[Catheter-based and surgical treatment for aortic valve diseases]

The pathophysiology of aortic valve diseases is of predominantly degenerative nature, characterized by calcific aortic valve stenosis, which is associated with a reduction in prognosis. The prevalence of aortic valve insufficiency also increases with advancing age. Timely causal treatment is crucial in the management of aortic valve diseases. Following the indication for intervention, the heart team plays a central role in evaluating the results and making therapeutic decisions that consider the patient's preferences. In the assessment of treatment options, considerations regarding the long-term perspective are particularly crucial, especially in younger patients. The most common therapeutic approach for aortic valve diseases is the introduction of a new valve prosthesis. In the majority of cases, this is now achieved through catheter-based implantation of a bioprosthetic heart valve, known as transcatheter aortic valve implantation (TAVI). Open surgical aortic valve replacement (AVR) is favored in younger patients with low surgical risk or in the case that TAVI is not feasible. In AVR, both biological and the longest-lasting mechanical prosthesis types are used. Surgical repair techniques are primarily applied in cases of aortic valve regurgitation. Notably, TAVI, as well as surgical procedures for the treatment of aortic valve diseases, have undergone significant advancements in recent years, including expanded indications for TAVI and, on the surgical side, in particular the development of minimally invasive surgical techniques.

ACURATE neo2 Versus SAPIEN 3 Ultra Transcatheter Heart Valve in Severe Aortic Valve Calcification: A Propensity-Matched Analysis

BACKGROUND

Comparative data on transcatheter self-expanding ACURATE neo2 (NEO2) and balloon-expandable SAPIEN 3 Ultra prostheses in technically challenging anatomy of severe aortic valve calcified aortic annuli are scarce.

METHODS

A total of 1987 patients with severe native aortic stenosis treated with the self-expanding NEO2 (n=1457) or balloon-expandable SAPIEN 3 Ultra (n=530) from January 2017 to April 2023 were evaluated. The primary end point was procedural outcome according to the Valve Academic Research Consortium 3 definitions. Propensity matching defined 219 pairs with severe calcification (calcium density cutoff, 758 AU/cm2) of the native aortic valve.

RESULTS

Technical success (90.4% versus 91.8%; risk difference, 1.4% [95% CI, -4.4 to -7.2]; P=0.737) and device success at 30 days (80.8% versus 75.8%; risk difference, -5.0% [95% CI, -13.2 to 3.1]; P=0.246) were comparable between NEO2 and SAPIEN 3 Ultra. The rate of severe prosthesis-patient mismatch (1.1% versus 10.1%; risk difference, 10.0% [95% CI, 4.0-13.9]; P<0.001) and mean transvalvular gradient ≥20 mm Hg (2.8% versus 14.3%; risk difference, 11.5% [95% CI, 5.8-17.1]; P<0.001) was lower with NEO2. The rate of more-than-mild paravalvular leakage or valve-in-valve due to paravalvular leakage was significantly higher (6.2% versus 0.0%; risk difference, 6.2% [95% CI, -10.1 to -2.7]; P=0.002), and there was a tendency for a higher rate of device embolization or migration (1.8% versus 0.0%; risk difference, -1.8% [95% CI, -4.1 to 0.4]; P=0.123) with NEO2. Multivarate regression revealed no independent impact of transcatheter heart valve selection on device success (odds ratio, 0.93 [95% CI, 0.48-1.77]; P=0.817).

CONCLUSIONS

In patients with severely calcified annuli, supraannular implantation of NEO2 showed hemodynamic advantages. Nevertheless, NEO2 was associated with a higher incidence of relevant paravalvular leakage and a numerically higher rate of device embolization than SAPIEN 3 Ultra in this particular patient group.

Comparison of two self-expanding transcatheter heart valves for degenerated surgical bioprostheses: the AVENGER multicentre registry

BACKGROUND

There is a lack of comparative data on transcatheter aortic valve implantation (TAVI) in degenerated surgical prostheses (valve-in-valve [ViV]).

AIMS

We sought to compare outcomes of using two self-expanding transcatheter heart valve (THV) systems for ViV.

