 mmHg for the MIAVR and CAVR group, respectively (p < .001). Cell-salvaged blood was most commonly used in the MIAVR group (25.8% vs 11.3%, p = .02). Finally, CPB temperature was 32.8°C (32.1-34.8) for MIAVR group vs 34.9°C (33.2-36.1) for the CAVR group (p = .02). Postoperative complications were similar between groups. CONCLUSIONS In conclusion, despite differences in CPB parameters in patients undergoing CAVR and MIAVR, the incidences of adverse outcomes were similar. However, compared to CAVR, MIAVR was associated with shorter durations of mechanical ventilation and hospital stay as well as less transfusion of blood products.
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Affiliation(s)
- Federico Cammertoni
- Department of Cardiovascular Sciences, Cardiac Surgery Unit, Fondazione Policlinico Universitario "A.Gemelli" IRCCS, Rome, Italy.,Catholic University of the Sacred Heart, Rome, Italy
| | - Piergiorgio Bruno
- Department of Cardiovascular Sciences, Cardiac Surgery Unit, Fondazione Policlinico Universitario "A.Gemelli" IRCCS, Rome, Italy.,Catholic University of the Sacred Heart, Rome, Italy
| | - Natalia Pavone
- Department of Cardiovascular Sciences, Cardiac Surgery Unit, Fondazione Policlinico Universitario "A.Gemelli" IRCCS, Rome, Italy
| | - Piero Farina
- Department of Cardiovascular Sciences, Cardiac Surgery Unit, Fondazione Policlinico Universitario "A.Gemelli" IRCCS, Rome, Italy
| | - Andrea Mazza
- Department of Cardiovascular Sciences, Cardiac Surgery Unit, Fondazione Policlinico Universitario "A.Gemelli" IRCCS, Rome, Italy
| | - Mauro Iafrancesco
- Department of Cardiovascular Sciences, Cardiac Surgery Unit, Fondazione Policlinico Universitario "A.Gemelli" IRCCS, Rome, Italy
| | - Marialisa Nesta
- Department of Cardiovascular Sciences, Cardiac Surgery Unit, Fondazione Policlinico Universitario "A.Gemelli" IRCCS, Rome, Italy
| | - Giovanni A Chiariello
- Department of Cardiovascular Sciences, Cardiac Surgery Unit, Fondazione Policlinico Universitario "A.Gemelli" IRCCS, Rome, Italy.,Catholic University of the Sacred Heart, Rome, Italy
| | - Claudio Spalletta
- Department of Cardiovascular Sciences, Cardiac Surgery Unit, Fondazione Policlinico Universitario "A.Gemelli" IRCCS, Rome, Italy
| | - Franco Cavaliere
- Catholic University of the Sacred Heart, Rome, Italy.,Department of Cardiovascular Sciences, Intensive Care Unit, Fondazione Policlinico Universitario "A.Gemelli" IRCCS, Rome, Italy
| | - Maria Calabrese
- Department of Cardiovascular Sciences, Intensive Care Unit, Fondazione Policlinico Universitario "A.Gemelli" IRCCS, Rome, Italy
| | | | | | - Francesco Conti
- Department of Cardiovascular Sciences, Perfusion Unit, Fondazione Policlinico Universitario "A.Gemelli" IRCCS, Rome, Italy
| | - Denise D'Errico
- Department of Cardiovascular Sciences, Perfusion Unit, Fondazione Policlinico Universitario "A.Gemelli" IRCCS, Rome, Italy
| | - Massimo Massetti
- Department of Cardiovascular Sciences, Cardiac Surgery Unit, Fondazione Policlinico Universitario "A.Gemelli" IRCCS, Rome, Italy.,Catholic University of the Sacred Heart, Rome, Italy
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15
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Alkhouli M, Alqahtani F, Ziada KM, Aljohani S, Holmes DR, Mathew V. Contemporary trends in the management of aortic stenosis in the USA. Eur Heart J 2021; 41:921-928. [PMID: 31408096 DOI: 10.1093/eurheartj/ehz568] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 03/31/2019] [Accepted: 07/25/2019] [Indexed: 01/01/2023] Open
Abstract
AIMS To assess the contemporary trends in aortic stenosis (AS) interventions in the USA before and after the introduction of transcatheter aortic valve implantation (TAVI). METHODS AND RESULTS We utilized the National-Inpatient-Sample to assess temporal trends in the incidence, cost, and outcomes of AS interventions between 1 January 2003 and 31 December 2016. During the study's period, AS interventions increased from 96 to 137 per 100 000 individuals > 60 years old, P < 0.001. In-hospital expenditure on AS interventions increased from $2.28 billion in 2003 to $4.33 in 2016 P < 0.001. Among patients who underwent aortic valve replacement, the proportion of TAVI increased from 11.9% in 2012 to 43.2% in 2016 (P < 0.001). Males and Hispanics had lower proportions of TAVI compared with females and White patients. Adjusted in-hospital mortality of isolated SAVR decreased from 5.4% in 2003 to 3.3% in 2016 (P < 0.001), whereas adjusted in-hospital mortality of TAVI decreased from 4.7% in 2012 to 2.2% in 2016, P < 0.001. The incidence of new dialysis, permanent pacemaker implantation, and blood transfusion decreased after both TAVI and SAVR between 2012 and 2016. However, the rate of post-operative stroke did not significantly decrease. Length of stay and cost of hospitalization decreased after both SAVR and TAVI, although the later remained higher with TAVI. Rates of non-home discharge decreased over time after TAVI but remained stable after isolated SAVR. CONCLUSION This nationwide survey documents the increasing incidence of AS interventions, the rising cost of modern AS care, and the paradigm shift in aortic valve replacement practice in the USA.
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Affiliation(s)
- Mohamad Alkhouli
- Division of Cardiology, Department of Medicine, West Virginia University, 1 Medical Drive, Morgantown, WV 26505, USA.,Department of Cardiology, Mayo Clinic School of Medicine, 200 First St. SW Rochester, MN 55905, USA
| | - Fahad Alqahtani
- Division of Cardiology, Department of Medicine, West Virginia University, 1 Medical Drive, Morgantown, WV 26505, USA
| | - Khaled M Ziada
- Division of Cardiovascular Medicine, University of Kentucky, 326 C.T. Wethington Bldg, 900 S Limestone St, Lexington, KY 40536, USA
| | - Sami Aljohani
- Division of Cardiology, Department of Medicine, West Virginia University, 1 Medical Drive, Morgantown, WV 26505, USA
| | - David R Holmes
- Department of Cardiology, Mayo Clinic School of Medicine, 200 First St. SW Rochester, MN 55905, USA
| | - Verghese Mathew
- Division of Cardiology, Loyola University Chicago Stritch School of Medicine, 2160 S 1st Ave, Maywood, IL 60153, USA
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16
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Ghoreishi M, Thourani VH, Badhwar V, Massad M, Svensson L, Taylor BS, Pasrija C, Gammie JS, Jacobs JP, Cox M, Grau-Sepulveda M, Brennan M, Griffith BP, Milliken JC, Abdelhady K, Kon Z. Less-Invasive Aortic Valve Replacement: Trends and Outcomes From The Society of Thoracic Surgeons Database. Ann Thorac Surg 2021; 111:1216-1223. [DOI: 10.1016/j.athoracsur.2020.06.039] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 06/01/2020] [Accepted: 06/08/2020] [Indexed: 10/23/2022]
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17
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Doyle MP, Woldendorp K, Ng M, Vallely MP, Wilson MK, Yan TD, Bannon PG. Minimally-invasive versus transcatheter aortic valve implantation: systematic review with meta-analysis of propensity-matched studies. J Thorac Dis 2021; 13:1671-1683. [PMID: 33841958 PMCID: PMC8024828 DOI: 10.21037/jtd-20-2233] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Minimally invasive aortic valve replacement (MiAVR) and transcatheter aortic valve implantation (TAVI) provide aortic valve replacement (AVR) by less invasive methods than conventional surgical AVR, by avoiding complete sternotomy. This study directly compares and analyses the available evidence for early outcomes between these two AVR methods. Methods Electronic databases were searched from inception until August 2019 for studies comparing MiAVR to TAVI, according to predefined search criteria. Propensity-matched studies with sufficient data were included in a meta-analysis. Results Eight studies with 9,744 patients were included in the quantitative analysis. Analysis of risk-matched patients showed no difference in early mortality (RR 0.76, 95% CI, 0.37–1.54, P=0.44). MiAVR had a signal towards lower rate of postoperative stroke, although this did not reach statistical significance (OR 0.42, 95% CI, 0.13–1.29, P=0.13). MiAVR had significantly lower rates of new pacemaker (PPM) requirement (OR 0.29, 95% CI, 0.16–0.52, P<0.0001) and postoperative aortic insufficiency (AI) or paravalvular leak (PVL) (OR 0.05, 95% CI, 0.01–0.20, P<0.0001) compared to TAVI, (OR 0.42, 95% CI, 0.13–1.29, P=0.13), while acute kidney injury (AKI) was higher in MiAVR compared to TAVI (11.1% vs. 5.2%, OR 2.28, 95% CI, 1.25–4.16, P=0.007). Conclusions In patients of equivalent surgical risk scores, MiAVR may be performed with lower rates of postoperative PPM requirement and AI/PVL, higher rates of AKI and no statistical difference in postoperative stroke or short-term mortality, compared to TAVI. Further prospective trials are needed to validate these results.
