A comparison of surgical, total percutaneous, and hybrid approaches to treatment of combined coronary artery and valvular heart disease

Heart valve surgery and the obesity paradox: A systematic review

Obesity has been associated with increased incidence of comorbidities and shorter life expectancy, and it has generally been assumed that patients with obesity should have inferior outcomes after surgery. Previous literature has often demonstrated equivalent or even improved rates of mortality after cardiac surgery when compared to their lower-weight counterparts, coined the obesity paradox. Herein, we aim to review the literature investigating the impact of obesity on surgical valve interventions. PubMed and Embase were systematically searched for articles published from 1 January 2000 to 15 October 2021. A total of 1315 articles comparing differences in outcomes between patients of varying body mass index (BMI) undergoing valve interventions were reviewed and 25 were included in this study. Patients with higher BMI demonstrated equivalent or reduced rates of postoperative myocardial infarction, stroke, reoperation rates, acute kidney injury, dialysis and bleeding. Two studies identified increased rates of deep sternal wound infection in patients with higher BMI, although the majority of studies found no significant difference in deep sternal wound infection rates. The obesity paradox has described counterintuitive outcomes predominantly in coronary artery bypass grafting and transcatheter aortic valve replacement. Recent literature has identified similar trends in other heart valve interventions. While the obesity paradox has been well characterized, its causes are yet to be identified. Further study is essential in order to identify the causes of the obesity paradox so patients of all body sizes can receive optimal care.

Clinical analysis of coronary artery bypass grafting and concurrent cardiac valve surgery in elderly patients

OBJECTIVE

This study aimed to investigate the clinical effects and perioperative treatment experience of elderly patients with valvular heart disease combined with coronary heart disease undergoing cardiac valve surgery (CVS) and coronary artery bypass grafting (CABG) concurrently.

METHODS

Seventy-eight patients with heart valve disease and coronary heart disease, aged over 65 and who underwent CVS and CABG concurrently between January 2016 and December 2020, were enrolled in this study. The clinical indexes related to cardiac function before and after surgery, early postoperative complications, and prognosis were analyzed retrospectively to explore the clinical effects and perioperative treatment experience of elderly patients undergoing these two procedures concurrently.

RESULTS

All patients were reexamined by echocardiography one month after surgery. The results showed that the left ventricular end-diastolic dimension, N-terminal pro-B-type natriuretic peptide levels, cardiothoracic ratio, and troponin-I levels were significantly lower than before surgery, and the differences were statistically significant (P < 0.05). The echocardiography revealed that the left ventricular end-diastolic volume, left ventricular ejection fraction, and left ventricular fractional shortening were larger than before surgery, and these differences were statistically significant (P < 0.05).

CONCLUSION

It is feasible and effective for elderly patients to undergo CVS and CABG concurrently. Perioperative management can reduce mortality, achieving good clinical effects.

Review of the differences in outcomes between males and females after revascularization

PURPOSE OF REVIEW

This review aims to compare outcomes of males and females undergoing coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), off-pump CABG (OPCAB), minimally invasive direct CABG (MIDCAB), and robotic total endoscopic CABG (TECAB).

RECENT FINDINGS

Females demonstrated increased rates of morbidity and mortality post PCI and CABG. In studies that performed risk adjustments, these differences were reduced. Although inferior outcomes were observed for females in some measures, generally outcomes between males and females were comparable post OPCAB, MIDCAB, and TECAB.

SUMMARY

Previous literature has demonstrated that females undergoing coronary revascularization experience inferior postoperative outcomes when compared to their male counterparts. The discrepancies between males and females narrow, but do not disappear when preoperative risks are accounted for and when considering minimally invasive approaches such as MIDCAB, OPCAB, and TECAB. Minimally invasive cardiac surgery has demonstrated numerous benefits with reduced morbidity, mortality, and shorter recovery times. In patients with increased comorbidities, minimally invasive approaches confer a greater advantage. As females often fall within this category, it is paramount that the diagnosis and referral process be optimized to account for preoperative differences to provide the most beneficial approach if the disparity between the sexes is to be addressed.

What Can We Learn from the Past by Means of Very Long-Term Follow-Up after Aortic Valve Replacement?

Background: Studies on very long-term outcomes after aortic valve replacement are sparse. Methods: In this retrospective cohort study, long-term outcomes during 25.1 ± 2.8 years of follow-up were determined in 673 patients who underwent aortic valve replacement with or without concomitant coronary artery bypass surgery for severe aortic stenosis and/or regurgitation. Independent predictors of decreased long-term survival were determined. Cumulative incidence rates of major adverse events in patients with a mechanical versus those with a biologic prosthesis were assessed, as well as of major bleeding events in patients with a mechanical prosthesis under the age of 60 versus those above the age of 60. Results: Impaired left ventricular function, severe prosthesis–patient mismatch, and increased aortic cross-clamp time were independent predictors of decreased long-term survival. Left ventricular hypertrophy, a mechanical or biologic prosthesis, increased cardiopulmonary bypass time, new-onset postoperative atrial fibrillation, and the presence of symptoms did not independently predict decreased long-term survival. The risk of major bleeding events was higher in patients with a mechanical in comparison with those with a biologic prosthesis. Younger age (under 60 years) did not protect patients with a mechanical prosthesis against major bleeding events. Conclusions: Very long-term outcome data are invaluable for careful decision-making on aortic valve replacement.

Review of the use of simulators in learning revascularization techniques

PURPOSE OF REVIEW

The apprentice model has been traditionally used to train cardiac surgery and cardiology learners the techniques for revascularization with the use of simulators recently becoming more prevalent in these training programs. This review aims to summarize research conducted on the use of simulation-based teaching (SBT) for trainees learning percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), and off-pump CABG (OPCAB).

RECENT FINDINGS

Prior literature evaluating the utility of SBT has demonstrated remarkable results including reduced procedural times, use of fluoroscopy, incidence of mistakes, improved stent placement, and confidence with PCI simulators. Similarly, the use of CABG and OPCAB simulators demonstrated improvement in forceps use, needle angles, Objective Structured Assessment of Technical Skill, and reduced completion times. The apprentice model has undoubtedly been successful as the most successful cardiac surgeons and cardiologists have been produced through this training model. Even so, many shortcomings have been identified including insufficient time to teach all relevant technical skills, inadequate exposure to rare adverse events, high-cost, and often unstructured format while being time-consuming and resource-intensive with little objective assessment of proficiency. SBT has been pursued as a potential adjunct to fill the gaps left by the traditional apprentice model. While simulations have been demonstrated to be successful in teaching both experienced and inexperienced learners complex techniques, it is unlikely that training will ever solely rely on simulations. The most efficient method of training learners for revascularization in the future will likely involve a combination of hands-on learning and SBT.