METHODS

In this retrospective multicentre registry, we included consecutive patients undergoing transfemoral ViV using either the ACURATE neo/neo2 (ACURATE group) or the Evolut R/PRO/PRO+ (EVOLUT group). The primary outcome measure was technical success according to Valve Academic Research Consortium (VARC)-3. Secondary outcomes were 30-day all-cause mortality, device success (VARC-3), coronary obstruction (CO) requiring intervention, rates of severe prosthesis-patient mismatch (PPM), and aortic regurgitation (AR) ≥moderate. Comparisons were made after 1:1 propensity score matching.

RESULTS

The study cohort comprised 835 patients from 20 centres (ACURATE n=251; EVOLUT n=584). In the matched cohort (n=468), technical success (ACURATE 92.7% vs EVOLUT 88.9%; p=0.20) and device success (69.7% vs 73.9%; p=0.36) as well as 30-day mortality (2.8% vs 1.6%; p=0.392) were similar between the two groups. The mean gradients and rates of severe PPM, AR ≥moderate, or CO did not differ between the groups. Technical and device success were higher for the ACURATE platform among patients with a true inner diameter (ID) >19 mm, whereas a true ID ≤19 mm was associated with higher device success - but not technical success - among Evolut recipients.

CONCLUSIONS

ViV TAVI using either ACURATE or Evolut THVs showed similar procedural outcomes. However, a true ID >19 mm was associated with higher device success among ACURATE recipients, whereas in patients with a true ID ≤19 mm, device success was higher when using Evolut.

Coronary Reaccess After Modified Chimney Stenting in a Self-Expanding Transcatheter Valve-in-Valve

We demonstrate a modified technique of heterotopic chimney stenting for coronary obstruction during valve-in-valve transcatheter aortic valve replacement With successful end-on cannulation via the stent ostium. Our technique was reproducible on the bench with successful reaccess and without any interaction between the deployed coronary stent and the prosthetic leaflets.

Cardiac decompensation of patients before transcatheter aortic valve implantation-clinical presentation, responsiveness to associated medication, and prognosis

Aims

Cardiac decompensation (CD) in patients with aortic stenosis is a "red flag" for future adverse events. We classified patients undergoing transcatheter aortic valve implantation (TAVI) into those with acute, prior, or no prior CD at the timepoint of TAVI and compared their clinical presentation, prognosis, and effects of the prescribed medication during follow-up.

Methods

Retrospective analysis of patients of one center fulfilling the criteria of 30-day device success after transfemoral TAVI.

Results

From those patients with no CD (n = 1,985) ranging to those with prior CD (n = 497) and to those with acute CD (n = 87), we observed a stepwise increase in the proportion of patients in poor clinical condition, NYHA class III/IV, low psoas muscle area, fluid overload (rales, oedema, pleural effusion), reduced ejection fraction, renal insufficiency, and anemia. More diuretics but less renin-angiotensin system inhibitors (ACEI/ARB) were prescribed for patients with acute CD compared to other groups. Prior CD (hazard ratio and 95% CI 1.40; 1.02-1.91) and acute CD (1.72; 1.01-2.91), a reduced general condition (1.53; 1.06-2.20), fluid overload (1.54;1.14-2.08), atrial fibrillation (1.76; 1.32-2.33), and anemia (1.43;1.08-1.89) emerged as strong independent predictors of one-year mortality. In all three classes of CD, prescribing of ACEI/ARB was associated with a substantial improvement of survival.

Conclusions

The clinical presentation of (acute or prior) cardiac decompensation in patients with AS overlapped substantially with that of patients with classical signs of heart failure. Our results may support an early treatment strategy in patients with left ventricular dysfuntion before clinical signs of congestion are manifest. Moreover, these patients require intensive medical attention after TAVI.

Comparison of the New-Generation Self-Expanding NAVITOR Transcatheter Heart Valve with Its Predecessor, the PORTICO, in Severe Native Aortic Valve Stenosis

BACKGROUND

Third-generation transcatheter heart valves (THVs) are designed to improve outcomes. Data on the new intra-annular self-expanding NAVITOR are scarce.

AIMS

The aim of this analysis was to compare outcomes between the PORTICO and the NAVITOR systems.

METHODS

Data from 782 patients with severe native aortic stenosis treated with PORTICO (n = 645) or NAVITOR (n = 137) from 05/2012 to 09/2022 were evaluated. The clinical and hemodynamic outcomes of 276 patients (PORTICO, n = 139; NAVITOR, n = 137) were evaluated according to VARC-3 recommendations.