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Affiliation(s)
- Mathew P Doyle
- The Royal Prince Alfred Hospital, Sydney, Australia.,The Baird Institute of Applied Heart and Lung Surgical Research, Sydney, Australia.,University of Wollongong School of Medicine, Keiraville, Australia
| | - Kei Woldendorp
- The Royal Prince Alfred Hospital, Sydney, Australia.,The Baird Institute of Applied Heart and Lung Surgical Research, Sydney, Australia.,The University of Sydney Medical School, Camperdown, Australia
| | - Martin Ng
- The Royal Prince Alfred Hospital, Sydney, Australia.,The University of Sydney Medical School, Camperdown, Australia
| | | | - Michael K Wilson
- Macquarie University Hospital, Macquarie University, Sydney, Australia
| | - Tristan D Yan
- The Royal Prince Alfred Hospital, Sydney, Australia.,Macquarie University Hospital, Macquarie University, Sydney, Australia.,Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
| | - Paul G Bannon
- The Royal Prince Alfred Hospital, Sydney, Australia.,The Baird Institute of Applied Heart and Lung Surgical Research, Sydney, Australia.,The University of Sydney Medical School, Camperdown, Australia
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18
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Sayed A, Almotawally S, Wilson K, Munir M, Bendary A, Ramzy A, Hirji S, Ibrahim Abushouk A. Minimally invasive surgery versus transcatheter aortic valve replacement: a systematic review and meta-analysis. Open Heart 2021; 8:openhrt-2020-001535. [PMID: 33455914 PMCID: PMC7813322 DOI: 10.1136/openhrt-2020-001535] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 12/23/2020] [Accepted: 12/23/2020] [Indexed: 02/06/2023] Open
Abstract
Transcatheter aortic valve replacement (TAVR) has recently been approved for use in patients who are at intermediate and low surgical risk. Moreover, recent years have witnessed a renewed interest in minimally invasive aortic valve replacement (miAVR). The present meta-analysis compared the outcomes of TAVR and miAVR in the management of aortic stenosis (AS). We conducted an electronic search across six databases from 2002 (TAVR inception) to December 2019. Data from relevant studies regarding the clinical and length of hospitalisation outcomes were extracted and analysed using R software. We identified a total of 11 cohort studies, of which seven were matched/propensity matched. Our analysis demonstrated higher rates of midterm mortality (≥1 year) with TAVR (risk ratio (RR): 1.93, 95% CI: 1.16 to 3.22), but no significant differences with respect to 1 month mortality (RR: 1.00, 95% CI: 0.55 to 1.81), stroke (RR: 1.08, 95% CI: 0.40 to 2.87) and bleeding (RR: 1.45, 95% CI: 0.56 to 3.75) rates. Patients undergoing TAVR were more likely to experience paravalvular leakage (RR: 14.89, 95% CI: 6.89 to 32.16), yet less likely to suffer acute kidney injury (RR: 0.38, 95% CI: 0.21 to 0.69) compared with miAVR. The duration of hospitalisation was significantly longer in the miAVR group (mean difference: 1.92 (0.61 to 3.24)). Grading of Recommendations Assessment, Development and Evaluation assessment revealed ≤moderate quality of evidence in all outcomes. TAVR was associated with lower acute kidney injury rate and shorter length of hospitalisation, yet higher risks of midterm mortality and paravalvular leakage. Given the increasing adoption of both techniques, there is an urgent need for head-to-head randomised trials with adequate follow-up periods.
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Affiliation(s)
- Ahmed Sayed
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | | | - Karim Wilson
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Malak Munir
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Ahmed Bendary
- Faculty of Medicine, Cardiology, Benha University, Benha, Egypt
| | - Ahmed Ramzy
- Faculty of Medicine, Cardiology, Benha University, Benha, Egypt
| | - Sameer Hirji
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
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19
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Abjigitova D, Veen KM, Mokhles MM, Bekkers JA, Oei FB, Bogers AJ. Initial clinical experience with minimally invasive surgical aortic valve replacement. THE JOURNAL OF CARDIOVASCULAR SURGERY 2020; 62:268-277. [PMID: 33302611 DOI: 10.23736/s0021-9509.20.11463-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The ministernotomy approach is increasingly used in aortic valve surgery. However, the advantages are still a matter of discussion. The aim of this study was to compare the postoperative outcome in patients undergoing elective aortic valve operation, either through mini-sternotomy or conventional sternotomy. METHODS We included 317 patients who were treated for their aortic valve, 63 patients underwent a minimally invasive aortic valve replacement (mini-AVR) and 254 patients underwent a full-sternotomy AVR. Patients with endocarditis, those who underwent previous cardiac surgery and those who required a concomitant procedure were excluded from the analysis. The method of matching weights according to propensity score was used to adjust for differences between the two treatment groups, and outcomes were compared. RESULTS The mediastinal drainage was significantly lower at 6, 24 hours and total after mini-AVR procedure than after full-sternotomy AVR (median: 373 vs. 499 mL, P<0.001). However, the number of patients receiving packed red blood cells transfusion was similar. Overall, the hospital mortality was lower in the full-sternotomy group, 0% vs. 3.2%, P=0.039. No difference was found in the median hospital length of stay, perioperative myocardial infarction, postoperative incidence of new pacemaker implantation, stroke, prolonged mechanical ventilation and mediastinitis. No patients in the mini-AVR group experienced paravalvular leakage. Midterm survival resulted in no difference between the treatment groups at 4-year (90.5% vs. 95.2%), P=0.75. CONCLUSIONS Although the minimally invasive surgery for AVR may increasingly be applied, our initial experience calls for a careful approach of adapting this procedure.
