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Moawad KR, Mohamed S, Hammad A, Barker T. The Clinical Impact of Paravalvular Leaks With Transcutaneous Aortic Valve Implantation (TAVI) Versus Surgical Aortic Valve Replacement (SAVR): A Systematic Review and Meta-Analysis. Heart Lung Circ 2024:S1443-9506(24)00155-0. [PMID: 38839468 DOI: 10.1016/j.hlc.2024.02.017] [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: 09/12/2023] [Revised: 02/01/2024] [Accepted: 02/13/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND Aortic valve stenosis is a common cardiac condition that requires intervention for symptomatic and/or prognostic reasons. The two most common interventions are surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI). The ratio of TAVI:SAVR has increased twofold over the past few years and is now being considered in intermediate-risk patients as well. One of the significant benefits of TAVI is that it is less invasive; however, one of the drawbacks is a high paravalvular leaks (PVLs) rate compared to SAVR. To assess the impact of PVLs on survival, progression of heart failure, and the need for re-intervention. METHOD We conducted a comprehensive systematic literature search from the conception of TAVI 2002 until December 2022 through Embase (Ovid), MEDLINE (Ovid), Science Direct, and CENTRAL (Wiley). We followed PRISMA guidelines and checklists. Review protocol registration ID in PROSPERO: CRD42023393742. RESULTS We identified 28 studies that met our eligibility criteria, and only 24 studies were suitable for pooling in a meta-analysis (including their hazard ratio with a confidence interval of 95%) assessing our primary outcome (all-cause mortality). The remaining four studies were narratively synthesised. RevMan V5.4 (Version 5.4. Cochrane Collaboration, 2020) was utilised to pool meta-analysis data to assess effect estimates of PVLs in both intervention arms, using a random effect model for calculation (hazard ratio 1.14 confidence interval 95% 1.08-1.21 [p<0.0001]), with a follow-up duration between 30 days to 5 years. CONCLUSION Patients with mild or higher degrees of PVLs in both intervention arms incurred unfavourable outcomes. The incidence of PVLs was significantly higher with TAVI; even a mild degree led to poor quality of life and increased all-cause mortality on long-term follow-up.
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Affiliation(s)
- Karim R Moawad
- Department of Cardio-Thoracic Surgery University Hospital Coventry and Warwickshire NHS Trust, Coventry, United Kingdom; Division of Surgical Sciences, University of Edinburgh, Edinburgh, Scotland.
| | - Saifullah Mohamed
- Department of Cardio-Thoracic Surgery University Hospital Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
| | - Alaa Hammad
- Department of Cardio-Thoracic Surgery University Hospital Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
| | - Thomas Barker
- Department of Cardio-Thoracic Surgery University Hospital Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
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2
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Shah VN, Binongo J, Wei J, Till BM, King C, McGee J, Plestis KA. Upper Hemisternotomy Versus Full Sternotomy for Replacement of the Supracoronary Ascending Aorta and Aortic Valve. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2024; 19:39-45. [PMID: 38087894 DOI: 10.1177/15569845231213074] [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: 03/06/2024]
Abstract
OBJECTIVE Upper hemisternotomy (UHS) for supracoronary ascending aorta replacement (scAAR) with concomitant aortic valve replacement (AVR) results in less trauma and potentially faster convalescence compared with full sternotomy (FS). Direct head-to-head studies are lacking. We compared a group of UHS patients with a matched group of FS patients undergoing scAAR and AVR. METHODS There were 198 patients who underwent scAAR and AVR procedures by a single surgeon between 1999 and 2020. After matching 6 preoperative characteristics, there were 50 UHS and 50 FS patients. Patients who required acute type A aortic dissection repair, reoperations, concomitant procedures, or hypothermic circulatory arrest were excluded. RESULTS In the matched sample, the hospital mortality rate was 1% (1 of 100). The median cardiopulmonary bypass time was 150 (interquartile range [IQR], 131 to 172) min and 164.5 (IQR, 138 to 190) min, respectively, for the UHS and FS groups (P = 0.08). The median aortic cross-clamp time was 121 (IQR, 107 to 139) min during UHS and 131 (IQR, 115 to 159) min during FS (P = 0.05). The median ventilation time was 7 (IQR, 3 to 14) h versus 17 (IQR, 10 to 24) h, respectively, after UHS and FS (P = 0.005). The median hospital length of stay was 7 (IQR, 6 to 9) days after UHS and 8 (IQR, 7 to 11) days after FS (P = 0.05). CONCLUSIONS The low morbidity and mortality support the wider use of UHS for scAAR and AVR in appropriately selected patients. Larger studies are needed to confirm these initial findings.