RESULTS

Rates of postprocedural more-than-mild paravalvular leakage (PVL) were significantly lower for NAVITOR than for PORTICO (7.2% vs. 1.5%, p = 0.041). In addition, severe bleeding rates (27.3% vs. 13.1%, p = 0.005) and major vascular complications (5.8% vs. 0.7%, p = 0.036) were lower in the NAVITOR group. The mean gradients (7 vs. 8 mmHg, p = 0.121) and calculated aortic valve areas (1.90 cm² vs. 1.99 cm², p = 0.235) were comparable. Rates of PPI were similarly high in both groups (15.3 vs. 21.6, p = 0.299).

CONCLUSIONS

The NAVITOR demonstrated favorable in-hospital procedural outcome data, with lower rates of relevant PVL, major vascular complications, and severe bleeding than its predecessor the PORTICO and preserved favorable hemodynamic outcomes.

Incidence and predictors of hemodynamic compromise due to high-grade AV block after TAVI

Background

High-grade AV block (HAVB) is the most frequent adverse event after transcatheter aortic valve implantation (TAVI). In rare cases, HAVB is associated with hemodynamic compromise (HC) followed by syncope or application of cardiopulmonary resuscitation (CPR), but data on this severe complication are scarce. The aim of the present study was to investigate the incidence and predictors of HC due to HAVB in patients undergoing TAVI.

Methods

In this retrospective analysis of 4,602 TAVI cases between 2010 and 2022, 466 developed HAVB. Baseline characteristics and procedural and postprocedural findings were compared for patients with HC versus those without. Univariate and multivariable regression analyses were used to investigate independent predictors of HC.

Results

Forty-nine of 466 patients (10.5%) had HC due to HAVB after TAVI. Patients with HC had a longer hospital stay [10 (8-13) vs. 13 (9-18) days; p < 0.001], more frequent peripheral artery disease (PAD) (28.6% vs. 15.1%; p = 0.016), and lower hemoglobin levels [11.8 (±) vs. 12.5 (±) g/dl; p = 0.006]. In the HC group, HAVB onset post-TAVI was delayed compared with the non-HC group [2 (1-4) vs. 1 (0-3) days; p < 0.001]. Before HAVB onset, patients in the HC group more frequently developed post-TAVI delirium [18 (4.6%) vs. 11 (25.0%); p < 0.001]. In univariate regression analysis, PAD, hemoglobin, procedural time, contrast agent volume, and post-TAVI delirium were significant predictors of HC. After adjustment, only post-TAVI delirium and contrast agent volume remained independent predictors [OR 3.22 (95% CI: 1.05-9.89); p = 0.042 and OR: 1.01 (95% CI: 1.0-1.01); p = 0.04, respectively].

Conclusion

HC due to HAVB after TAVI occurred in over 10% of cases. Development of post-TAVI delirium and contrast agent volume are independent predictors of this severe complication.

Procedural Outcomes of a Self-Expanding Transcatheter Heart Valve in Patients with Porcelain Aorta

BACKGROUND

Severe calcification of the ascending aorta increases the peri-operative risk for neurological complications in patients with severe aortic stenosis. Transcatheter aortic valve implantation (TAVI) seems to be an optimal treatment option in these patients. However, the impact of the extent of aortic calcification on procedural and neurological outcomes during TAVI is unclear.

METHODS

Data from 3010 patients with severe native aortic valve stenosis treated with ACURATE neo/neo2 from May 2012 to July 2022 were evaluated and matched by 2-to-1 nearest-neighbor matching to identify one patient with porcelain aorta (PA) (n = 492) compared with two patients without PA (n = 984). PA was additionally subdivided into circumferential (classic PA) (n = 89; 3.0%) and non-circumferential (partial PA) (n = 403; 13.4%) calcification. We compared outcomes according to VARC-3 criteria among patients with and without PA and identified predictors for occurrence of stroke in the overall population.

