The impact of cardiopulmonary bypass time on the Sequential Organ Failure Assessment score after cardiac surgery

OBJECTIVES

Postoperative organ dysfunction is common after cardiac surgery, particularly when cardiopulmonary bypass (CPB) is used. The Sequential Organ Failure Assessment (SOFA) score is validated to predict morbidity and mortality in cardiac surgery. However, the impact of CPB duration on postoperative SOFA remains unclear.

METHODS

This is a retrospective study. Categorical values are presented as percentages. The comparison of SOFA groups utilized the Kruskal-Wallis chi-squared test, complemented by ad hoc Dunn's test with Bonferroni correction. Multinomial logistics regressions were employed to evaluate the relationship between CPB time and SOFA.

RESULTS

A total of 1032 patients were included. CPB time was independently associated with higher postoperative SOFA scores at 24 h. CPB time was significantly higher in patients with SOFA 4-5 (**P = 0.0022) or higher (***P < 0.001) when compared to SOFA 0-1. The percentage of patients with no/mild dysfunction decreased with longer periods of CPB, down to 0% for CPB time >180min (50% of the patients with >180m in of CPB presented SOFA ≥ 10). The same trend is observed for each of the SOFA variables, with higher impact in the cardiovascular and renal systems. Severe dysfunction occurs especially >200 min of CPB (cardiovascular system >100 min; other systems mainly >200 min).

CONCLUSIONS

CPB time may predict the probability of postoperative SOFA categories. Patients with extended CPB durations exhibited higher SOFA scores (overall and for each variable) at 24 h, with higher proportion of moderate and severe dysfunction with increasing times of CPB.

Procedural selection strategy and clinical outcomes in mitral valve surgery with concomitant aortic valve replacement in elderly patients

Introduction

In the context of double-valve surgery for elderly high-risk patients involving both the aortic and mitral valves, a clinically significant problem has been that no clear criteria or surgical strategies have been reported for the selection of mitral valve plasty (MVP) or mitral valve replacement (MVR) for mitral valve disease management during surgical aortic valve replacement (SAVR) to achieve better clinical outcomes. This study investigated valve durability and survival using our surgical strategy for mitral valve disease with concomitant SAVR in elderly patients.

Methods

Eighty-six patients aged > 65 years (mean 75 years) who underwent a double-valve procedure for mitral valve surgery with concomitant SAVR from 2010 to 2022 were reviewed. Our surgical strategy for mitral valve disease with concomitant SAVR for the elderly patients was as follows: MVP was selected for patients in whom mitral valve disease was expected to be controlled with simple surgical procedures (n = 47), otherwise MVR was selected (n = 39).

Results

The hospital mortality rate was 8% (n = 7). The mean follow-up was 4.9 (0-12.3) years. And the 10-year survival rate was 62%. The 10-year freedom from aortic valve reoperation rate was 95%. No mitral valve reintervention was performed during follow-up. Echocardiographic follow-up demonstrated freedom from at least moderate mitral regurgitation in 86% of cases at 10 years.

Conclusion

In double-valve surgery for elderly high-risk patients, appropriate selection of the mitral valve procedure with concomitant SAVR provided better early and long-term survival and valve durability. This surgical strategy may be beneficial in elderly patients with combined aortic and mitral valve disease.

The Northern New England Rapid Deployment Valve Experience: Survival and Procedural Outcomes From 2015 to 2021

OBJECTIVE

The optimal approach and choice of initial aortic valve replacement (AVR) is evolving in the growing era of transcatheter AVR. Further survival and hemodynamic data are needed to compare the emerging role of rapid deployment (rdAVR) versus stented (sAVR) valve options for AVR.

METHODS

The Northern New England Cardiovascular Database was queried for patients undergoing either isolated AVR or AVR + coronary artery bypass grafting (CABG) with rdAVR or sAVR aortic valves between 2015 and 2021. Exclusion criteria included endocarditis, mechanical valves, dissection, emergency case status, and prior sternotomy. This resulted in a cohort including 1,616 sAVR and 538 rdAVR cases. After propensity weighting, procedural characteristics, hemodynamic variables, and survival outcomes were examined.

RESULTS

The breakdown of the overall cohort (2,154) included 1,164 isolated AVR (222 rdAVR, 942 sAVR) and 990 AVR + CABG (316 rdAVR, 674 sAVR). After inverse propensity weighting, cohorts were well matched, notable only for more patients <50 years in the sAVR group (4.0% vs 1.9%, standardized mean difference [SMD] = -0.12). Cross-clamp (89 vs 64 min, SMD = -0.71) and cardiopulmonary bypass (121 vs 91 min, SMD = -0.68) times were considerably longer for sAVR versus rdAVR. Immediate postreplacement aortic gradient decreased with larger valve size but did not differ significantly between comparable sAVR and rdAVR valve sizes or overall (6.5 vs 6.7 mm Hg, SMD = 0.09). Implanted rdAVR tended to be larger with 51% either size L or XL versus 37.4% of sAVR ≥25 mm. Despite a temporal decrease in pacemaker rate within the rdAVR cohort, the overall pacemaker frequency was less in sAVR versus rdAVR (4.4% vs 7.4%, SMD = 0.12), and significantly higher rates were seen in size L (10.3% vs 3.7%, P < 0.002) and XL (15% vs 5.6%, P < 0.004) rdAVR versus sAVR. No significant difference in major adverse cardiac events (4.6% vs 4.6%, SMD = 0.01), 30-day survival (1.5% vs 2.6%, SMD = 0.08), or long-term survival out to 4 years were seen between sAVR and rdAVR.

CONCLUSIONS

Rapid deployment valves offer a safe alternative to sAVR with significantly decreased cross-clamp and cardiopulmonary bypass times. Despite larger implantation sizes, we did not appreciate a comparative difference in immediate postoperative gradients, and although pacemaker rates are improving, they remain higher in rdAVR compared with sAVR. Longer-term hemodynamic and survival follow-up are needed.

Aortic Valve Replacement with Single-Strip Autologous Pericardium

BACKGROUND

 Aortic valve replacement with mechanical valves is the standard treatment for aortic valve disease in Indonesia. Its usage is associated with high cost, risk of endocarditis and thromboembolic event, and lifetime consumption of anticoagulants. We performed a novel replacement technique of the aortic valve using an autologous pericardium and evaluated the short-term outcomes.

METHODS

 From April 2017 to April 2020, 16 patients underwent aortic valve replacement with a single-strip autologous pericardium. Outcomes of the left ventricular reverse remodeling (LVRR), 6-minute walk test (6MWT), and soluble suppression of tumorigenicity-2 (sST-2) were measured at 6 months postoperation.