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Affiliation(s)
- Djamila Abjigitova
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Kevin M Veen
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Mostafa M Mokhles
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Jos A Bekkers
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Frans B Oei
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Ad J Bogers
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands -
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20
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Berretta P, Andreas M, Carrel TP, Solinas M, Teoh K, Fischlein T, Santarpino G, Folliguet T, Villa E, Meuris B, Mignosa C, Martinelli G, Misfeld M, Glauber M, Kappert U, Savini C, Shrestha M, Phan K, Albertini A, Yan T, Di Eusanio M. Minimally invasive aortic valve replacement with sutureless and rapid deployment valves: a report from an international registry (Sutureless and Rapid Deployment International Registry)†. Eur J Cardiothorac Surg 2020; 56:793-799. [PMID: 30820549 DOI: 10.1093/ejcts/ezz055] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 02/01/2019] [Accepted: 02/04/2019] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES The impact of sutureless and rapid deployment (SURD) valves on the clinical outcomes of patients undergoing minimally invasive aortic valve replacement (MI-AVR) has still to be defined. The aim of this study was to assess clinical characteristics and in-hospital results of patients receiving SURD-AVR through less invasive approaches in the large population of the Sutureless and Rapid Deployment International Registry (SURD-IR). METHODS Of the 1935 patients who received primary isolated SURD-AVR between 2009 and 2018, a total of 1418 (73.3%) underwent MI interventions and were included in this analysis. SURD-AVR was performed using upper ministernotomy in 56.4% (n = 800) of cases and anterior right thoracotomy in 43.6% (n = 618). Perceval S was implanted in 1011 (71.3%) patients and Edwards Intuity or Intuity Elite in 407 (28.7%) patients. RESULTS Overall in-hospital mortality and stroke rates were 1.7% and 2%, respectively. A definitive pacemaker implantation was reported in 9% of cases and significantly decreased over the observational period, from 20.6% to 5.6% (P = 0.002). The Perceval valve was associated with shorter operative times and was more frequently implanted in patients receiving anterior right thoracotomy incision. The Intuity valve was preferred in younger patients and revealed superior postoperative haemodynamic results. CONCLUSIONS SURD-AVR was largely performed through less invasive approaches and can be considered as a primary indication in MI surgery. In the SURD-IR cohort, MI SURD-AVR using both Perceval and Intuity valves appeared a safe and reproducible procedure associated with promising early results.
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Affiliation(s)
- Paolo Berretta
- Cardiac Surgery Unit, Ospedali Riuniti, Polytechnic University of Marche, Ancona, Italy
| | - Martin Andreas
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | | | | | - Kevin Teoh
- Southlake Regional Health Centre, Newmarket, ON, Canada
| | - Theodor Fischlein
- Cardiovascular Center, Paracelsus Medical University, Nuremberg, Germany
| | | | | | | | - Bart Meuris
- Gasthuisberg, Cardiale Heelkunde, Leuven, Belgium
| | - Carmelo Mignosa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation IRCCS-ISMETT, Palermo, Italy
| | | | | | - Mattia Glauber
- Istituto Clinico Sant'Ambrogio, Clinical & Research Hospitals IRCCS Gruppo San Donato, Milan, Italy
| | - Utz Kappert
- Dresden Heart Center, Department of Cardiac Surgery, Dresden University Hospital, Dresden, Germany
| | - Carlo Savini
- Cardiac Surgery Department, Sant'Orsola Malpighi Hospital, University of Bologna, Bologna, Italy
| | | | | | | | - Tristan Yan
- The Collaborative Research (CORE) Group.,Macquarie University, Sydney, NSW, Australia
| | - Marco Di Eusanio
- The Collaborative Research (CORE) Group.,Cardiac Surgery Unit, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ospedali Riuniti, Ancona, Italy
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21
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Akintoye E, Ando T, Sandio A, Adegbala O, Salih M, Zubairu J, Oseni A, Sistla P, Alqasrawi M, Egbe A, Mentias A, Afonso L, Briasoulis A, Panaich S, Desai MY. Aortic Valve Replacement for Severe Aortic Stenosis Before and During the Era of Transcatheter Aortic Valve Implantation. Am J Cardiol 2020; 126:73-81. [PMID: 32336533 DOI: 10.1016/j.amjcard.2020.03.038] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Revised: 03/27/2020] [Accepted: 03/27/2020] [Indexed: 12/20/2022]
Abstract
Recent positive results of transcatheter aortic valve replacement (TAVI) in clinical trials have sparked debate on whether TAVI should be first line for all patients with aortic stenosis. However, limited evidence exists on the clinical impact of TAVI on a national level. Using the national inpatient sample (NIS) of hospital discharges in the United States from 2001 to 2016, we evaluated the rate of AVR and associated in-hospital outcomes in pre-TAVI and TAVI era. Hierarchical mixed effect modeling was used to assess for trend and calculate risk adjusted estimates. Annual volume of AVR increased from 49,357 in 2001 to 100,050 in 2016 (103% increase). Compared with the pre-TAVI era, mean annual change in volume of AVR was higher in the TAVI era (+2.9% vs +9.4%, respectively, p <0.001). In contrast, rate of in-hospital mortality decreased from 5.4% in 2001 to 2.7% in 2016 (50% decrease). Compared with the pre-TAVI era, magnitude of mean annual change in mortality was higher in TAVI era (-4.0% vs -6.7%, respectively, p = 0.04). Unlike SAVR for which risk-adjusted rate for most outcomes seems to have plateaued, TAVI demonstrated significant improvement from 2012 to 2016 for mortality (4.6% to 1.8%), acute kidney injury (15.1% to 2.6%) and nonroutine home discharge (63.6% to 44.6%). However, no significant change in the rate of stroke (2.4% to 2.1%) and pacemaker implantation remained high (8.1% to 9.4%). Lastly, median length of stay was shorter for TAVI compared with isolated SAVR (3 vs 8 days, respectively). In conclusion, the adoption of TAVI has led to increase in volume of AVR for severe aortic stenosis in the United States with favorable short-term outcome.
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Affiliation(s)
- Emmanuel Akintoye
- Division of Cardiovascular Medicine, University of Iowa Hospital and Clinics, Iowa City, Iowa.
| | - Tomo Ando
- Division of Cardiology, Columbia University Medical Center, New York, New York
| | - Aubin Sandio
- Division of Cardiology, Wayne State University/Detroit Medical Center, Detroit, Michigan
| | - Oluwole Adegbala
- Division of Cardiology, Wayne State University/Detroit Medical Center, Detroit, Michigan
| | - Mohamed Salih
- Division of Cardiovascular Medicine, University of Iowa Hospital and Clinics, Iowa City, Iowa
| | - Josiah Zubairu
- Division of Cardiovascular Medicine, University of Iowa Hospital and Clinics, Iowa City, Iowa
| | - Abdullahi Oseni
- Division of Cardiovascular Medicine, University of Iowa Hospital and Clinics, Iowa City, Iowa
| | - Phanicharan Sistla
- Division of Cardiovascular Medicine, University of Iowa Hospital and Clinics, Iowa City, Iowa
| | - Musab Alqasrawi
- Division of Cardiovascular Medicine, University of Iowa Hospital and Clinics, Iowa City, Iowa
| | - Alexander Egbe
- Division of Cardiology, Mayo Clinic, Rochester, Minnesota
| | - Amgad Mentias
- Division of Cardiovascular Medicine, University of Iowa Hospital and Clinics, Iowa City, Iowa
| | - Luis Afonso
- Division of Cardiology, Wayne State University/Detroit Medical Center, Detroit, Michigan
| | - Alexandros Briasoulis
- Division of Cardiovascular Medicine, University of Iowa Hospital and Clinics, Iowa City, Iowa
| | - Sidakpal Panaich
- Division of Cardiovascular Medicine, University of Iowa Hospital and Clinics, Iowa City, Iowa
| | - Milind Y Desai
- Center for Heart Valve Disease, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
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22
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Di Eusanio M, Berretta P. The sutureless and rapid-deployment aortic valve replacement international registry: lessons learned from more than 4,500 patients. Ann Cardiothorac Surg 2020; 9:289-297. [PMID: 32832410 PMCID: PMC7415696 DOI: 10.21037/acs-2020-surd-21] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 04/28/2020] [Indexed: 01/04/2023]
Abstract
The treatment options for patients with aortic valve disease have considerably expanded over the last decade. The remarkable advances in catheter-based technology, the popularizing of minimally invasive (MI) surgery, and the introduction of new valve technologies, such as sutureless and rapid-deployment (SURD) valves have led to a paradigm shift in the management of aortic valve pathologies. Yet, given their recent introduction, the current evidence on sutureless and rapid-deployment aortic valve replacement (SURD-AVR) has been limited thus far. The Sutureless and Rapid-Deployment Aortic Valve Replacement International Registry (SURD-IR) was established in 2015 by a consortium of 18 research centers to assess safety, efficacy, short- and long-term outcomes of SURD-AVR interventions. The present keynote lecture aims to assess and comment on the real-world evidence for SURD-AVR surgery generated from the SURD-IR.