RESULTS

Technical success (88.5% vs. 87.4%, p = 0.589) and device success at 30 days (82.3% vs. 81.5%, p = 0.755) after transcatheter ACURATE neo/neo2 implantation according to VARC-3 definition was high and did not differ between non-calcified aortas or PA. The rate of in-hospital complications according to VARC-3-definitions was low in both groups. Rates of all stroke (3.2% (n = 31) vs. 2.6% (n = 13), p = 0.705) or transitory ischemic attacks (1.1% vs. 1.2%, p = 1.000) did not differ significantly. Thirty-day all-cause mortality did not differ (3.0% vs. 3.2%, RR 1.1; p = 0.775). Overall device migration/embolization (OR 5.0 [2.10;11.87]), severe bleeding (OR 1.79 [1.11;2.89]), and major structural cardiac complications (OR 3.37 [1.32;8.57]) were identified as independent predictors for in-hospital stroke in a multivariate analysis after implantation of ACURATE neo/neo2.

CONCLUSION

A porcelain aorta does not increase the risk of neurological complications after transfemoral ACURATE neo/neo2 implantation. Based on these findings, transfemoral ACURATE neo/neo2 implantation is safe in these particularly vulnerable patients.

Effects of renin-angiotensin system inhibitor type and dosage on survival after transcatheter aortic valve implantation

AIMS

The objective of the study was to determine the effect of renin-angiotensin system inhibitors (RASI) on the survival of subgroups of patients with aortic stenosis after transcatheter aortic valve implantation (TAVI) and to assess the impact of types and dosages of RASI on outcomes.

METHODS AND RESULTS

This single-centre, retrospective analysis included 2862 patients (n = 2227 with RASI and n = 635 without RASI) after successful TAVI. Propensity score matching established comparable patient populations (n = 625 per group). Survival was analysed by Kaplan-Meier curves and Cox regression and was corrected for baseline, procedural, and medical parameters. Self-reported adherence to RASI therapy 3 months after hospital discharge was 94%. Three-year all-cause mortality rates were 12.3% and 20.2% for patients with or without RASI, respectively (log-rank <0.001). In the matched study populations, mortality rates were 14.2% vs. 20.0% (log-rank <0.03). RASI was particularly beneficial in patients with ejection fraction <40% [adjusted hazard ratio (HR) and 95% confidence interval 0.50 (0.29-0.87)], EuroScore II ≥4% [HR 0.47 (0.35-0.65)], or low-flow, low-gradient aortic stenosis [HR 0.53 (0.31-0.93)] who were also on beta-blockers and statins. An association between discharge dosage and survival was observed, with HR 0.75 (0.58-0.96) and 0.57 (0.44-0.72) for patients on <50% and ≥50% target dose, respectively. Angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) reduced mortality rates similarly (13.9% vs. 9.8%, log-rank 0.103).

CONCLUSIONS

The beneficial association between RASI after TAVI and improved survival during follow-up is particularly evident in high-risk patients and may be dose dependent. No superiority was noted in the effectiveness of ACEI or ARB.

Impact of pressure recovery on the assessment of pulmonary homograft function using Doppler ultrasound

Relevant pressure recovery (PR) has been shown to increase functional stenotic aortic valve orifice area and reduce left ventricular load. However, little is known about the relevance of PR in the pulmonary artery. The study examined the impact of PR using 2D-echocardiography in the pulmonary artery distal to the degenerated homograft in patients after Ross surgery. Ninety-two patients with pulmonary homograft were investigated by Doppler echocardiography (mean time interval after surgery 31 ± 26 months). PR was measured as a function of pulmonary artery diameter determined by computed tomography angiography. Homograft orifice area, valve resistance, and transvalvular stroke work were calculated with and without considering PR. PR decreased as the pulmonary artery diameter increased (r = -0.69, p < 0.001). Mean PR was 41.5 ± 7.1% of the Doppler-derived pressure gradient (P_max ), which resulted in a markedly increased homograft orifice area (energy loss coefficient index [ELCOI] vs. effective orifice area index [EOAI], 1.3 ± 0.4 cm² /m² vs. 0.9 ± 0.4 cm² /m² , p < 0.001). PR significantly reduced homograft resistance and transvalvular stroke work (822 ± 433 vs. 349 ± 220 mmHg × ml, p < 0.0001). When PR was considered, the correlations of the parameters used were significantly better, and 11 of 18 patients (61%) in the group with severe homograft stenosis (EOAI <0.6 cm² /m² ) could be reclassified as moderate stenosis. Our results showed that the Doppler measurements overestimated the degree of homograft stenosis and thus the right ventricular load, when PR was neglected in the pulmonary artery. Therefore, Doppler measurements that ignore PR can misclassify homograft stenosis and may lead to premature surgery.