RESULTS

 A total of 16 surgeries were performed using aortic valve replacement with single-strip pericardium without conversion to mechanical valve replacement. The patients included eight males and eight females, and the mean age was 49.63 ± 12.54 years. The most common diagnosis was mixed aortic valve stenosis and regurgitation (9 cases). Five patients underwent a concomitant coronary artery bypass graft (CABG) procedure and 12 patients underwent either mitral or tricuspid valve repair. The mean aortic cross-clamp time was 139.88 ± 23.21 minutes and cardiopulmonary bypass time was 174.37 ± 33.53 minutes. At 6 months postoperation, there was an increase in the distance walked at the 6MWT (p = 0.006) and a decrease of the sST-2 level (p = 0.098). Echocardiogram showed two patients had LVRR. Survival and freedom from reoperation are 100% at 1 year of follow-up.

CONCLUSION

 Aortic valve replacement with a single strip of pericardium is a good alternative to aortic valve replacement with a mechanical valve. Short-term evaluation at 6 months postoperation showed improvement in clinical status and echocardiographic parameters compared to baseline.

Prognostic Factors for Postoperative Bleeding Complications and Prolonged Intensive Care after Percutaneous Hepatic Chemosaturation Procedures with Melphalan

Percutaneous hepatic melphalan perfusion (chemosaturation) in patients with liver metastases is known to be associated with procedure-related hemodynamic depression and coagulation impairment, which may cause bleeding complications and/or a prolonged intensive care unit length of stay (ICU LOS). We retrospectively analyzed possible predictive factors for bleeding complications and an ICU LOS > 1 d in a cohort of 31 patients undergoing 90 chemosaturation procedures. Using a multivariable mixed-model approach, we identified the amount of perioperative fluid volume (OR 12.0, 95% CI 2.3-60.0, p = 0.003) and protamine (OR 0.065, 95% CI 0.007-0.55, p = 0.012) to be associated with bleeding complications. Furthermore, the amount of perioperative fluid volume was associated with an ICU LOS > 1 d (OR 5.2, 95% CI 1.4-19.0, p = 0.011). Heparin dosage, melphalan dosage, extracorporeal circulation time, and noradrenaline dosage had no significant effects on outcomes. Protamine use was not associated with anaphylactic or thromboembolic complications. Despite the limited sample size, these results suggest a restrictive perioperative fluid regime to be beneficial, and support the use of protamine for heparin reversal after chemosaturation procedures. Further prospective randomized trials are needed to confirm these findings.

Rapid-Deployment Aortic Valve Replacement: Patient Selection and Special Considerations

Sutureless or rapid deployment valves in the setting of aortic valve replacement (AVR) is an emerging surgical technique using the transcatheter valve technology, which may lead to reduction in cross-clamp time and potentially better hemodynamics compared to a stented bioprosthetic valve. The absence of subannular pledgets results to excellent hemodynamic performance with reduced turbulent flow and larger effective orifice area. However, complications from both surgical and transcatheter AVR may still occur and impact survival. The incidence of paravalvular leakage and permanent pacemaker implantation are not low. Although technical modifications can improve these outcomes, there is a learning curve effect. Therefore, technical and anatomical considerations as well as better patient selection are paramount for better outcomes. In this review, we discuss the use of sutureless or rapid deployment valves in setting of (1) complex procedures, (2) minimally invasive AVR, and (3) small aortic annulus. The advantage of sutureless or rapid deployment valves in terms of mortality remains to be clarified; therefore, it is necessary to accumulate long-term outcomes in an appropriate patient cohort.

Repeated valve replacement: approaches and devices (literature review)

Bioprosthetic valve dysfunction represent a serious drawback that limits the wider clinical use of these medical devices for valvular heart disease surgery. Modern studies describe the view of pathophysiologists on this problem as a multifactorial multi-stage process that causes irreversible changes in bioprosthesis components, ultimately leading to its dysfunction. However, in addition to under- standing the causes and manifestations of prosthetic valve dys- function, an applied question arises about the treatment strategies — determining the most attenuated and accessible low-risk method/ device. The aim of this review was to analyze and systematize current literature data on methods and designs used in repeated surgical and transcatheter interventions on heart valves.

Machine Learning to Predict Outcomes and Cost by Phase of Care After Coronary Artery Bypass Grafting

BACKGROUND

Machine learning may enhance prediction of outcomes after coronary artery bypass grafting (CABG). We sought to develop and validate a dynamic machine learning model to predict CABG outcomes at clinically relevant pre- and postoperative time points.

METHODS

The Society of Thoracic Surgeons (STS) registry data elements from 2086 isolated CABG patients were divided into training and testing datasets and input into Extreme Gradient Boosting decision-tree machine learning algorithms. Two prediction models were developed based on data from preoperative (80 parameters) and postoperative (125 parameters) phases of care. Outcomes included operative mortality, major morbidity or mortality, high cost, and 30-day readmission. Machine learning and STS model performance were assessed using accuracy and the area under the precision-recall curve (AUC-PR).

RESULTS

Preoperative machine learning models predicted mortality (accuracy, 98%; AUC-PR = 0.16; F1 = 0.24), major morbidity or mortality (accuracy, 75%; AUC-PR = 0.33; F1 = 0.42), high cost (accuracy, 83%; AUC-PR = 0.51; F1 = 0.52), and 30-day readmission (accuracy, 70%; AUC-PR = 0.47; F1 = 0.49) with high accuracy. Preoperative machine learning models performed similarly to the STS for prediction of mortality (STS AUC-PR = 0.11; P = .409) and outperformed STS for prediction of mortality or major morbidity (STS AUC-PR = 0.28; P < .001). Addition of intraoperative parameters further improved machine learning model performance for major morbidity or mortality (AUC-PR = 0.39; P < .01) and high cost (AUC-PR = 0.64; P < .01), with cross-clamp and bypass times emerging as important additive predictive parameters.

CONCLUSIONS

Machine learning can predict mortality, major morbidity, high cost, and readmission after isolated CABG. Prediction based on the phase of care allows for dynamic risk assessment through the hospital course, which may benefit quality assessment and clinical decision-making.

Intelligence outcome of pediatric intensive care unit survivors: a systematic meta-analysis and meta-regression

BACKGROUND

Long-term morbidity after pediatric intensive care unit (PICU) admission is a growing concern. Both critical illness and accompanying PICU treatments may impact neurocognitive development as assessed by its gold standard measure; intelligence. This meta-analysis and meta-regression quantifies intelligence outcome after PICU admission and explores risk factors for poor intelligence outcome.

METHODS

PubMed, Embase, CINAHL and PsycINFO were searched for relevant studies, published from database inception until September 7, 2021. Using random-effects meta-analysis, we calculated the standardized mean difference in full-scale intelligence quotient (FSIQ) between PICU survivors and controls across all included studies and additionally distinguishing between PICU subgroups based on indications for admission. Relation between demographic and clinical risk factors and study's FSIQ effect sizes was investigated using random-effects meta-regression analysis.