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Affiliation(s)
- Vishal N Shah
- Division of Cardiothoracic Surgery, Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Jose Binongo
- Department of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Jane Wei
- Department of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Brian M Till
- Division of Cardiothoracic Surgery, Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Colin King
- Division of Cardiothoracic Surgery, Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Jacqueline McGee
- Division of Cardiothoracic Surgery, Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Konstadinos A Plestis
- Division of Cardiothoracic Surgery, Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
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Agrawal T, Qamar F, Chebrolu LB, El-Tallawi KC. Prosthetic Aortic Valve Regurgitation. JACC Case Rep 2022; 4:775-779. [PMID: 35818604 PMCID: PMC9270610 DOI: 10.1016/j.jaccas.2022.05.005] [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: 01/20/2022] [Revised: 05/02/2022] [Accepted: 05/05/2022] [Indexed: 11/06/2022]
Abstract
A 65-year-old man presented with acute decompensated heart failure. He was found to have severe prosthetic aortic valve regurgitation caused by a fractured strut of a sutureless prosthetic aortic valve that embolized to the distal portion of the aorta. We highlight the importance of multimodality imaging in diagnosis and management. (Level of Difficulty: Intermediate.)
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Shah VN, Kilcoyne MF, Buckley M, Orlov OI, Sicouri S, Plestis KA. How We Perform a David Procedure With an Upper Hemisternotomy Approach. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2021; 16:545-552. [PMID: 34882491 DOI: 10.1177/15569845211045965] [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: 11/17/2022]
Abstract
OBJECTIVE Valve-sparing aortic root replacement (David procedure) is the technique of choice in appropriately selected patients with aortic root aneurysms. These procedures are seldom performed in a minimally invasive fashion. We describe our systematic approach to the David procedure using an upper hemisternotomy (UHS). Methods: Our method involves a J-type UHS exiting the right third or fourth intercostal space. Ascending aortic and femoral venous cannulation are performed using the Seldinger technique under transesophageal echocardiographic guidance. Between August 2005 and August 2014, 27 patients underwent an isolated elective David procedure using a full sternotomy (FS). Sixteen underwent an isolated elective UHS David procedure from May 2015 to February 2019. Perioperative safety outcomes were compared between the 2 cohorts. Results: The UHS and FS David cohorts were primarily male (87.5% and 85.2%, respectively) and 51 and 50 years old on average, respectively. Custodiol-histidine-tryptophan-ketoglutarate cardioplegia (93.8% vs 37.0%, P < 0.001) and Cor-Knot (100% vs 0%, P < 0.001) were used significantly more in the UHS David cohort. There were no significant differences in cardiopulmonary bypass (200 [183-208] vs 212 [183-223] min, P = 0.309) and aortic cross-clamp (169 [155-179] vs 188 [155-199] min, P = 0.128) times in the UHS and FS cohorts. There were no instances of hospital or 30-day mortality in either cohort. Intensive care unit and hospital stays were comparable between the 2 cohorts. Conclusions: The David procedure via UHS is a safe and reproducible technique for aortic root replacement.
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Affiliation(s)
- Vishal N Shah
- Department of Cardiothoracic Surgery, 12284University of Nebraska Medical Center, Omaha, NE, USA
| | | | - Meghan Buckley
- 20284Lankenau Institute for Medical Research, Wynnewood, PA, USA
| | - Oleg I Orlov
- 20284Lankenau Institute for Medical Research, Wynnewood, PA, USA
| | - Serge Sicouri
- 20284Lankenau Institute for Medical Research, Wynnewood, PA, USA
| | - Konstadinos A Plestis
- Department of Cardiothoracic Surgery, 6529Thomas Jefferson University Hospital, Philadelphia, PA, USA
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5
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Abstract
PURPOSE OF REVIEW Given the low occurrence of clinically important paravalvular leak (PVL), there are no large registries or trials in this space to investigate management strategies. This review integrates newer evidence, particularly in imaging guidance for these complex procedures, novel techniques and approaches that our group has taken, as well as approaches to more complex PVL plugging reported in case reports. RECENT FINDINGS Perhaps the largest area of growth in the management of PVL is the use of advanced imaging in both pre-procedure evaluation and intra-procedural guidance with gated cardiac CT, 3D TEE, and fluoroscopy fusion technologies. Outside the USA, a new device, the Occlutech PLD, has become available with early data indicating high success rates. There remains little randomized data to support the efficacy of percutaneous PVL closure. Gated cardiac CT has become key to the pre-procedure evaluation for transcatheter closure as it allows for increased procedural efficiency and more accurate pre-procedure planning, particularly when combined with 3D printing. Intra-procedural TEE-fluoro fusion allows for more rapid crossing of defects by providing a visual target for interventionalists. The advent of purpose-built devices for PVL closure may further increase the efficacy and efficiency of percutaneous closure, but significant barriers remain for approval of these devices in the USA.