Comparison of the Acurate Neo Vs Neo2 Transcatheter Heart Valves

BACKGROUND

Few data exist on immediate outcomes of the next-generation Acurate neo2 prosthesis (Boston Scientific), which is distinguished by an active sealing mechanism. We sought to determine procedural outcomes of transfemoral transcatheter aortic valve replacement using the neo2 in comparison with its predecessor, the Acurate neo.

METHODS

In this retrospective analysis, consecutive neo2 and neo cases were compared from 2 high-volume centers. The primary outcome of interest was the rate of relevant paravalvular regurgitation (PVR), defined as PVR ≥ moderate, or valve-in-valve and/or surgical aortic valve replacement for PVR ≥ moderate. Secondary outcomes of interest were assessed according to Valve Academic Research Consortium (VARC)-3 criteria. Logistic regression analysis was used to identify predictors of relevant PVR.

RESULTS

A total of 810 neo2 and 2055 neo cases comprised the study cohort. The rate of relevant PVR was significantly lower in the neo2 group (2.7% vs 4.5%; P=.04). The technical success rate was numerically higher in the neo2 group (91.5% vs 89.3%; P=.10) and the rate of device success at 30 days was significantly higher (86.5% vs 82.9%; P=.02). In the neo group, a greater amount of aortic valve calcification (AVC), the presence of eccentric AVC, less oversizing, and a higher sinotubular junction annulus index were predictors of relevant PVR, whereas in the neo2 population only the presence of eccentric AVC, less oversizing, and a higher sinotubular junction annulus index was predictive.

CONCLUSION

The neo2 valve shows superior outcomes over the neo valve, with a lower burden of PVR and a higher device success rate at 30 days.

Risk and protective factors for atrial fibrillation after cardiac surgery and valvular interventions: an umbrella review of meta-analyses

Objective

Postoperative atrial fibrillation (POAF) is a common complication affecting approximately one-third of patients after cardiac surgery and valvular interventions. This umbrella review systematically appraises the epidemiological credibility of published meta-analyses of both observational and randomised controlled trials (RCT) to assess the risk and protective factors of POAF.

Methods

Three databases were searched up to June 2021. According to established criteria, evidence of association was rated as convincing, highly suggestive, suggestive, weak or not significant concerning observational studies and as high, moderate, low or very low regarding RCTs.

Results

We identified 47 studies (reporting 61 associations), 13 referring to observational studies and 34 to RCTs. Only the transfemoral transcatheter aortic valve replacement (TAVR) approach was associated with the prevention of POAF and was supported by convincing evidence from meta-analyses of observational data. Two other associations provided highly suggestive evidence, including preoperative hypertension and neutrophil/lymphocyte ratio. Three associations between protective factors and POAF presented a high level of evidence in meta-analyses, including RCTs. These associations included atrial and biatrial pacing and performing a posterior pericardiotomy. Nineteen associations were supported by moderate evidence, including use of drugs such as amiodarone, b-blockers, glucocorticoids and statins and the performance of TAVR compared with surgical aortic valve replacement.

Conclusions

Our study provides evidence confirming the protective role of amiodarone, b-blockers, atrial pacing and posterior pericardiotomy against POAF as well as highlights the risk of untreated hypertension. Further research is needed to assess the potential role of statins, glucocorticoids and colchicine in the prevention of POAF.

PROSPERO registration number

CRD42021268268.

Surgical reconstruction of a giant left ventricular aneurysm with prior unloading using a microaxial pump

A 46-year-old male patient presented with cardiac decompensation due to a giant left ventricular aneurysm combined with a severely reduced left ventricular function after a silent myocardial infarction. Left ventricular unloading was performed with a microaxial pump as a bridge to surgery. Myocardial function in the basal segments was preserved and surgical ventricular reconstruction was performed successfully.