RESULTS

A total of 123 articles was included, published between 1973 and 2021, including 8,119 PICU survivors and 1,757 controls. We found 0.47 SD (7.1 IQ-points) lower FSIQ scores in PICU survivors compared to controls (95%CI -0.55 to -0.40, p < .001). All studied PICU subgroups had lower FSIQ compared to controls (range 0.38-0.88 SD). Later year of PICU admission (range 1972-2016) and longer PICU stay were related to greater FSIQ impairment (R² = 21%, 95%CI -0.021 to -0.007, p < .001 and R² = 2%, 95%CI -0.027 to -0.002, p = .03, respectively), whereas male sex and higher rate of survivors were related to smaller FSIQ impairment (R² = 5%, 95%CI 0.001 to 0.014, p = .03 and R² = 11%, 95%CI 0.006 to 0.022, p < .001, respectively). Meta-regression in PICU subgroups showed that later year of PICU admission was related to greater FSIQ impairment in children admitted after cardiac surgery and heart- or heart-lung transplantation. Male sex was related to smaller FSIQ impairment in children admitted after cardiac surgery. Older age at PICU admission and older age at follow-up were related to smaller FSIQ impairment in children admitted after heart- or heart-lung transplantation.

CONCLUSIONS

PICU survivors, distinguished in a wide range of subgroups, are at risk of intelligence impairment. Length of PICU stay, female sex and lower rate of survivors were related to greater intelligence impairment. Intelligence outcome has worsened over the years, potentially reflecting the increasing percentage of children surviving PICU admission.

Using machine learning to predict perfusionists' critical decision-making during cardiac surgery

The cardiac surgery operating room is a high-risk and complex environment in which multiple experts work as a team to provide safe and excellent care to patients. During the cardiopulmonary bypass phase of cardiac surgery, critical decisions need to be made and the perfusionists play a crucial role in assessing available information and taking a certain course of action. In this paper, we report the findings of a simulation-based study using machine learning to build predictive models of perfusionists' decision-making during critical situations in the operating room (OR). Performing 30-fold cross-validation across 30 random seeds, our machine learning approach was able to achieve an accuracy of 78.2% (95% confidence interval: 77.8% to 78.6%) in predicting perfusionists' actions, having access to only 148 simulations. The findings from this study may inform future development of computerised clinical decision support tools to be embedded into the OR, improving patient safety and surgical outcomes.

Supplementing Existing Societal Risk Models for Surgical Aortic Valve Replacement With Machine Learning for Improved Prediction

Background

This study evaluated the role of supplementing Society of Thoracic Surgeons (STS) risk models for surgical aortic valve replacement with machine learning (ML).

Methods and Results

Adults undergoing isolated surgical aortic valve replacement in the STS National Database between 2007 and 2017 were included. ML models for operative mortality and major morbidity were previously developed using extreme gradient boosting. Concordance and discordance in predicted risk between ML and STS models were defined using equal‐size tertile‐based thresholds of risk. Calibration metrics and discriminatory capability were compared between concordant and discordant patients. A total of 243 142 patients were included. Nearly all calibration metrics were improved in cases of concordance. Similarly, concordance indices improved substantially in cases of concordance for all models with the exception of deep sternal wound infection. The greatest improvements in concordant versus discordant cases were in renal failure: ML model (concordance index, 0.660 [95% CI, 0.632–0.687] discordant versus 0.808 [95% CI, 0.794–0.822] concordant) and STS model (concordance index, 0.573 [95% CI, 0.549–0.576] discordant versus 0.797 [95% CI, 0.782–0.811] concordant) (each P<0.001). Excluding deep sternal wound infection, the concordance indices ranged from 0.549 to 0.660 for discordant cases and 0.674 to 0.808 for concordant cases.

Conclusions

Supplementing ML models with existing STS models for surgical aortic valve replacement may have an important role in risk prediction and should be explored further. In particular, for the roughly 25% to 50% of patients demonstrating discordance in estimated risk between ML and STS, there appears to be a substantial decline in predictive performance suggesting vulnerability of the existing models in these patient subsets.

Minimally invasive mitral valve reconstruction: Is it an "all-comers" procedure?

BACKGROUND AND AIM OF THE STUDY

The debate on the usefulness of the minimally invasive approach in mitral valve surgery is still open. The aim of this study is to describe a single-center case series of all comers undergoing minimally invasive mitral valve reconstruction.

METHODS

From 2010 to 2019, all the data recorded in the medical records of 893 consecutive patients undergoing mitral valve reconstruction through a right mini-thoracotomy were retrospectively collected. All patients were contacted by telephone for remote evaluation and integration of echocardiographic information on surgical results.

RESULTS

Mean age was 62.2 ± 14.5; 447 (50%) were female and mean log EuroSCORE was 2.5 ± 2.8%. At a mean follow-up of 4.1 ± 2.2 years (median 3.9), a total of 24 deaths (2.68%) were recorded. Twenty-four patients required rehospitalization for cardiac causes, 13 (1.4%) patients had at least moderate mitral insufficiency on follow-up echocardiography and, of these, seven patients underwent reoperation (0.8%). The cumulative hazard showed that 8.3% of patients experienced at least one event at 5 years. NYHA class improved significantly with 874 patients in NYHA class I, 13 in NYHA class II, 6 in NYHA class III, and 0 in NYHA class IV at last follow-up (p < .001 from baseline as reference point).

CONCLUSIONS

In a high-volume center, mitral valve surgery using a minimally invasive approach is a feasible treatment option for all-comers and is associated with excellent results that are maintained at clinical and echocardiographic follow-up.

Effect of aortic cross-clamp time on late survival after isolated aortic valve replacement

OBJECTIVES

Longer aortic cross-clamp (ACC) time is associated with decreased early survival after cardiac surgery. Because maximum follow-up in previous studies on this subject is confined to 28 months, it is unknown whether this adverse effect is sustained far beyond this term. We aimed to determine whether longer ACC time was independently associated with decreased late survival after isolated aortic valve replacement in patients with severe aortic stenosis during 25 years of follow-up.

METHODS

In this retrospective cohort study, multivariable analysis was performed to identify possible independent predictors of decreased late survival, including ACC and cardiopulmonary bypass (CPB) time, in a cohort of 456 consecutive patients with severe aortic stenosis, who had undergone isolated aortic valve replacement between 1990 and 1993.

RESULTS

Mean follow-up was 25.3 ± 2.7 years. Median (interquartile range) and mean ACC times were normal: 63.0 (20.0) and 64.2 ± 16.1 min, respectively. Age, operative risk scores and New York Heart Association class were similar in patients with ACC time above, versus those with ACC time below the median. Longer ACC time was independently associated with decreased late survival: hazards ratio (HR) 1.01 per minute increase of ACC time (95% confidence interval [CI] 1.00-1.02; P = 0.012). Longer CPB time was not associated with decreased late survival (HR 1.00 per minute increase of CPB time [95% CI 1.00-1.00; P = 0.30]).