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Affiliation(s)
- Aken Desai
- Division of Cardiovascular Medicine, Department of Medicine, University of Colorado Anschutz School of Medicine, 12401 E. 17th Ave, Leprino Building, Room 511, Mail Stop B132, Aurora, CO, 80045, USA.
| | - John C Messenger
- Division of Cardiovascular Medicine, Department of Medicine, University of Colorado Anschutz School of Medicine, 12401 E. 17th Ave, Leprino Building, Room 511, Mail Stop B132, Aurora, CO, 80045, USA
| | - Robert Quaife
- Division of Cardiovascular Medicine, Department of Medicine, University of Colorado Anschutz School of Medicine, 12401 E. 17th Ave, Leprino Building, Room 511, Mail Stop B132, Aurora, CO, 80045, USA
| | - John Carroll
- Division of Cardiovascular Medicine, Department of Medicine, University of Colorado Anschutz School of Medicine, 12401 E. 17th Ave, Leprino Building, Room 511, Mail Stop B132, Aurora, CO, 80045, USA
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Sazzad F, Xian OZ, Ler A, Guohao C, Swee KG, Kofidis T. Incidence of valvular regurgitation and leaflet perforation by using automated titanium fasteners (CORKNOT®) in heart valve repair or replacement: less usual than reported. J Cardiothorac Surg 2021; 16:163. [PMID: 34099017 PMCID: PMC8186203 DOI: 10.1186/s13019-021-01512-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 05/05/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND CORKNOT® facilitates a reduction in cardiopulmonary bypass (CPB) time, aortic cross clamp (ACC) time and operative time, but reported to be associated with other complications. We aim to quantify the incidence of valvular complications related to CORKNOT® and determine the feasibility of its use between different valvular surgeries. METHODS Patients who underwent heart valve repair or replacement surgery via the use of automated titanium suture fasteners (CORKNOT®) in a tertiary care hospital were included in the study. This single-centre retrospective study was conducted on 132 patients between January 2016 and June 2018. RESULTS In our study, the overall mean operative time was 320.0 ± 97.0 min, mean CPB time was 171.4 ± 76.0 min and the calculated mean ACC time was 105.9 ± 54.0 min. Fifty-eight patients (43.9%) underwent minimally invasive valve replacement or repair surgery and 66 patients (50.0%) underwent concomitant procedures. A total of 157 valves were operated on, with 112 (84.8%) single valve surgeries, 15 (11.4%) double valve surgeries and 5 (3.8%) triple valve surgeries. After reviewed by the cardiologist blinded towards the study, we report trivial and/or mild paravalvular leak (PVL) in immediate post-operative echocardiography was found in 1 (1.01%) patients. There were no reported cases of valvular thrombosis, leaflet perforation, device dislodgement or embolization, moderate and/or severe PVL during hospitalization and follow-up echocardiography within 1 year. Single mitral valve and aortic surgeries had comparable incidences of post surgical complications. CONCLUSION We conclude the feasibility of CORKNOT® utilisation in mitral and aortic valve surgeries. Additionally, incidence of CORKNOT® related complications in heart valve repair or replacement surgery is less usual in our setting than previously reported. These results motivate the use of CORKNOT® as a valid alternative with complete commitment.
