The safety and efficacy of a modified Wrapping technique for the treatment of ascending aortic dilatation

Background

Current data are unclear in terms of the simultaneous treatment of Ascending Aorta Aneurysms (AAD) with a coexisting surgical pathology requiring open heart surgery (OHS), since replacement of the ascending aorta in all of those AAD patients may increase morbidity and mortality in respect with longer time in extracorporeal circulation. To overcome the aforementioned complications in patients with ADD and a concomitant indication for OHS, we have applied a less invasive technique, in contrast to the conventional method of replacement of the ascending aorta with a supracoronary synthetic tubular graft interposition

Purpose

We tested the safety and the efficacy of the Wrapping Ascending Aorta Dilatation (WAAD) technique that is based on the wrapping of the dilated ascending aorta with a synthetic graft from the sinotubular junction to the origin of innominate artery.

Methods

We retrospectively studied 254 patients who underwent ascending aorta surgery from 2000 to 2020 at Euroclinic Hospital of Athens Greece, from the same senior Cardiac Surgeon. Patients with an AAD with a diameter of 40–45mm in combination with a coexisting cardiac surgical pathology requiring OHS were treated with the wrapping technique, while patients with AAD diameter more than 45mm were treated with replacement. The WAAD technique was applied during patient's rewarming period using a longitudinally opened synthetic tubular Dacron graft around the AAD, without increasing the patient's time on extracorporeal circulation. The mean follow-up interval was 12.2±4.5 years.

Results

Two hundred and three patients (80%) were treated with OHS with replacement of the ascending aorta. Fifty one patients (20%) had an AAD with a diameter of 40–45mm (mean diameter 43±3.3mm) in combination with a coexisting cardiac surgical pathology requiring OHS and were treated with the WAAD technique. due to concomitant aortic valve surgery in 34 patients (67%), coronary artery bypass Graft in 10 patients (19.6%) and mitral valve surgery in 7 (14%). One of the patients who underwent mitral valve surgery exhibited AAD as well as dilation of the common pulmonary trunk extending to the right pulmonary artery and had both treated with the wrapping technique. During follow up no AAD recurrence or any other event concerning the ascending aorta or pulmonary artery were observed.

Conclusion

In patients with AAD undergoing OHS for a different cardiac pathology, WAAD is safe and effective and may be beneficial for patients with AAD with an aortic diameter of 40–45mm. Further randomized control studies are needed to confirm our results.

Funding Acknowledgement

Type of funding sources: None.

The wrapping technique as an alternative method for the treatment of ascending aortic dilatation

Background

The natural history of Ascending Aorta Dilatations (AAD) is unpredictable because acute dissections and ruptures have been observed even at aortic diameter sizes as small as 40s mm. Current data are unclear in terms of the simultaneous treatment of Ascending Aorta Aneurysms (AAD) with a coexisting surgical pathology requiring open heart surgery (OHS). To overcome the aforementioned complications in patients with ADD and a concomitant indication for OHS, we have applied a less invasive technique, in contrast to the conventional method of replacement of the ascending aorta with a supracoronary synthetic tubular graft interposition.

Purpose

The safety and efficacy of the Wrapping Ascending Aorta Dilatation (WAAD) technique that is based on the wrapping of the dilated ascending aorta with a synthetic graft from the sinotubular junction to the origin of innominate artery.

Methods

We studied 254 patients who underwent ascending aorta surgery from 2000 to 2020 at a Euroclinic Hospital Greece, from the same senior Cardiac Surgeon. Patients with an AAD with a diameter of 40–45mm in combination with a coexisting cardiac surgical pathology requiring OHS were treated with the wrapping technique, while patients with AAD diameter more than 45mm were treated with replacement. The WAAD technique was applied during patient's rewarming period using a longitudinally opened synthetic tubular Dacron graft around the AAD, without increasing the patient's time on extracorporeal circulation. The mean follow-up interval was 12.2±4.5 years.

Results

Two hundred and three patients (80%) were treated with OHS with replacement of the ascending aorta. Fifty one patients (20%) had an AAD with a diameter of 40–45mm (mean diameter 43±3.3mm) in combination with a coexisting cardiac surgical pathology requiring OHS and were treated with the WAAD technique. due to concomitant aortic valve surgery in 34 patients (67%), coronary artery bypass Graft in 10 patients (19.6%) and mitral valve surgery in 7 (14%). One of the patients who underwent mitral valve surgery exhibited AAD as well as dilation of the common pulmonary trunk extending to the right pulmonary artery and had both treated with the wrapping technique. During follow up no AAD recurrence or any other event concerning the ascending aorta or pulmonary artery were observed.