CONCLUSIONS

Longer ACC time, although still within normal limits, was independently associated with decreased late survival after isolated aortic valve replacement in patients with severe aortic stenosis.

Sutureless aortic valve replacement in multivalve procedures

Background

Despite the rapid expansion of transcatheter approaches for aortic valve implantation, surgical aortic valve replacement remains the treatment of choice in patients presenting with multiple valvular heart disease. We sought to review our clinical experience with sutureless aortic valve replacement (SU-AVR) in the setting of multivalve procedures, addressing the postoperative outcomes and technical challenges.

Methods

Between December 2019 and December 2020, 20 consecutive high-risk patients at our institution underwent SU-AVR and concomitant mitral valve procedure for various indications.

Results

The mean age of the patients at operation was 72.6±9.3 years. Fifty five percent of the patients (n=11) presented with moderate to severe symptomatic aortic valve stenosis, while 35% (n=7) suffered from severe aortic regurgitation. All patients had concomitant moderate to severe mitral valve disease, including regurgitation in 95% (n=19) and stenosis in 25% (n=5). Mean logistic EuroSCORE was 34.3%±24.7%. Cardiopulmonary bypass and cross-clamp times were 101 (88.0-123) minutes and 67.5 (51.7-85.2) minutes, respectively. Optimal sutureless aortic valve prosthesis device success was achieved in 20 patients (100%). One patient (5%) required permanent pacemaker implantation. Thirty-day mortality was 10% and no strokes were detected.

Conclusions

SU-AVR is a safe and feasible surgical alternative to conventional procedures in patients presenting with multiple valvular heart disease. It provides excellent hemodynamic performance with low risk of paravalvular leakage and low transvalvular gradients, whilst simplifying the surgical procedure. Precise sizing and positioning of the valve prostheses is crucial to ensure optimal postoperative outcome.

Minimally invasive aortic valve replacement: short-term efficacy of sutureless compared with stented bioprostheses

OBJECTIVES

Sutureless aortic valve prostheses have been introduced to facilitate the implant process, speed up the operating time and improve haemodynamic performance. The goal of this study was to assess the potential advantages of using sutureless prostheses during minimally invasive aortic valve replacement in a large multicentre population.

METHODS

From 2011 to 2019, a total of 3402 patients in 11 hospitals underwent isolated aortic valve replacement with minimal access approaches using a bioprosthesis. A total of 475 patients received sutureless valves; 2927 received standard valves. The primary outcome was the incidence of 30-day deaths. Secondary outcomes were the occurrence of major complications following procedures performed with sutureless or standard bioprostheses. Propensity matched comparisons was performed based on a multivariable logistic regression model.

RESULTS

The annual number of sutureless valve implants increased over the years. The matching procedure paired 430 sutureless with 860 standard aortic valve replacements. A total of 0.7% and 2.1% patients with sutureless and standard prostheses, respectively, died within 30 days (P = 0.076). Cross-clamp times [48 (40-62) vs 63 min (48-74); P = 0.001] and need for blood transfusions (27.4% vs 33.5%; P = 0.022) were lower in patients with sutureless valves. No difference in permanent pacemaker insertions was observed in the overall population (3.3% vs 4.4% in the standard and sutureless groups; P = 0.221) and in the matched groups (3.6% vs 4.7% in the standard and sutureless groups; P = 0.364).

CONCLUSIONS

The use of sutureless prostheses is advantageous and facilitates the adoption of a minimally invasive approach, reducing cardiac arrest time and the number of blood transfusions. No increased risk of permanent pacemaker insertion was observed.

Effect of Prolonged Hypothermic Cardiopulmonary Bypass, Heparin, and Protamine on Platelet: A Small-Group Study

Cardiopulmonary bypass (CPB) is associated with platelet dysfunction (PD), an important cause of postoperative bleeding. The etiology of PD is not completely understood. We mapped the platelets' function during CPB to determine the etiology of PD. Platelets activation, measured by procaspase activating compound-1 and P-selectin expression (CD62P), after activation by adenosine diphosphate and thrombin receptor activator peptide, were decreased by protamine. Changes during CPB were insignificant. Platelet-leukocyte aggregation was increased by CPB but not by protamine. Platelet apoptosis marker, annexin V, was increased by protamine. Changes during CPB were insignificant. Our findings demonstrate that protamine given after CPB plays a central role in PD and count decrease.

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

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

Sutureless valve and rapid deployment valves: a systematic review and meta-analysis of comparative studies

Background

The treatment of aortic valve disease is the most common valvular surgery in industrialized nations, with 3-9% of the population over the age of eighty having at least moderate aortic stenosis. As transcatheter aortic valve replacement (TAVR) has become more established, newer surgical prostheses have been developed with a variety of anchoring systems that do not rely solely on sutures to hold the valve in an appropriate position. The Edwards Intuity valve is a bovine pericardial prosthesis that is modelled on the widely implanted Perimount MagnaEase aortic prosthesis. The Perceval valve is a bovine pericardial valve attached to a self-expanding nitinol stent, which uses the radial force exerted on the patient's aortic annulus and aortic root by the stent portion to hold the valve in position. This meta-analysis compares the outcomes of comparative studies of these two valve systems.

Methods

This systematic review and meta-analysis compares the outcomes of rapid deployment valves (RDV) and sutureless valves (SURD) and was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations and guidance. The search strategy interrogated six electronic databases. Outcomes measured included all-cause mortality at latest follow up, stroke, cross-clamp and cardiopulmonary bypass (CPB) times, pacemaker implantation rates, paravalvular leak and post-operative transvalvular gradient.

Results

The search strategy identified 407 unique papers for initial assessment with seven studies qualifying for inclusion in the analysis. The outcomes of 4,076 patients (1,650 RDV, 2,426 SURD) were included. There was no difference in mortality, stroke or moderate or worse paravalvular regurgitation between the two groups. SURD had significantly shorter CPB time by 15.7 minutes [95% confidence interval (CI): 4.2-27.1; P=0.007] and a shorter cross-clamp time by 11.3 minutes (95% CI: 6.3-16.3; P<0.001) compared to RDV. RDV had a lower post-operative transvalvular gradient by 2.5 mmHg (95% CI: 1.2-3.8; P<0.001) and a lower rate of mild paravalvular regurgitation (OR 2.51; 95% CI: 1.435-4.768; P=0.004).

Conclusions

Both valve types have an adequate safety profile and are comparable to conventional sutured prostheses. There was a significant reduction in cross-clamp and CPB times associated with SURD. This may be of benefit for patients requiring multiple concomitant procedures and increases the utility of minimally invasive valve replacement. However, SURD was associated with higher post-operative transvalvular gradients and a higher incidence of paravalvular regurgitation.