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Affiliation(s)
- Marco Di Eusanio
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy
| | - Paolo Berretta
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy
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Berretta P, Arzt S, Fiore A, Carrel TP, Misfeld M, Teoh K, Villa E, Albertini A, Fischlein T, Martinelli G, Shrestha M, Savini C, Miceli A, Santarpino G, Andreas M, Mignosa C, Phan K, Meuris B, Solinas M, Yan T, Di Eusanio M. Current trends of sutureless and rapid deployment valves: an 11-year experience from the Sutureless and Rapid Deployment International Registry. Eur J Cardiothorac Surg 2020; 58:1054-1062. [DOI: 10.1093/ejcts/ezaa144] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 02/28/2020] [Accepted: 03/18/2020] [Indexed: 11/14/2022] Open
Abstract
Abstract
OBJECTIVES
Current evidence on sutureless and rapid deployment aortic valve replacement (SURD-AVR) is limited and does not allow for the assessment of the clinical impact and the evolution of procedural and clinical outcomes of this new valve technology. The Sutureless and Rapid Deployment International Registry (SURD-IR) represents a unique opportunity to evaluate the current trends and outcomes of SURD-AVR interventions.
METHODS
Data from 3682 patients enrolled between 2007 and 2018 were analysed. Patients were divided according to the date of surgery into 6 equal groups and by the type of intervention: isolated SURD-AVR (n = 2472) and combined SURD-AVR (n = 1086).
RESULTS
Across the 11-year study period, significant changes occurred in patient characteristics including a decrease in age and in estimated surgical risk. Less invasive approaches for isolated SURD-AVR increased considerably from 49.4% to 85.5%. The overall in-hospital mortality rate was 1.6% and 3.9% in isolated and combined procedures, respectively, with no change over time. The rate of perioperative stroke decreased significantly (from 4% to 0.5%), as did the rates of postoperative pacemaker implantation (from 12.8% to 5.9%) and aortic regurgitation (from 17.8% to 2.7%).
CONCLUSIONS
The present study provides a comprehensive analysis of the current trends and results of SURD-AVR interventions. The most notable changes over time were the increasing implantation of SURD valves in a younger population, with more frequent utilization of less invasive techniques. SURD-AVR demonstrated remarkable improvements in clinical outcomes with a significant reduction in the rates of stroke, pacemaker implantation and postoperative aortic regurgitation.
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Affiliation(s)
- Paolo Berretta
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ospedali Riuniti, Ancona, Italy
| | - Sebastian Arzt
- Department of Cardiac Surgery, University Heart Centre Dresden, Dresden, Germany
| | - Antonio Fiore
- Henri Mondor Hospital, University of Paris, Paris, France
| | - Thierry P Carrel
- Department of Cardiovascular Surgery, University Hospital, University of Bern, Bern, Switzerland
| | - Martin Misfeld
- University Clinic for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Kevin Teoh
- Southlake Regional Health Centre, Newmarket, ON, Canada
| | | | - Alberto Albertini
- Cardiovascular Surgery Unit, Maria Cecilia Hospital GVM Care & Research, Cotignola, Italy
| | - Theodor Fischlein
- Cardiovascular Center, Paracelsus Medical University, Nuremberg, Germany
| | | | | | - Carlo Savini
- Cardiac Surgery Department, Sant’Orsola Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Antonio Miceli
- Istituto Clinico Sant’Ambrogio, Clinical & Research Hospitals IRCCS Gruppo San Donato, Milan, Italy
| | | | - Martin Andreas
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Carmelo Mignosa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT, Palermo, Italy
| | - Kevin Phan
- The Collaborative Research (CORE) Group, Sydney, Australia
| | - Bart Meuris
- Gasthuisberg, Cardiale Heelkunde, Leuven, Belgium
| | | | - Tristan Yan
- The Collaborative Research (CORE) Group, Sydney, Australia
- Department of Cardiothoracic Surgery, The Royal Prince Alfred Hospital, Sydney, Australia
| | - Marco Di Eusanio
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ospedali Riuniti, Ancona, Italy
- The Collaborative Research (CORE) Group, Sydney, Australia
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24
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Mattke S, Schneider S, Orr P, Lakdawalla D, Goldman D. Temporal Trends in Mortality after Transcatheter Aortic Valve Replacement: A Systematic Review and Meta-Regression Analysis. STRUCTURAL HEART 2019. [DOI: 10.1080/24748706.2019.1689321] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Soeren Mattke
- Center for Improving Chronic Illness Care, University of Southern California, Los Angeles, California, USA
| | - Stefan Schneider
- Center for Self-Report Science, University of Southern California, Los Angeles, California, USA
| | - Patrick Orr
- Center for Improving Chronic Illness Care, University of Southern California, Los Angeles, California, USA
| | - Darius Lakdawalla
- Leonard D. Schaeffer Center for Health Policy & Economics, University of Southern California, Los Angeles, California, USA
| | - Dana Goldman
- Leonard D. Schaeffer Center for Health Policy & Economics, University of Southern California, Los Angeles, California, USA
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25
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Salmasi MY, Chien L, Hartley P, Al-Balah A, Lall K, Oo A, Casula R, Athanasiou T. What is the safety and efficacy of the use of automated fastener in heart valve surgery? J Card Surg 2019; 34:1598-1607. [PMID: 31725943 DOI: 10.1111/jocs.14265] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Cor-Knot automated fastener has been used as an adjunct in heart valve surgery to eliminate the need for manual tying during valve implantation. Although reduced operative time and facilitation for minimally invasive surgery are clear benefits, whether their use translates to improved patient outcome remains debatable. This study aims to review the safety and efficacy of automated fasteners in heart valve surgeries. METHOD Specific searches were conducted via online medical databases (Pubmed, Embase, Ovid) between 1950 and June 2019. Longitudinal studies were included that provided operative parameters. RESULTS The initial literature search identified 3773 articles, but only eight met the inclusion criteria and were used for analysis: four studies related to aortic valve replacement (AVR), four related to mitral valve (MV) intervention (total n = 810). The meta-analysis revealed the significantly shorter aortic cross-clamp time in the Cor-knot group compared to manual tying, both in AVR and MV surgeries (P < .05). Cardiopulmonary bypass time was significantly shorter in the Cor-knot group when analyzing studies in MV surgery (weighted mean difference [WMD]: 110.0; 95% confidence interval: 12.3-207.7; P = .027) The use of Cor-Knot did not increase the risk of permanent pacemaker implantation, paravalvular leak, and 30-day mortality. The majority of studies reported no change in the length of intensive unit care and total hospital stay. CONCLUSION We confirmed that the majority of existing literatures indicated the safety and intraoperative efficacy with automated fastener application. Nevertheless, there is currently no evidence to support automated fastened sutures can translate its intraoperative advantages to improved patient outcome.