Percutaneous trans-axilla transcatheter aortic valve replacement

The left axillary artery is an attractive alternative access route for transcatheter aortic valve replacement (TAVR) and may provide better outcomes compared to other alternatives. Nevertheless, there remain concerns about vascular complications, lack of compressibility, and thorax-related complications. Between March 2019 and March 2021, 13 patients underwent transaxillary TAVR for severe aortic stenosis at the University Hospital Bonn. The puncture was performed with a puncture at the distal segment of the axillary artery through the axilla, with additional femoral access for applying a safety wire inside the axillary artery. Device success was defined according to the VARC 2 criteria. The study participants were advanced in age (77 ± 9 years old), and 54% were female, with an intermediate risk for surgery (STS risk score 4.7 ± 2.0%). The average diameter of the distal segment of the axillary artery was 5.8 ± 1.0 mm (i.e., the puncture site) and 7.6 ± 0.9 mm for the proximal axillary artery. Device success was achieved in all patients. 30-day major adverse cardiac and cerebrovascular events were 0%. With complete percutaneous management, stent-graft implantation was performed at the puncture site in 38.5% of patients. Minor bleeding was successfully managed with manual compression. Moreover, no thorax-related complications, hematomas, or nerve injuries were observed. Percutaneous trans-axilla TAVR was found to be feasible and safe. This modified approach may mitigate the risk of bleeding and serious complications in the thorax and be less invasive than surgical alternatives.

First transfemoral TAV-in-TAV implantation of an ACURATE neo2 into a degenerated Lotus prosthesis

We report the first transcatheter aortic valve (TAV)-in-TAV implantation of an ACURATE neo2 into a degenerated Lotus prosthesis. Despite the good final result in this case, TAV-in-TAV of the ACURATE neo2 into a Lotus prosthesis may not be the first choice, as potential pitfalls must be taken into account.

The zone 2 concept and distal stent graft positioning in TH 2-3 are associated with high rates of secondary aortic interventions in frozen elephant trunk surgery

OBJECTIVES

The goal of this study was to investigate the association between the localization of the distal anastomosis (zone 2/3), the stent graft length (100-160 mm), the position of the distal end of the hybrid prosthesis and the need for secondary aortic intervention (SAI) in acute and chronic thoracic aortic disease after the frozen elephant trunk procedure.

METHODS

From 2009 through 2020, a total of 232 patients (137 men; mean age, 61.7 ± 13.8 years) were treated with the frozen elephant trunk procedure. The main indications were acute aortic dissection type A (n = 106, 46%), chronic aortic dissection type A (n = 52, 22%) and degenerative thoracic aortic aneurysm (n = 74, 32%).

RESULTS

The rate of SAI was significantly higher when we performed a distal anastomosis in zone 2 rather than in zone 3, whereas the rate of SAI was less frequent if the distal positioning of the hybrid prosthesis was below TH 4-5. Combining the zone 2 concept and the short stent graft length (100 mm) was associated with a significantly higher rate of SAIs. Patients with a distal anastomosis in zone 2 were significantly less likely to have a recurrent laryngeal nerve injury (P < 0.001). However, no association between a specific arch zone of a distal anastomosis and the occurrence of spinal cord injury was observed.

CONCLUSIONS

Rates of SAIs are highest in patients who were treated with a distal anastomosis in zone 2 and a short stent graft (100 mm) with the distal end of the hybrid prosthesis at vertebral level TH 2-3.

The reinforced full-root technique for the Ross operation: surgical considerations and operative insights

Background

Surgical treatment of young and middle-aged patients suffering from aortic valve disease remains an unresolved issue due to the limited durability of bioprosthetic heart valve replacements and the valve-related morbidity of patients with mechanical valve substitutes. Theoretically, the "living valve" principle of the Ross operation may represent a potentially viable solution to this dilemma. In this paper, we report on the surgical techniques of the Ross procedure and present long-term post-operative outcomes using the reinforced full-root technique.

Methods

From 1995 to 2020, a total of 832 consecutive patients (mean age, 43.4±13.7 years; 617 males) underwent a Ross operation using the full-root technique. Patients were prospectively monitored with clinical and echocardiographic follow-up. Total follow-up was 9,046 patients-years and was 92% complete. Mean-follow-up was 10.9±6.9 years (range, 0-24.9 years).

Results

Survival at twenty years was 92% (95% CI: 90-94%). Freedom from autograft or right ventricle to pulmonary artery connection reoperation at twenty years was 79% (95% CI: 74-85%). Eighty-nine pulmonary autograft reoperations had to be performed in eighty patients; salvage of the pulmonary autograft could be performed in forty-six of them. Fifty-seven patients required sixty-three reoperations on the right ventricle to pulmonary artery connection. Major cerebral bleeding occurred in one patient and neurological events in seventeen patients, respectively.