Intra-operative hyperoxia and the risk of delirium in elderly patients after cardiac surgery

Delirium is a common complication after cardiac surgery. The aim of our study was to determine the impact of hyperoxia episodes occurring during cardiopulmonary bypass (CBP) on the rate of delirium episodes in the postoperative period. 93 patients, aged ≥ 65, who underwent elective cardiac surgery (CBP <90 minutes) were enrolled. The occurrence of delirium episodes was examined every 12 hours for three days after surgery. Eleven patients (11.8%) developed postoperative delirium (POD (+)) and 83 did not (POD (-)). More incidences of severe hyperoxia (PaO2 ≥ 26.6kPa) during CBP were observed in the POD (+) group: 64% had ≥ 2 episodes of hyperoxia, 27% ≥ 3, and 18% ≥ 4, while in the POD (-) group: 42%, 13% and 1%, respectively (P=0.02). Patients in the POD (+) group had a higher maximum PaO₂ during CBP than the POD (-) group (37 ± 5.8 vs 31.6 ± 6.6 kPa; P=0.01) and a higher mean PaO₂ (30.1 ± 4.5 vs 26.1 ± 5.6 kPa; P=0.01). The optimal maximum PaO₂ cut-off point for the occurrence of delirium was 33.2 kPa (AUC 0.72, P=0.001, sensitivity 75%, specificity 38%). We conclude that CBP hyperoxia episodes may be a risk factor associated with the occurrence of postoperative delirium.

Association between cardiopulmonary bypass time and 90-day post-operative mortality in patients undergoing arch replacement with the frozen elephant trunk: a retrospective cohort study

Supplemental Digital Content is available in the text

Background

The aortic arch replacement and cardiopulmonary bypass (CPB) are both associated with the early mortality after cardiothoracic surgery. This study aimed to investigate the relationship between CPB time and 90-day post-operative mortality in patients undergoing aortic arch surgery using the frozen elephant trunk (FET) technique with selective ante-grade cerebral perfusion (SACP).

Methods

We retrospectively reviewed data of 377 adult patients undergoing aortic arch surgery via FET with SACP from July 1, 2017 to December 31, 2018 at Beijing Anzhen Hospital. The baseline characteristics, intra-operative data, and post-operative data were collected. Univariate and multivariate Cox regression analyses were used to determine independent predictors of 90-day post-operative mortality.

Results

The 90-day post-operative mortality was 13.53%. The 78.51% of patients were men. There were 318 (84.35%) type A aortic dissections and 28 (7.43%) aortic aneurysms. Among those, 264 (70.03%) were emergency operations. Median CPB time was 202.0 (176.0, 227.0) min. Multivariate Cox regression analysis revealed that CPB time was independently associated with 90-day post-operative mortality after adjusting confounding factors (hazard ratio: 1.21/10 min increase in CPB time, 95% confidence interval: 1.15–1.27, P < 0.001). Kaplan-Meier analysis based on CPB time tertiles revealed that the top tertile (median 236.0 min) was associated with reduced survival rate compared with middle and bottom tertiles (P < 0.001). Each sub-group analysis based on the complexity of the underlying disease process showed similar associations between CPB time and 90-day post-operative mortality.

Conclusions

CPB time remains a significant factor in determining 90-day post-operative mortality in patients undergoing aortic arch surgery using FET with SACP. Surgeons should be aware of the relationship between CPB time and 90-day post-operative mortality during operative procedures and avoid extended CPB time as far as possible.

Comparison of automated fastener device Cor-Knot versus manually-tied knot in minimally-invasive isolated aortic valve replacement surgery

BACKGROUND

The aim of our prospective study was to evaluate the efficacy and the safety of the Cor-Knot device in isolated aortic valve replacement by right anterior minithoracotomy.

METHODS

A single-center, prospective study was conducted between September 2009 and June 2018. Four hundred and forty patients were operated on for aortic valve replacement by right anterior minithoracotomy. Of these patients, 221 underwent isolated AVR surgery with stented prosthesis. Sutures were secured using the Cor-Knot titanium fastener in 63 patients (28.5%) and knots were hand-tied in 158 (71.5%). Statistical analyses were done using a propensity score with 1:1 matching for the automatically tied (AT) and manually tied (MT) patients.

RESULTS

The aortic cross-clamping and cardiopulmonary bypass times were significantly decreased in the AT group (74±13.8 minutes vs. 90.4±23.7 minutes, P<0.0001, and 100.8±20.6 minutes vs. 117.6±33.1 minutes, P<0.0001), compared with the MT group. Clinical outcomes were similar in the two groups, whether in the analysis of non-matched or matched groups. There was no difference in 30 day-mortality (1.2% vs. 0%, P=0.37), and the stroke and transient ischemic attack rates were comparable (2.5% vs. 1.6%; P=0.67). There was no significant increase in pacemaker implantation in the AT group (1.3% vs. 0%, P=0.36), and the rate of aortic regurgitation ≥ 2 was lower (3.9% vs. 0%; P=0.11) but not statistically significant.

CONCLUSIONS

The automated Cor-Knot fastener is an easy-to-use, time-saving device which does not increase perioperative morbidity and mortality in patients undergoing aortic valve replacement by right anterior minithoracotomy.

Titanium Fastener Utilization During HeartMate 3 Left Ventricular Assist Device Implantation

OBJECTIVE

The objective of this study was to investigate the feasibility of using titanium fasteners for securement of the inflow sewing ring during HeartMate 3 implantation. The secondary objective was to compare cardiopulmonary bypass and total operative times between the titanium fastener and hand-tied knot groups.

METHODS

Clearance between the sewing ring and the HeartMate 3 device was assessed in vitro. Thirty-one patients undergoing HeartMate 3 implantation via median sternotomy at a single center from April 2017 to February 2018 were reviewed. The sewing ring was secured with hand-tied knots (n = 18) or titanium fasteners (n = 13). Cannulation strategy and implantation technique were otherwise identical between groups. Central arterial and venous cannulation was performed for cardiopulmonary bypass. The left ventricular apex was cored, and the sewing ring was attached with hand-tied knots or titanium fasteners.

RESULTS

There was adequate clearance for the titanium fastener to secure the inflow sewing ring and then connect to the HeartMate 3 in vitro. The inflow sewing ring was successfully secured during HeartMate 3 implantation in the titanium fastener group. Cardiopulmonary bypass time was 75 and 92 minutes for the titanium fastener and hand-tied groups, respectively (P < 0.03). Total operative time was 177 and 193 minutes for the titanium fastener and hand-tied groups, respectively (P = 0.513).