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Affiliation(s)
- M Yousuf Salmasi
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Lueh Chien
- Department of Medical Sciences, Faculty of Medicine, Imperial College London, London, UK
| | - Philip Hartley
- Department of Medical Sciences, Faculty of Medicine, Imperial College London, London, UK
| | - Amer Al-Balah
- Department of Medical Sciences, Faculty of Medicine, Imperial College London, London, UK
| | | | - Aung Oo
- Barts Health Centre, Barts Health Trust, London, UK
| | - Roberto Casula
- Department of Cardiac Surgery, Hammersmith Hospital, London, UK
| | - Thanos Athanasiou
- Department of Surgery and Cancer, Imperial College London, London, UK
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26
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Bruno P, Cammertoni F, Rosenhek R, Mazza A, Pavone N, Iafrancesco M, Nesta M, Chiariello GA, Spalletta C, Graziano G, Sanesi V, D’Errico D, Massetti M. Improved Patient Recovery With Minimally Invasive Aortic Valve Surgery: A Propensity-Matched Study. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2019; 14:419-427. [DOI: 10.1177/1556984519868715] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective Despite conflicting evidence available, minimally invasive aortic valve replacement (MIAVR) is increasingly used as an alternative to full sternotomy. We sought to compare early outcomes of aortic valve replacement through a full sternotomy (conventional aortic valve replacement [CAVR]) and upper ministernotomy (MIAVR). Methods We analyzed 297 patients having undergone primary, elective, isolated MIAVR or CAVR between January 2014 and June 2018. Following propensity score matching, 120 patients remained in each group. Results MIAVR required longer bypass (93 ± 26 vs 81 ± 24 minutes, P < 0.01) and operative times (214 ± 39 vs 182 ± 37 minutes, P < 0.01). However, aortic cross-clamp times were comparable (57 ± 17 vs 54 ± 14 minutes for MIAVR and CAVR, respectively, P = 0.14). MIAVR had less 24-hour blood loss (253 ± 204 vs 323 ± 296 mL, P = 0.03), less red blood cells transfusions [1.4 packs (1.1 o 1.9) vs 2.1 packs (1.8 to 2.7), P = 0.01], and shorter assisted ventilation time (7.1 ± 3.3 vs 9.7 ± 3.8 hours, P < 0.01) when compared to CAVR. These results led to significantly shorter intensive care unit and hospital stays for MIAVR patients (2.5 ± 1.3 vs 3.4 ± 1.1 days, P < 0.01 and 6.9 ± 4.1 vs 8.2 ± 4.8 days, P = 0.03, respectively). Thirty-day mortality and clinical outcomes did not differ significantly among groups. Conclusions MIAVR through upper ministernotomy was shown to be as safe and reliable as CAVR. Patient recovery time was improved by shortening mechanical ventilation and reducing blood loss and transfusions. These results may be significant for high-risk patients undergoing aortic valve surgery.
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Affiliation(s)
- Piergiorgio Bruno
- Department of Cardiovascular Sciences, Cardiac Surgery Unit, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
| | - Federico Cammertoni
- Department of Cardiovascular Sciences, Cardiac Surgery Unit, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
| | - Raphael Rosenhek
- Department of Cardiology, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
| | - Andrea Mazza
- Department of Cardiovascular Sciences, Cardiac Surgery Unit, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
| | - Natalia Pavone
- Department of Cardiovascular Sciences, Cardiac Surgery Unit, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
| | - Mauro Iafrancesco
- Department of Cardiovascular Sciences, Cardiac Surgery Unit, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
| | - Marialisa Nesta
- Department of Cardiovascular Sciences, Cardiac Surgery Unit, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
- Catholic University of the Sacred Heart, Rome, Italy
| | | | | | | | | | - Denise D’Errico
- Department of Cardiovascular Sciences, Perfusion Unit, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
| | - Massimo Massetti
- Department of Cardiovascular Sciences, Cardiac Surgery Unit, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
- Catholic University of the Sacred Heart, Rome, Italy
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27
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Cluckey A, Perino AC, Fan J, Askari M, Nasir J, Marcus GM, Baykaner T, Narayan SM, Wang PJ, Turakhia MP. Urinary tract infection after catheter ablation of atrial fibrillation. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2019; 42:951-958. [DOI: 10.1111/pace.13738] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 05/06/2019] [Accepted: 05/30/2019] [Indexed: 12/17/2022]
Affiliation(s)
- Andrew Cluckey
- Department of MedicineStanford University School of Medicine Stanford California
- Veterans Affairs Palo Alto Health Care System Palo Alto California
| | - Alexander C. Perino
- Department of MedicineStanford University School of Medicine Stanford California
- Veterans Affairs Palo Alto Health Care System Palo Alto California
| | - Jun Fan
- Veterans Affairs Palo Alto Health Care System Palo Alto California
| | - Mariam Askari
- Veterans Affairs Palo Alto Health Care System Palo Alto California
| | - Javed Nasir
- Department of MedicineStanford University School of Medicine Stanford California
| | - Gregory M. Marcus
- Section of Cardiac ElectrophysiologyDivision of Cardiology, UCSF San Francisco California
| | - Tina Baykaner
- Department of MedicineStanford University School of Medicine Stanford California
| | - Sanjiv M. Narayan
- Department of MedicineStanford University School of Medicine Stanford California
| | - Paul J. Wang
- Department of MedicineStanford University School of Medicine Stanford California
| | - Mintu P. Turakhia
- Department of MedicineStanford University School of Medicine Stanford California
- Veterans Affairs Palo Alto Health Care System Palo Alto California
- Center for Digital HealthStanford University School of Medicine Stanford California
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28
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Di Eusanio M, Cefarelli M, Zingaro C, Capestro F, Matteucci SML, D'alfonso A, Pierri MD, Aiello ML, Berretta P. Mini Bentall operation: technical considerations. Indian J Thorac Cardiovasc Surg 2019; 35:87-91. [PMID: 33061071 DOI: 10.1007/s12055-018-0669-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 02/11/2018] [Accepted: 03/06/2018] [Indexed: 01/16/2023] Open
Abstract
Bentall operation via median sternotomy has been largely shown to be safe and long-term efficacious and currently represents the "gold standard" intervention in patients presenting with aortic valve and root disease. However, over the last years, minimally invasive techniques have gained wider clinical application in cardiac surgery. In particular, minimally invasive aortic valve replacement through ministernotomy has shown excellent outcomes and becomes the first choice approach in numerous experienced centers. Based on these favorable results, ministernotomy approach has also been proposed for complex cardiac procedures such as aortic root replacement and arch surgery. Herein, we present our technique for minimally invasive Bentall operation using a ministernotomy approach.