Conclusion

In patients with AAD undergoing OHS for a different cardiac pathology, WAAD is safe and effective and may be beneficial for patients with AAD with an aortic diameter of 40–45mm. Further randomized control studies are needed to confirm our results.

Funding Acknowledgement

Type of funding sources: None.

One-year echocardiographic outcomes of transcatheter aortic valve implantation with or without predilatation of the aortic valve: insights from the multicenter, randomized DIRECT trial

Introduction

Transcatheter aortic valve implantation (TAVI) has become the standard of care for high-risk and inoperable surgical patients and a valid alternative in intermediate-risk patients with severe aortic stenosis.The DIRECT trial (Predilatation in Transcatheter Aortic Valve Implantation Trial) was a multicenter, randomized, clinical trial designed to evaluate the safety and efficacy of TAVI with or without balloon aortic valvuloplasty (BAV) in patients with symptomatic, severe aortic valve stenosis.

Purpose

To compare the one year echocardiographic findings among patients, who underwent TAVI using a self-expanding valve with or without BAV.

Methods

A total of 171 patients with severe aortic stenosis were randomly assigned at 4 tertiary centers to undergo TAVI with the use of self-expanding prostheses with (pre-BAV) or without pre-dilatation (no-BAV). Follow up transthoracic echocardiography was performed 1 year after TAVI.

Results

Of 171 patients, 86 patients were randomized to pre-BAV group and 85 to no-BAV group. One year echocardiographic follow up was available in 146 patients. In one year follow up there was no significant difference between pre-BAV and no-BAV group in aortic valve area (1.84±0.39cm2 vs. 1.85±0.44cm2, p=0.79), peak aortic valve gradient (15.95±9.97 mmHg vs. 14.51±6.60 mmHg, p=0.35), mean aortic valve gradient (8.37±5.01 mmHg vs. 7.99±4.04 mmHg, p=0.64), aortic valve peak velocity (1.90±0.51 m/s vs. 1.80±0.42m/s, p=0.24), ejection fraction (54.19±8.36% vs. 53.19±9.58%, p=0.52) and pulmonary artery systolic pressure (41.86±14.34 mmHg vs. 40.71±12.40 mmHg, p=0.64). The incidence of moderate or severe paravalvular regurgitation (PVL) in 1 year follow up was 6.2% without significant difference between the 2 study groups (5.7% in the no-BAV group vs. 6.6% in the pre-BAV group, p=0.83).

Conclusions

Direct transcatheter aortic valve implantation has no impact on one-year prosthesis function and PVL in patients undergoing TAVI with self-expanding valve

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Medtronic

Echocardiographic assessment of functional changes of prosthetic valve after transcatheter aortic valve implantation in one year follow up: insights from the multicenter, randomized DIRECT trial

Introduction

The DIRECT trial (Predilatation in Transcatheter Aortic Valve Implantation (TAVI) Trial) was a multicenter, randomized, clinical trial designed to evaluate the safety and efficacy of TAVI with or without balloon aortic valvuloplasty (BAV) in patients with symptomatic, severe aortic valve stenosis.

Purpose

To investigate by echocardiography the functional changes of self-expanding prosthetic valves during the first year after TAVI with or without BAV.

Methods

One hundred seventy one consecutive patients with severe aortic stenosis were enrolled at 4 centers and randomized to TAVI using self-expanding prostheses with (pre-BAV) or without pre-dilatation (no-BAV). Transthoracic echocardiography was obtained at baseline, 30 days and 1 year after TAVI.