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Affiliation(s)
- Faizus Sazzad
- Cardiac Surgery Experimental Laboratory, Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, 1E Kent Ridge Road, Singapore, 119228, Singapore.,Cardiovascular Research Institute, National University of Singapore, Singapore, Singapore
| | - Ong Zhi Xian
- Cardiac Surgery Experimental Laboratory, Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Ashlynn Ler
- Cardiac Surgery Experimental Laboratory, Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,School of Medicine, National University of Ireland, Galway, Ireland
| | - Chang Guohao
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, 1E Kent Ridge Road, Singapore, 119228, Singapore.,National University Hospital, National University Health System, Singapore, Singapore
| | - Kang Giap Swee
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, 1E Kent Ridge Road, Singapore, 119228, Singapore.,National University Hospital, National University Health System, Singapore, Singapore
| | - Theo Kofidis
- Cardiac Surgery Experimental Laboratory, Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore. .,Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, 1E Kent Ridge Road, Singapore, 119228, Singapore. .,Cardiovascular Research Institute, National University of Singapore, Singapore, Singapore. .,National University Hospital, National University Health System, Singapore, Singapore.
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7
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Sicouri S, Shah VN, Orlov CP, Buckley M, Dedeilia K, Plestis KA. Assessment of pain, anxiety and depression, and quality of life after minimally invasive aortic surgery. J Card Surg 2021; 36:886-893. [PMID: 33442874 DOI: 10.1111/jocs.15320] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 12/11/2020] [Accepted: 12/21/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Minimally invasive cardiac surgery may reduce surgical trauma, diminish postoperative pain and improve quality of life (QOL). The aim of this study is to assess pain, hospital anxiety and depression scale (HADS), and QOL in patients undergoing minimally invasive aortic surgery. METHODS This is a prospective, single-center cohort study of 24 consecutive patients undergoing upper ministernotomy aortic valve, aortic root, and concomitant aortic valve and ascending aorta replacement. Visual analog scale (VAS) pain scores and HADS and Short-Form-36 (SF-36) questionnaires were evaluated at preoperative baseline, during hospitalization, and at 1 and 3 months postoperatively. RESULTS At discharge, the average VAS pain score was significantly lower than postoperative Day 1 (2.7 ± 0.4 vs. 6.5 ± 0.4; p ≤ .001). By 1 month, the pain scores were not significantly different from baseline (1.7 ± 0.4 vs. 1.0 ± 0.4; p = 1.000), and by 3 months, pain scores returned to baseline (1.0 ± 0.4; p = 1.000). HADS scores show that compared with preoperative baseline, average anxiety scores decreased by 1 month (3.1 ± 0.7 vs. 4.3 ± 0.6; p = 1.000) and decreased significantly by 3 months (1.8 ± 0.7 vs. 4.3 ± 0.6; p = .012). Additionally, depression scores were unchanged at 1 month (3.0 ± 0.4 vs. 3.1. ± 0.4; p = 1.000) and decreased by 3 months (1.3 ± 0.5 vs. 3.0 ± 0.4; p = .060). SF-36 scores revealed no changes in scores in 7 of 8 domains at 1 month and a significant increase in "physical functioning," "energy," and "general health" domains compared to preoperative baseline at 3 months. CONCLUSIONS Following minimally invasive aortic surgery, VAS pain scores, HADS and scores in 7 of 8 SF-36 domains returned to preoperative baseline or improved compared to preoperative baseline at 1 month. At 3 months, scores in 3 of 8 SF-36 domains significantly improved compared to preoperative baseline. Larger studies are necessary for further investigation.
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Affiliation(s)
- Serge Sicouri
- Lankenau Institute for Medical Research, Wynnewood, Pennsylvania, USA
| | - Vishal N Shah
- Department of Cardiothoracic Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Cinthia P Orlov
- Lankenau Institute for Medical Research, Wynnewood, Pennsylvania, USA
| | - Meghan Buckley
- Lankenau Institute for Medical Research, Wynnewood, Pennsylvania, USA
| | - Katerina Dedeilia
- Lankenau Institute for Medical Research, Wynnewood, Pennsylvania, USA
| | - Konstadinos A Plestis
- Department of Cardiothoracic Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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8
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Jenkin I, Prachee I, Sokal PA, Harky A. The role of Cor‐Knot in the future of cardiac surgery: A systematic review. J Card Surg 2020; 35:2987-2994. [DOI: 10.1111/jocs.14953] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 07/25/2020] [Accepted: 08/05/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Ifan Jenkin
- Medical Sciences Division University of Oxford Oxford UK
| | - Ishika Prachee
- Medical Sciences Division University of Oxford Oxford UK
| | | | - Amer Harky
- Department of Cardiothoracic Surgery Liverpool Heart and Chest Hospital Liverpool UK
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