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Affiliation(s)
- Marco Di Eusanio
- Cardiac Surgery Unit, Cardiovascular Department, Ospedali Riuniti, Politechnic University of Marche, Via Conca 71, 60126 Ancona, Italy
| | - Mariano Cefarelli
- Cardiac Surgery Unit, Cardiovascular Department, Ospedali Riuniti, Politechnic University of Marche, Via Conca 71, 60126 Ancona, Italy
| | - Carlo Zingaro
- Cardiac Surgery Unit, Cardiovascular Department, Ospedali Riuniti, Politechnic University of Marche, Via Conca 71, 60126 Ancona, Italy
| | - Filippo Capestro
- Cardiac Surgery Unit, Cardiovascular Department, Ospedali Riuniti, Politechnic University of Marche, Via Conca 71, 60126 Ancona, Italy
| | - Sacha Marco Luciano Matteucci
- Cardiac Surgery Unit, Cardiovascular Department, Ospedali Riuniti, Politechnic University of Marche, Via Conca 71, 60126 Ancona, Italy
| | - Alessandro D'alfonso
- Cardiac Surgery Unit, Cardiovascular Department, Ospedali Riuniti, Politechnic University of Marche, Via Conca 71, 60126 Ancona, Italy
| | - Michele Danilo Pierri
- Cardiac Surgery Unit, Cardiovascular Department, Ospedali Riuniti, Politechnic University of Marche, Via Conca 71, 60126 Ancona, Italy
| | - Marco Luigi Aiello
- Cardiac Surgery Unit, Cardiovascular Department, Ospedali Riuniti, Politechnic University of Marche, Via Conca 71, 60126 Ancona, Italy
| | - Paolo Berretta
- Cardiac Surgery Unit, Cardiovascular Department, Ospedali Riuniti, Politechnic University of Marche, Via Conca 71, 60126 Ancona, Italy
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Liang NE, Wisneski AD, Wozniak CJ, Ge L, Tseng EE. Evolution of Minimally Invasive Surgical Aortic Valve Replacement at a Veterans Affairs Medical Center. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2019; 14:251-262. [PMID: 31081708 DOI: 10.1177/1556984519843498] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The majority of minimally invasive surgical aortic valve replacements (MIAVRs) are performed at high-volume cardiac surgery centers. However, outcomes at lower volume federal facilities are not yet reported in the literature and not captured in the national Society of Thoracic Surgeons (STS) database. Our study objective was to describe the evolution of MIAVR at a Veterans Affairs Medical Center (VAMC). METHODS A single-center retrospective cohort study was performed of 114 patients who underwent MIAVR for isolated aortic valvular disease between January 2011 and August 2018. Preoperative STS risk factors were determined and perioperative outcomes were analyzed. RESULTS By 2016, 100% of isolated surgical aortic valve replacements were performed as MIAVRs at our VAMC. Introduction of automatic knot-fastening devices, single-shot del Nido cardioplegia, and rapid deployment valves decreased aortic cross-clamp (AXC) times from a median of 96 (interquartile range [IQR]: 84 to 103) to 53 minutes (38 to 61, P < 0.001, Kruskal-Wallis). Thirty-day mortality was 0.9%. Median length of hospital stay was 9 days (7 to 13). Postoperative atrial fibrillation occurred in 54% of patients, stroke occurred in 1.8% of patients, and 7.1% of patients required permanent pacemakers. Transition to rapid deployment valves decreased postoperative mean pressure gradient from median 14 mmHg (10 to 17) to 7 mmHg (4.7 to 10, P < 0.001, Mann-Whitney). At median 1.5-year follow-up echocardiogram, mean gradient was 10.8 mmHg with mild paravalvular leak rate of 1.8%. CONCLUSIONS Facilitating technologies decreased operative times during MIAVR adoption at our VAMC. For patients with isolated aortic valve pathology, MIAVR can be performed with low morbidity and mortality at lower volume federal institutions, with outcomes comparable to those reported from higher volume centers.
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Affiliation(s)
- Norah E Liang
- 1 Department of Surgery, Division of Cardiothoracic Surgery, University of California San Francisco and the San Francisco VA Medical Center, CA, USA
| | - Andrew D Wisneski
- 1 Department of Surgery, Division of Cardiothoracic Surgery, University of California San Francisco and the San Francisco VA Medical Center, CA, USA
| | - Curtis J Wozniak
- 1 Department of Surgery, Division of Cardiothoracic Surgery, University of California San Francisco and the San Francisco VA Medical Center, CA, USA
| | - Liang Ge
- 1 Department of Surgery, Division of Cardiothoracic Surgery, University of California San Francisco and the San Francisco VA Medical Center, CA, USA
| | - Elaine E Tseng
- 1 Department of Surgery, Division of Cardiothoracic Surgery, University of California San Francisco and the San Francisco VA Medical Center, CA, USA
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Olds A, Saadat S, Azzolini A, Dombrovskiy V, Odroniec K, Lemaire A, Ghaly A, Lee LY. Improved operative and recovery times with mini-thoracotomy aortic valve replacement. J Cardiothorac Surg 2019; 14:91. [PMID: 31072356 PMCID: PMC6509756 DOI: 10.1186/s13019-019-0912-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 04/23/2019] [Indexed: 11/25/2022] Open
Abstract
Background The small incisions of minimally invasive surgery have the proposed benefit of less surgical trauma, less pain, and faster recovery. This study was done to compare minimally invasive techniques for aortic valve replacement, including right anterior mini-thoracotomy and mini-sternotomy, to conventional sternotomy. Methods We retrospectively reviewed 503 patients who underwent isolated aortic valve replacement at our institution from 2012 to 2015 using one of three techniques: 1) Mini-thoracotomy, 2) Mini-sternotomy, 3) Conventional sternotomy. Demographics, operative morbidity, mortality, and postoperative complications were compared. Results Of the 503 cases, 267 (53.1%) were mini-thoracotomy, 120 (23.8%) were mini-sternotomy, and 116 (23.1%) were conventional sternotomy. Mini-thoracotomy patients, compared to mini-sternotomy and conventional sternotomy, had significantly shorter bypass times [82 (IQ 67–113) minutes; vs. 117 (93.5–139.5); vs. 102.5 (85.5–132.5), respectively (p < 0.0001)], a lower incidence of prolonged ventilator support [3.75% vs. 9.17 and 12.9%, respectively (p = 0.0034)], and required significantly shorter ICU and postoperative stays, resulting in an overall shorter hospitalization [6 (IQ 5–9) days; vs. 7 (5–14.5); vs 9 (6–15.5), respectively (p < 0.05)]. Incidence of other postoperative complications were lower in the mini-thoracotomy group compared to mini-sternotomy and conventional sternotomy, without significance. Minimally invasive techniques trended towards better survival [mini-thoracotomy 1.5%, mini-sternotomy 1.67%, and conventional sternotomy 5.17% (p = 0.13)]. Conclusions Minimally invasive aortic valve replacement approaches are safe, effective alternatives to conventional sternotomy. The mini-thoracotomy approach showed decreased operative times, decreased lengths of stay, decreased incidence of prolonged ventilator time, and a trend towards lower mortality when compared to mini-sternotomy and conventional sternotomy.