Results

Of 171 patients, 86 patients were randomized to pre-BAV group and 85 to no-BAV group. Over the one year, 7 (4%) patients died and in 18 (10%) there was no available paired 30 day/1 year echo. At baseline echocardiography the peak and mean aortic valve gradient and the aortic valve area (AVA) in no-BAV group were 77.31±22.56 mmHg, 47.23±14.98 mmHg and 0.69±0.16cm2 and in pre-BAV group 81.97±23.17 mmHg, 49.39±14.78 mmHg and 0.65±0.15cm2 respectively. One year after TAVI, patients in no-BAV and pre-BAV group showed stable peak and mean aortic valve gradients similar to those at 30 days (from 16.36±7.88 to 14.51±6.6 mmHg vs. 17.17±8.88 to 15.95±9.97 mmHg and from 8.87±4.23 to 7.99±4.04 mmHg vs. 9.39±4.79 to 8.38±5.02 mmHg respectively, P<0.001 vs. baseline). The AVA was similarly stable in one year follow up in no-BAV group (from 1.85±0.43cm2 to 1.85±0.44cm2, P<0.001 vs. baseline) and in pre-BAV group (from 1.86±0.49cm2 to 1.84±0.39cm2, P<0.001 vs. baseline). The incidence of moderate or severe paravalvular regurgitation remained unchanged in both groups (from 4.7% to 5.7% in no-BAV group and from 5.8% to 6.6% in pre-BAV group).

Conclusions

In both pre-BAV and no-BAV groups the improvement in hemodynamics of self-expanding prosthetic valves remained durable during the one year echocardiographic follow up assessment.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): MEDTRONIC

No impact of direct implantation of a self-expanding valve on one-year clinical outcomes. Insights from the multicenter, randomized DIRECT trial

Introduction

The DIRECT trial (Predilatation in Transcatheter Aortic Valve Implantation Trial) evaluated in a randomized fashion the safety and efficacy of direct (without balloon pre-dilatation) implantation of a self-expanding valve in all comers undergoing TAVI.

Purpose

To investigate the impact of direct implantation of a self-expanding valve on one-year clinical outcomes.

Methods

DIRECT trial randomized consecutive patients with severe aortic stenosis at 4 tertiary centers to undergo TAVI with the use of self-expanding prostheses with (pre-BAV) or without pre-dilatation (no-BAV). The primary endpoint was device success according to the VARC-2 criteria. Secondary endpoints included periprocedural mortality and stroke, new permanent pacemaker implantation and vascular complications.

All cause death, cardiac death, stroke and heart failure hospitalizations were recorded at one year and compared between the two groups using Kaplan-Meier plots.

Results

In total 171 patients were randomized in 4 centers. In the intention to treat analysis 86 patients were randomized to the pre-BAV group and 85 patients to the no-BAV TAVI group.

The device success according to the VARC-2 criteria was non-inferior in the no-BAV group compared to the pre-BAV group (65/85 - 76.5% for no-BAV versus 64/86 – 74.4% for pre-BAV, mean difference = 2.1%, 90% CI: −8.9 to 13). In the no-BAV group 25 (29.4%) patients underwent post balloon dilatation and in the pre-BAV group 13 patients (15.1%) (p=0.03).

At one year 4 deaths were recorded in pre-BAV group (4.7%) and 3 deaths in no-BAV group (3.5%). There was no difference in Kaplan-Meier plots between the two groups in all-cause mortality (log-rank p=0.72, figure). Similarly, there was no difference in one-year incidence of stroke (1 in pre-BAV and 2 in no-BAV group, log-rank p=0.55), cardiac death (log-rank p=0.66), non-cardiac death (log-rank p=0.98) and heart failure hospitalizations (1 in pre-BAV versus 3 in no-BAV group, log-rank p=0.31). Lastly, there was no difference in the incidence of permanent pacemaker implantation between the two groups at one year (27/67 in no-BAV group versus 20/69 in pre-BAV group, log-rank p=0.24)

Conclusions

Direct transcatheter aortic valve implantation is non-inferior to the procedure with pre-dilatation in self-expanding valve. Despite the overall low rate of events, direct procedure has no impact on clinical outcomes at one year.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Medtronic

[Lower extremity arteriopathy disease in the elderly: A systematic review]

Lower Extremity Arteriopathy Disease in the elderly is frequent with an ongoing increase of it prevalence and incidence mainly due to diabetes, hypertension and aging of the population. Despite improvement of revascularization therapy, outcome in this population is poor affected by frailty of elderly patient. Aging is associated with a higher prevalence of below the knee disease and wound, often with diagnostic delay leading to a major rate of amputation, mortality and alteration of quality of life. Moreover, it leads to an important health cost for society. This review aims to describe main features of LEAD in the elderly, providing keys for early recognition and managing of such disease in this population.