CONCLUSIONS

The inflow sewing ring of the HeartMate 3 was efficiently secured using titanium fasteners. Titanium fasteners resulted in shorter cardiopulmonary bypass times compared with the hand-tied group. There was no difference in total operative time.

Sutureless aortic valves: who is the right patient?

PURPOSE OF REVIEW

Sutureless aortic valve replacement (AVR) has emerged as an alternative to traditional AVR for patients with aortic stenosis who present a higher surgical risk, such as the elderly, or those with small or highly calcified aortic roots. With transcatheter aortic valve implantation - the other major AVR alternative - being used in increasingly lower-risk patients, the place of sutureless valves in the AVR landscape needs to be defined. In this review, we discuss recent data and expert opinion as it pertains to the subject of sutureless AVR.

RECENT FINDINGS

Several recent studies have evaluated the performance of sutureless valves in a variety of clinical contexts, including minimally invasive operations and high-risk surgical procedures. The optimal surgical technique for sutureless AVR has been refined through the publication of several reports addressing technical considerations. Reduction in operative times represents the main advantage of sutureless valves over conventional surgical prostheses, and the possibility of complete annular decalcification - and hence a reduced incidence of paravalvular leak - is the primary advantage over TAVI.

SUMMARY

Sutureless valves have emerged as an attractive option for high-risk patients or for complex surgeries where a minimization of bypass time is critical. However, there is limited data regarding long-term outcomes, durability or reoperation.

Comparison of Automated Titanium Fasteners to Hand-Tied Knots in Open Aortic Valve Replacement

Objective

Aortic cross-clamp and cardiopulmonary bypass times are independent predictors of postoperative morbidity and mortality. Reducing ischemic times with automated titanium fasteners may improve surgical outcomes. This study compared operative times and costs of titanium fasteners versus hand-tied knots for prosthesis securement in open aortic valve replacement.

Methods

A randomized control trial was conducted during a 16-month period at a single university medical center. Patients undergoing elective aortic valve replacement were randomized to the titanium fastener (n = 37) or hand-tied groups (n = 36). Knotting, aortic cross-clamp, cardiopulmonary bypass, and total operating room times were recorded. Hospital charges were also calculated for these procedures.

Results

Baseline characteristics, concomitant procedures, prosthetic valve size, and sutures were similar between groups. The titanium fastener group had significantly reduced knotting (7.4 vs. 13.0 minutes, P < 0.001), aortic cross-clamp (69 vs. 90 minutes, P < 0.05), cardiopulmonary bypass (86 vs. 114 minutes, P < 0.05), and total operating room times (234 vs. 266 minutes, P < 0.05). Intraoperative complications occurred more frequently in the hand-tied group compared with the titanium fastener group. Postoperative complications were similar between groups. Operating room costs were significantly higher in the titanium fastener group (US $10,428 vs. US $9671, P = 0.01). Hospitalization costs did not differ significantly between the titanium fastener and hand-tied group (US $23,987 vs. US $21,068, P = 0.12).

Conclusions

Titanium fastener use was associated with shorter knotting, aortic cross-clamp, cardiopulmonary bypass, and operating room times and fewer intraoperative complications in open aortic valve replacement, without significantly increasing hospitalization cost.

Continuous Suture Technique for Aortic Valve Replacement Shortens Cross-Clamp and Bypass Times

The interrupted noneverting mattress suture technique is typically used in conventional surgical aortic valve replacement. The continuous suture technique, although faster, has been associated with a higher incidence of paravalvular leak. Using a slightly modified technique to minimize this risk, we investigated whether continuous suturing would shorten aortic cross-clamp time in aortic valve replacement in comparison with interrupted suturing. We reviewed the cases and compared the perioperative data of 60 consecutive patients in Japan and Australia (35 men and 25 women; median age, 70 yr) who had undergone aortic valve replacement with or without septal myectomy. The continuous suture technique had been used in 41 patients (Group CS) and the standard interrupted suture technique in 19 (Group IS). The groups were similar in age, sex, pathologic valvular conditions, and operative urgency. In Group CS, aortic cross-clamp time (47 vs 63 min; P=0.0001) and cardiopulmonary bypass time (76 vs 89 min; P=0.04) were significantly shorter. Neither group had early paravalvular leak. Using our continuous suture technique safely shortened aortic cross-clamp time during surgical aortic valve replacement.

Revisiting the utility of technical performance scores following tetralogy of Fallot repair

OBJECTIVE

Although an important quality metric, current technical performance scores may not be generalizable and may omit operative factors that influence outcomes. We examined factors not included in current technical performance scores that may contribute to increased postoperative length of stay, major complications, and cost after primary repair of tetralogy of Fallot.

METHODS

This is a retrospective single site study of patients younger than age 2 years with tetralogy of Fallot undergoing complete repair between 2007 and 2015. Medical record data and discharge echocardiograms were reviewed to ascertain component and composite technical performance scores. Primary outcomes included postoperative length of stay, major complications, and total hospital costs. Multivariable logistic and linear regression identified determinants of each outcome.

RESULTS

Patient population (n = 115) had a median postoperative length of stay of 8 days (interquartile range, 6-10 days), and a median total cost of $71,147. Major complications occurred in 33 patients (29%) with 1 death. Technical performance scores assigned were optimum in 28 patients (25%), adequate in 59 patients (52%), and inadequate in 26 patients (23%). Neither technical performance score components nor composite scores were associated with increased postoperative length of stay. Optimum or adequate repairs versus inadequate had equal risk of a complication (P = .79), and equivalent mean total cost ($100,000 vs $187,000; P = .25). Longer cardiopulmonary bypass time per 1-minute increase (P < .01) was associated with longer postoperative length of stay and reintervention (P = .02). The need to return to bypass also increased total cost (P < .01).

CONCLUSIONS

Current tetralogy of Fallot technical performance scores were not associated with selected outcomes in our postoperative population. Although returning to bypass and bypass length are not included as components in the current score, these are important factors influencing complications and resource use in our population. Revisions anticipated from a prospective trial should consider including these variables.

Minimally Invasive Aortic Valve Replacement via Right Anterior Minithoracotomy and Central Aortic Cannulation

Objective

This study reports the evolution of a minimally invasive aortic valve replacement (mini-AVR) technique that uses a right anterior minithoracotomy approach with central cannulation, for a 13-year period. This technique has become our standard approach for isolated primary AVR in nearly all patients.

Methods

This observational study evaluated perioperative clinical outcomes of patients 18 years or older who underwent mini-AVR from November 2003 to June 2015.