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Affiliation(s)
- Anna Olds
- Division of Cardiothoracic Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Siavash Saadat
- Division of Cardiothoracic Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA. .,, Boston, USA.
| | - Anthony Azzolini
- Division of Cardiothoracic Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Viktor Dombrovskiy
- Division of Cardiothoracic Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Karen Odroniec
- Division of Cardiothoracic Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Anthony Lemaire
- Division of Cardiothoracic Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Aziz Ghaly
- Division of Cardiothoracic Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Leonard Y Lee
- Division of Cardiothoracic Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
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The first 5 years: Building a minimally invasive valve program. J Thorac Cardiovasc Surg 2019; 157:1958-1965. [DOI: 10.1016/j.jtcvs.2018.10.037] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 09/24/2018] [Accepted: 10/03/2018] [Indexed: 12/20/2022]
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Nguyen TC, Rice RD, Umana-Pizano JB, Loyalka P. Minimally invasive removal of an infected Edwards S3 transcatheter aortic valve. J Thorac Cardiovasc Surg 2018; 157:e113-e116. [PMID: 33207405 DOI: 10.1016/j.jtcvs.2018.06.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 05/18/2018] [Accepted: 06/05/2018] [Indexed: 11/24/2022]
Affiliation(s)
- Tom C Nguyen
- Department of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center Houston, McGovern Medical School, Memorial Hermann Hospital-Heart and Vascular Institute, Houston, Tex.
| | - Robert D Rice
- Department of Cardiothoracic Surgery, Dwight D. Eisenhower Army Medical Center, Fort Gordon, Ga
| | - Juan B Umana-Pizano
- Department of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center Houston, McGovern Medical School, Memorial Hermann Hospital-Heart and Vascular Institute, Houston, Tex
| | - Pranav Loyalka
- Division of Cardiology, Department of Internal Medicine, University of Texas Health Science Center Houston, McGovern Medical School, Memorial Hermann Hospital-Heart and Vascular Institute, Houston, Tex
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33
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Berretta P, Cefarelli M, Vessella W, Pierri MD, Carozza R, Abramucci G, Munch C, Zahedi HM, Di Eusanio M. Ultra fast track surgery: a rapid deployment aortic valve replacement through a J-ministernotomy. J Vis Surg 2018; 4:90. [PMID: 29963379 DOI: 10.21037/jovs.2018.04.14] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 04/13/2018] [Indexed: 01/25/2023]
Abstract
Aortic valve surgery has been undergone continuous development over the last years, involving less invasive techniques and the use of new technologies to reduce the traumatic impact of the intervention and extend the operability toward increasingly high-risk patients. Minimally invasive aortic valve replacement (AVR) has gradually been recognized as a less traumatic technique compared to median sternotomy, becoming first choice approach in numerous experienced centers. Herein we present our multidisciplinary minimally invasive approach for AVR, involving: (I) reduced chest incision; (II) rapid deployment AVR; (III) minimally invasive extracorporeal circulation system; and (IV) ultra fast track (UFT) anaesthetic management.
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Affiliation(s)
- Paolo Berretta
- Cardiac Surgery Unit, Ospedali Riuniti, Polytechnic University of Marche, Ancona, Italy
| | - Mariano Cefarelli
- Cardiac Surgery Unit, Ospedali Riuniti, Polytechnic University of Marche, Ancona, Italy
| | - Walter Vessella
- Cardiac Anaesthesia and Intensive Care Unit, Ospedali Riuniti, Ancona, Italy
| | - Michele D Pierri
- Cardiac Surgery Unit, Ospedali Riuniti, Polytechnic University of Marche, Ancona, Italy
| | | | - Giulia Abramucci
- Preventive Cardiology and Rehabilitation Unit, Ospedali Riuniti, Ancona, Italy
| | - Christopher Munch
- Cardiac Anaesthesia and Intensive Care Unit, Ospedali Riuniti, Ancona, Italy
| | - Hossein M Zahedi
- Cardiac Anaesthesia and Intensive Care Unit, Ospedali Riuniti, Ancona, Italy
| | - Marco Di Eusanio
- Cardiac Surgery Unit, Ospedali Riuniti, Polytechnic University of Marche, Ancona, Italy
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Di Eusanio M, Vessella W, Carozza R, Capestro F, D’Alfonso A, Zingaro C, Munch C, Berretta P. Ultra fast-track minimally invasive aortic valve replacement: going beyond reduced incisions. Eur J Cardiothorac Surg 2018; 53:ii14-ii18. [DOI: 10.1093/ejcts/ezx508] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 12/21/2017] [Indexed: 12/22/2022] Open
Affiliation(s)
- Marco Di Eusanio
- Cardiovascular Department, Cardiac Surgery Unit, Opsedali Riuniti, Marche Polytechnic University, Ancona, Italy
| | - Walter Vessella
- Cardiovascular Department, Cardiac Anaesthesia and Intensive Care Unit, Ospedali Riuniti, Ancona, Italy
| | - Roberto Carozza
- Cardiovascular Department, Perfusion Unit, Ospedali Riuniti, Ancona, Italy
| | - Filippo Capestro
- Cardiovascular Department, Cardiac Surgery Unit, Opsedali Riuniti, Marche Polytechnic University, Ancona, Italy
| | - Alessandro D’Alfonso
- Cardiovascular Department, Cardiac Surgery Unit, Opsedali Riuniti, Marche Polytechnic University, Ancona, Italy
| | - Carlo Zingaro
- Cardiovascular Department, Cardiac Surgery Unit, Opsedali Riuniti, Marche Polytechnic University, Ancona, Italy
| | - Christopher Munch
- Cardiovascular Department, Cardiac Anaesthesia and Intensive Care Unit, Ospedali Riuniti, Ancona, Italy
| | - Paolo Berretta
- Cardiovascular Department, Cardiac Surgery Unit, Opsedali Riuniti, Marche Polytechnic University, Ancona, Italy
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35
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Nguyen TC. Gazing into the crystal ball: Preventing the inevitable shortage of cardiothoracic surgeons. J Thorac Cardiovasc Surg 2018; 155:830-831. [DOI: 10.1016/j.jtcvs.2017.09.105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 09/22/2017] [Indexed: 11/26/2022]
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36
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Banovic MD, Nikolic SD. Treatment Strategies in Symptomatic Intermediate, Low-Risk, and Asymptomatic Patients With Severe Aortic Stenosis. Curr Probl Cardiol 2017; 43:335-354. [PMID: 29290389 DOI: 10.1016/j.cpcardiol.2017.12.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Survival of symptomatic patients with severe aortic stenosis (AS) is very poor, with an average mortality reaching up to 2% per month. Approach to diagnosis and treatment of patients with AS was conservative; patients were referred to surgery only if the AS-induced symptoms become apparent and significantly limit the quality of patient' life. In the past 15 years, the novel treatment strategy in subgroups of symptomatic patients with AS have been the subject of extensive research, starting from introduction of transcatheter aortic valve implant (TAVI) in inoperable symptomatic patients with severe AS and continuing further to patients with very high and high operative risk. In the past few years, the focus has further shifted toward the patients with lower operative risk, as well as to asymptomatic patients with severe AS. In the former group, the question relates to whether TAVI is beneficial when compared to SAVR in intermediate- to low-risk patients with symptomatic AS. In the latter group, the main issue is if and when the SAVR should be performed. This article analyzes current status and evidences regarding treatment strategies in symptomatic high, intermediate, low-risk, and asymptomatic patients with isolated severe AS.
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Easterwood RM, Bostock IC, Nammalwar S, McCullough JN, Iribarne A. The evolution of minimally invasive cardiac surgery: from minimal access to transcatheter approaches. Future Cardiol 2017; 14:75-87. [PMID: 29199850 DOI: 10.2217/fca-2017-0048] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
The field of minimally invasive cardiac surgery has undergone rapid transformation over recent years. In this review, we provide a summary of the most current evidence supporting the use of minimally invasive aortic and mitral valve replacement techniques, as well as transcatheter approaches for aortic and mitral valve disease. As an adjunct, the use of robotically assisted coronary bypass surgery and hybrid coronary revascularization procedures is discussed. In order to obtain optimal patient outcomes, a collaborative, heart-team approach between cardiac surgeons and interventional cardiologists is necessary.
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Affiliation(s)
- Rachel M Easterwood
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - Ian C Bostock
- Heart & Vascular Center, Section of Cardiac Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03766, USA
| | - Shruthi Nammalwar
- Heart & Vascular Center, Section of Cardiac Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03766, USA
| | - Jock N McCullough
- Heart & Vascular Center, Section of Cardiac Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03766, USA
| | - Alexander Iribarne
- Heart & Vascular Center, Section of Cardiac Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03766, USA.,The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, NH 03766, USA
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Antonides CFJ, Mack MJ, Kappetein AP. Approaches to the Role of The Heart Team in Therapeutic Decision Making for Heart Valve Disease. STRUCTURAL HEART 2017. [DOI: 10.1080/24748706.2017.1380377] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Christiaan F. J. Antonides
- Department of Cardio-Thoracic Surgery, Erasmus University Medical Center Rotterdam, Thoraxcentrum, Rotterdam, The Netherlands
| | - Michael J. Mack
- Baylor Scott and White Healthcare System, Baylor University Medical Center, Baylor Heart and Vascular Hospital, Dallas, Texas, USA
- The Heart Hospital Baylor Plano, Plano, Texas, USA
| | - A. Pieter Kappetein
- Department of Cardio-Thoracic Surgery, Erasmus University Medical Center Rotterdam, Thoraxcentrum, Rotterdam, The Netherlands
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Hoffmann CT, Heiner JA, Nguyen TC. Review of minimal access versus transcatheter aortic valve replacement for patients with severe aortic stenosis. Ann Cardiothorac Surg 2017; 6:498-503. [PMID: 29062745 PMCID: PMC5639223 DOI: 10.21037/acs.2017.09.02] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 08/30/2017] [Indexed: 11/06/2022]
Abstract
Transcatheter aortic valve replacement (TAVR) and minimally invasive aortic valve replacement (miniAVR) have become alternatives to surgical aortic valve replacement via median sternotomy (SAVR) to treat severe aortic stenosis (AS). Despite increased interest and utilization, few studies have directly compared TAVR and miniAVR. A review of the current literature shows TAVR to be an indispensable tool for inoperable, high-risk, and perhaps intermediate-risk patients with severe AS. However, it is associated with a number of deleterious perioperative outcomes, such as valvular regurgitation and vascular complications. MiniAVR is associated with decreased intensive care unit (ICU) and hospital length of stay, a lower incidence of blood transfusions, decreased ventilation time, and improved cosmetic results. MiniAVR maintains potential advantages over SAVR, including the implantation of a durable prosthesis and low rates of perioperative myocardial infarction and paravalvular leak. It is associated with longer aortic cross clamp and cardiopulmonary bypass (CPB) times; however, the use of sutureless valve implants can circumvent this. Studies comparing TAVR and miniAVR demonstrate decreased postoperative mortality, valvular regurgitation, and incidence of stroke in the miniAVR cohorts. Few studies currently exist comparing TAVR and miniAVR, as it is hard to compare the typically low-risk miniAVR versus high-risk TAVR patient populations. It is clear that both strategies will be cornerstones in the modern AVR era, but the situations in which to apply each strategy have not yet been clearly delineated. This highlights the need for surgeons to adopt these minimally invasive techniques. We believe there is a compelling role for miniAVR in low- and intermediate-risk patients, but due to the paucity of data, neither TAVR nor miniAVR should be discounted before a randomized, risk-stratified trial is performed. More studies are needed to compare TAVR and miniAVR in low- and intermediate-risk patients.
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Affiliation(s)
- Carson T Hoffmann
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School, University of Texas at Houston, Memorial Hermann Hospital-Heart and Vascular Institute, Houston, Texas, USA
| | - Jacob A Heiner
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School, University of Texas at Houston, Memorial Hermann Hospital-Heart and Vascular Institute, Houston, Texas, USA
| | - Tom C Nguyen
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School, University of Texas at Houston, Memorial Hermann Hospital-Heart and Vascular Institute, Houston, Texas, USA
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Hirji SA, Ramirez-Del Val F, Kolkailah AA, Ejiofor JI, McGurk S, Chowdhury R, Lee J, Shah PB, Sobieszczyk PS, Aranki SF, Pelletier MP, Shekar PS, Kaneko T. Outcomes of surgical and transcatheter aortic valve replacement in the octogenarians-surgery still the gold standard? Ann Cardiothorac Surg 2017; 6:453-462. [PMID: 29062740 DOI: 10.21037/acs.2017.08.01] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Contemporary options for aortic valve replacement (AVR) include transcatheter and surgical approaches (TAVR and SAVR). As evidence accrues for TAVR in high and intermediate risk patients, some clinicians advocate that all patients aged over 80 years should only receive TAVR. Our aim was to investigate the utility of SAVR and minimally invasive AVR (mAVR) among octogenarians in the current era of TAVR. METHODS From 2002 to 2015, 1,028 octogenarians underwent isolated AVR; 306 TAVR and 722 SAVR, of which 378 patients underwent mAVR. Logistic regression and Cox modeling were used to evaluate overall operative mortality and mid-term survival, respectively. Patients were stratified based on procedural approaches (mAVR or full sternotomy for SAVR, and transfemoral or alternate access for TAVR). Median follow-up was 35 [interquartile range (IQR) 14-65] months. RESULTS Compared to SAVR patients, TAVR patients were relatively older (86.2 versus 84.2 years) with co-morbidities such as chronic kidney disease (CKD), diabetes mellitus (DM), cerebrovascular disease (CVD), and prior myocardial infarction (MI), all P<0.05. The mean STS-PROM for the TAVR group was statistically higher, 6.81 versus 5.58 for the SAVR group (P<0.001). The median in-hospital LOS was statistically higher for the SAVR group (P<0.05). Cox proportional hazard modeling, adjusted for temporal differences in procedure and patient selection, identified age, New York Heart Association (NYHA) class III/IV, preoperative creatinine, severe chronic lung disease, prior cardiac surgery as significant predictors of decreased survival (all P<0.05), while type of intervention (approach) was non-contributory. Adjusted operative mortality stratified by procedure approaches was similar between full sternotomy SAVR and mAVR, and between alternative access and transfemoral TAVR. CONCLUSIONS After adjusting for confounders, TAVR (regardless of approach), SAVR, and mAVR had comparable operative mortality and mid-term survival. Treatment decisions should be individualized with consensus from a multi-disciplinary heart team, taking into account patient co morbidities, frailty, and quality of life. We believe certain patient groups will still benefit from SAVR even in this elderly population.
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Affiliation(s)
- Sameer A Hirji
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Fernando Ramirez-Del Val
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ahmed A Kolkailah
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Julius I Ejiofor
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Siobhan McGurk
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ritam Chowdhury
- Center for Surgery and Public Health (CSPH), Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jiyae Lee
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Pinak B Shah
- Department of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Piotr S Sobieszczyk
- Department of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sary F Aranki
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Marc P Pelletier
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Prem S Shekar
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Tsuyoshi Kaneko
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Kappetein AP, Vahanian A. Effectiveness in a Real-World Observation Confirms Efficacy of Controlled Clinical Trials. J Am Coll Cardiol 2017; 70:451-452. [PMID: 28728689 DOI: 10.1016/j.jacc.2017.06.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 06/07/2017] [Indexed: 11/18/2022]
Affiliation(s)
| | - Alec Vahanian
- Cardiology Department, Hôpital Bichat, Université Paris VI, Paris, France
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Minimalinvasiver Aortenklappenersatz über eine anteriore rechtsseitige Thorakotomie. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2017. [DOI: 10.1007/s00398-017-0167-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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