Results

The mini-AVR technique was used in 202 patients during two periods of 2003 to 2009 (n = 65, “early”) and 2010 to 2015 (n = 137, “late”). The mean ± SD age was 72.5 ± 12.9 years and 60% were male. Demographic parameters were statistically similar between the study periods, except for increased body weight in the later period (75.3 ± 14.7 vs 80.9 ± 20.8 kg, P = 0.03). The mean cardiopulmonary bypass and aortic cross-clamp times were significantly different by each year and Bonferroni adjustment, with significant decreases in cardiopulmonary bypass and aortic cross-clamp times beginning 2006. Compared with the early study period, late study period patients were more often extubated intraoperatively (52% vs 12%, P < 0.001), had less frequent prolonged ventilator use postoperatively (6% vs 16%, P = 0.018), required fewer blood transfusions (mean, 2.0 ± 2.3 U vs 3.6 ± 3.0 U; P = 0.011), and had shorter postoperative stay (6.3 ± 4.5 days vs 8.0 ± 5.9 days, P = 0.026). Numerically, fewer postoperative strokes (1% vs 6%, P = 0.09) and fewer reoperations for bleeding (3% vs 6%, P = 0.3) occurred in the late period. In-hospital mortality did not differ (1/65 early vs 3/137 late).

Conclusions

Overall mini-AVR intraoperative and postoperative clinical outcomes improved for this 13-year experience.

Sutureless Aortic Valves: Combining the Best or the Worst?

Aortic valve replacement is a life saving intervention. Significant progress has been made toward reducing surgical trauma through minimally invasive surgery and transcatheter techniques. Each of these approaches has its advantages and limitations. Sutureless aortic valves have been proposed to overcome these limitations and have been in use in Europe. It is however less than clear whether these valves will prove advantageous and whether they will have a role in the future. We review the published literature for sutureless aortic valves and their performance against standard and transcatheter aortic valve replacements.

Right ventricular function following surgical aortic valve replacement and transcatheter aortic valve implantation: A cardiovascular MR study

OBJECTIVE

The response of the RV following treatment of aortic stenosis is poorly defined, reflecting the challenge of accurate RV assessment. Cardiovascular magnetic resonance (CMR) is the established reference for imaging of RV volumes, mass and function. We sought to define the impact of transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR) upon RV function in patients treated for severe aortic stenosis using CMR.

METHODS

A 1.5T CMR scan was performed preoperatively and 6months postoperatively in 112 (56 TAVI, 56 SAVR; 76±8years) high-risk severe symptomatic aortic stenosis patients across two UK cardiothoracic centres.

RESULTS

TAVI patients were older (80.4±6.7 vs. 72.8±7.2years, p<0.05) with a higher STS score (2.13±0.73 vs. 5.54±3.41%, p<0.001). At 6months, SAVR was associated with a significant increase in RV end systolic volume (33±10 vs. 37±10ml/m², p=0.008), and decrease in RV ejection fraction (58±8 vs. 53±8%, p=0.005) and tricuspid annular plane systolic excursion (22±5 vs. 14±3mm, p<0.001). Only 4 (7%) SAVR patients had new RV late gadolinium hyper-enhancement with no new cases seen in the TAVI patients at 6months. Longer surgical cross-clamp time was the only predictor of increased RV end systolic volume at 6months. Post-TAVI, there was no observed change in RV volumes or function. Over a maximum 6.3year follow-up, 18(32%) of TAVI patients and 1(1.7%) of SAVR patients had died (p=0.001). On multivariable Cox analysis, the RV mass at 6m post-TAVI was independently associated with all-cause mortality (HR 1.359, 95% CI 1.108-1.666, p=0.003).

CONCLUSIONS

SAVR results in a deterioration in RV systolic volumes and function associated with longer cross-clamp times and is not fully explained by suboptimal RV protection during cardiopulmonary bypass. TAVI had no adverse impact upon RV volumes or function.

Early Outcomes of Sutureless Aortic Valves

Background

In elderly high-risk surgical patients, sutureless aortic valve replacement (AVR) should be an alternative to standard AVR. The potential advantages of sutureless aortic prostheses include reducing cross-clamping and cardiopulmonary bypass (CPB) time and facilitating minimally invasive surgery and complex cardiac interventions, while maintaining satisfactory hemodynamic outcomes and low rates of paravalvular leakage. The current study reports our single-center experience regarding the early outcomes of sutureless aortic valve implantation.

Methods

Between October 2012 and June 2015, 65 patients scheduled for surgical valve replacement with symptomatic aortic valve disease and New York Heart Association function of class II or higher were included to this study. Perceval S (Sorin Biomedica Cardio Srl, Sallugia, Italy) and Edwards Intuity (Edwards Lifesciences, Irvine, CA, USA) valves were used.

Results

The mean age of the patients was 71.15±8.60 years. Forty-four patients (67.7%) were female. The average preoperative left ventricular ejection fraction was 56.9±9.93. The CPB time was 96.51±41.27 minutes and the cross-clamping time was 60.85±27.08 minutes. The intubation time was 8.95±4.19 hours, and the intensive care unit and hospital stays were 2.89±1.42 days and 7.86±1.42 days, respectively. The mean quantity of drainage from chest tubes was 407.69±149.28 mL. The hospital mortality rate was 3.1%. A total of five patients (7.69%) died during follow-up. The mean follow-up time was 687.24±24.76 days. The one-year survival rate was over 90%.

Conclusion

In the last few years, several models of valvular sutureless bioprostheses have been developed. The present study evaluating the single-center early outcomes of sutureless aortic valve implantation presents the results of an innovative surgical technique, finding that it resulted in appropriate hemodynamic conditions with acceptable ischemic time.

Advances in the management of severe aortic stenosis

BACKGROUND

Recent developments in the management of severe aortic stenosis have resulted in a paradigm shift in the way we view the condition. Patients previously denied intervention in the form of surgical aortic valve replacement (SAVR) are now candidates for transcatheter aortic valve implantation and the risk and age profiles of those undergoing SAVR are rising with the ageing population. This review article is designed to provide an overview of developments in the surgical management of severe aortic stenosis. We also discuss the expanding role of minimally invasive surgical approaches to outline the current techniques available to treat patients with severe aortic stenosis.

METHODS

PubMed was searched using the terms 'severe aortic stenosis', 'surgical aortic valve replacement', 'transcatheter aortic valve replacement', 'mechanical aortic valve replacement' and 'sutureless aortic valve replacement'. Selection of articles was based on peer review, journal and relevance. Where possible articles from high-impact factor peer review journals were included.

RESULTS

Minimally invasive operative approaches include mini-sternotomy and mini-thoracotomy. Sutureless aortic prostheses reduce aortic cross-clamp time and cardiopulmonary bypass time; however, long-term follow-up data are unavailable at this time. Mechanical prostheses are advised for those under 60.

CONCLUSION

Multiple advances in the surgical management of aortic stenosis have occured in the past decade. An evolving spectrum of surgical and transcatheter interventions is now available depending on patient age and operative risk.

Clinical Outcome and Cost Analysis of Sutureless Versus Transcatheter Aortic Valve Implantation With Propensity Score Matching Analysis

Surgical sutureless and interventional transcatheter aortic valve prostheses are nowadays extensively adopted in high-risk elderly patients. An explorative analysis was carried out to compare the clinical outcome and costs associated to these approaches. Since 2010, a total of 626 patients were distributed between transcatheter aortic valve implantation (TAVI; n = 364) and sutureless (n = 262) groups. Patients of both groups were not comparable for clinical and surgical characteristics, but many patients were in a "gray zone"; therefore, a retrospective propensity score analysis was possible and performed. For the matched pair samples, postoperative, follow-up clinical data, and costs data were obtained. In-hospital death occurred in 5 patients in sutureless group and 3 patients in TAVI group (p = 0.36). Blood transfusions were higher in sutureless group (2.1 ± 2.3 vs 0.4 ± 1.0 U). TAVI group had a shorter intensive care unit and hospital stay (2.2 ± 2.7 vs 3.2 ± 3.5 days, p = 0.037; 12 ± 6 vs 14 ± 6 days, p = 0.017). No differences in postoperative neurologic (p = 0.361), renal (p = 0.106), or respiratory (p = 0.391) complications were observed between groups. At follow-up (24.5 ± 13.8 months), 1 patient in sutureless group and 7 patients in TAVI group died (p = 0.032). Paravalvular leakage occurred more frequently in patients in TAVI group (35 [34%] vs 7 [6.9%]; p <0.001) with an impact on follow-up survival rate. The costs associated to the 2 procedures are similar when the cost of the device was excluded (p = 0.217). When included, the sutureless approach resulted a cost saving (€22,451 vs €33,877, p <0.001). In conclusion, the patients in the "gray zone" record a satisfying clinical outcome after sutureless surgery and TAVI. Patients in the sutureless group endure more hospital complications, but TAVI entails a higher follow-up mortality. On the costs aspects, TAVI technologies are more expensive, and it reflects on higher overall hospital costs.

A Meta-Analysis Examining Differences in Short-Term Outcomes between Sutureless and Conventional Aortic Valve Prostheses

Objective

Sutureless aortic valve prostheses are anchored by radial force in a mechanism similar to that of transcatheter aortic valve implantation. Transcatheter aortic valve implantation is associated with an increased permanent pacemaker (PPM) requirement in a significant proportion of patients. We undertook a meta-analysis to examine the incidence of PPM insertion associated with sutureless compared with conventional surgical aortic valve replacement.

Methods

A systematic review was conducted in accordance with the Prisma guidelines.1 All searches were performed on August 10, 2014. Studies between 2007 and 2014 were included in the search.

Results

A total of 832 patients were included in the sutureless group and 3,740 in the conventional group. Aortic cross-clamp (39.8 vs 62.4 minutes; P < 0.001) and cardiopulmonary bypass (64.9 vs 86.7 minutes; P = 0.002) times were shorter in the sutureless group. Permanent pacemaker implantation rate was higher in the sutureless cohort (9.1% vs 2.4%; P = 0.025).

Conclusions

Sutureless aortic valve prostheses are associated with significantly shorter cardiopulmonary bypass and aortic cross-clamp times and a higher incidence of PPM insertion than conventional. Further investigation of the prognostic significance is required.

[Cardiopulmonary bypass duration as predictor of immediate results after cardiac surgery]

It was analyzed the results of treatment of 152 patients who underwent heart valve surgery. Depending on cardiopulmonary bypass (CPB) duration patients were divided into 4 groups: the 1st--up to 90 min, the 2nd--90-120 min, the 3rd--120-180 min, the 4th--more than 180 min. Severity of initial comorbidities was comparable in all groups. It was revealed that CPB duration effects on intraoperative blood loss, incidence of acute renal failure, encephalopathy, use of inotropic and angiotonic support (p<0.05). Accession of CPB duration was associated with increased number of postoperative complications in all groups (p<0.05). "Critical periods" of CPB for every type of postoperative complications are defined.

Sutureless aortic valve replacement

The increasing incidence of aortic stenosis and greater co-morbidities and risk profiles of the contemporary patient population has driven the development of minimally invasive aortic valve surgery and percutaneous transcatheter aortic valve implantation (TAVI) techniques to reduce surgical trauma. Recent technological developments have led to an alternative minimally invasive option which avoids the placement and tying of sutures, known as "sutureless" or rapid deployment aortic valves. Potential advantages for sutureless aortic prostheses include reducing cross-clamp and cardiopulmonary bypass (CPB) duration, facilitating minimally invasive surgery and complex cardiac interventions, whilst maintaining satisfactory hemodynamic outcomes and low paravalvular leak rates. However, given its recent developments, the majority of evidence regarding sutureless aortic valve replacement (SU-AVR) is limited to observational studies and there is a paucity of adequately-powered randomized studies. Recently, the International Valvular Surgery Study Group (IVSSG) has formulated to conduct the Sutureless Projects, set to be the largest international collaborative group to investigate this technology. This keynote lecture will overview the use, the potential advantages, the caveats, and current evidence of sutureless and rapid deployment aortic valve replacement (AVR).

Aortic valve replacement through full sternotomy with a stented bioprosthesis versus minimally invasive sternotomy with a sutureless bioprosthesis

OBJECTIVES

The aim of this study was to analyse early postoperative outcomes and 2-year survival after aortic valve replacement (AVR) through a ministernotomy with a sutureless bioprosthesis implantation compared with a full sternotomy with implantation of a stented bioprosthesis.

METHODS

Patients who underwent primary isolated non-emergent AVR at six European centres were included in the study. Of these, 182 (32%) underwent a ministernotomy with a sutureless bioprosthesis (ministernotomy sutureless group) and 383 (68%) a full sternotomy with a stented bioprosthesis (full sternotomy stented group). Propensity score matching was used to reduce selection bias.

RESULTS

In the overall cohort, 30-day mortality was 1.6 and 2.1%, and 2-year survival was 92 and 92% in the ministernotomy sutureless group and in the full sternotomy stented group, respectively. Propensity score matching resulted in 171 pairs with similar characteristics and operative risk. Aortic cross-clamp (40 vs 65 min, P < 0.001) and cardiopulmonary bypass time (69 vs 87 min, P < 0.001) were shorter in the ministernotomy sutureless group. Patients undergoing ministernotomy received less packed red blood cells but the risk for postoperative permanent pacemaker implantation was higher. There were no differences regarding 30-day mortality or 2-year survival between the two groups.

CONCLUSIONS

AVR through a ministernotomy with implantation of a sutureless bioprosthesis was associated with shorter aortic cross-clamp and cardiopulmonary bypass time and less transfusion of packed red blood cells, but a higher risk for postoperative permanent pacemaker implantation compared with a full sternotomy with a stented bioprosthesis.