Conclusions

Over a follow-up interval of up to twenty-five years, the Ross operation with the reinforced full-root technique demonstrated excellent survival in young and middle-aged patients. The rate of pulmonary autograft and right ventricular outflow graft reoperations were low in this patient subset. Therefore, the Ross operation with the reinforced full-root technique represents an enduring and valid treatment option in young and middle-aged patients suffering from aortic valve disease.

Atrial fibrillation recurrence and spontaneous conversion to sinus rhythm after cardiac surgery: Insights from 426 patients with continuous rhythm monitoring

INTRODUCTION

Cardiac surgery may influence occurrence and persistence of atrial fibrillation (AF). In patients with a history of cardiac surgery and postoperative pacemaker or implantable cardioverter defibrillator implantation we attempted to quantify AF characteristics and investigate factors that influence AF recurrence.

METHODS

In 426 patients (319 male; age: 73 SD: 9 years) with a history of cardiac surgery (364 CABG; 69 mitral valve; 57 aortic valve and 59 combination procedures) the heart rhythm history (mean: 351 days SD: 54 days) was reconstructed and investigated for AF recurrence patterns.

RESULTS

AF developed and subsequently recurred in 75% of patients (n = 320). The mean AF burden in these patients was 0.21 (21% of the total observed time spent in AF) and 4085 episodes of AF were observed and analyzed. AF episodes spontaneously terminated within 24 h (n = 2509), 48 h (n = 700), 72 h (n = 279), and 1 week (n = 31). The probability of spontaneous conversion to sinus rhythm (SR) decreased with time spent in AF and plateaued after approximately 7 days. Patient age, LVEF and presence of coronary artery disease significantly influenced the probability of spontaneous conversion to SR. Type of cardiac surgery also significantly influenced AF episode characteristics.

CONCLUSION

AF episodes are common in patients with a history of cardiac surgery. Spontaneous conversion to SR diminishes with increasing time spent in AF and is influenced by AF characteristics and several patient-related factors. Continuous monitoring can provide detailed information about AF recurrence that may immensely improve our understanding and influence the clinical management of AF.

Mannitol Is Associated with Less Postoperative Delirium after Aortic Valve Surgery in Patients Treated with Bretschneider Cardioplegia

Background  Heart surgery with extracorporeal circulation (ECC) often leads to postoperative delirium (POD). This is associated with increased morbidity resulting in longer hospital stay and associated costs. The purpose of our study was to analyze the effect of intraoperative mannitol application on POD in patients undergoing elective aortic valve replacement (AVR).

Materials and Method s In our retrospective single-center study, 259 patients underwent elective AVR, using Bretschneider cardioplegic solution for cardiac arrest, between 2014 and 2017. Patients were divided in mannitol ( n  = 188) and nonmannitol ( n  = 71) groups. POD was assessed using the confusion assessment method for the intensive care unit (ICU). Statistical significance was assumed at p  < 0.05.

Results  Baseline patient characteristics did not differ between the groups. Incidence of POD was significantly higher in the nonmannitol group (33.8 vs. 13.8%; p  = 0.001). These patients required longer ventilation time (24.1 vs. 17.1 hours; p  = 0.021), higher reintubation rate (11.3 vs. 2.7%; p  = 0.009), ICU readmission (12.7 vs. 4.8%; p  = 0.026), prolonged ICU (112 vs. 70 hours; p  = 0.040), and hospital stay (17.8 vs. 12.6 days; p  < 0.001), leading to higher expenses (19,349 € vs. 16,606 €, p  < 0.001). A 30-day mortality was not affected, but nonmannitol group showed higher Simplified Acute Physiology Score II score (32.2 vs. 28.7; p  < 0.001). Mannitol substitution was independently associated with lower incidence of POD (odds ratio: 0.40; 95% confidence interval: 0.18–0.89; p  = 0.02).

Conclusion  Treatment with mannitol during ECC was associated with decreased incidence of POD. This was accompanied by shorter ventilation time, ICU and hospital stay, and lower treatment expenses.

Gender-Dependent Clinical Outcome and Other Predictors of In-Hospital Mortality Following Out-Of-Center Extracorporeal Membrane Oxygenation and Extracorporeal Life Support: A Single Center Experience

Background: Out-of-center extracorporeal membrane oxygenation (ECMO) and extracorporeal life support (ECLS) implantation for the treatment of acute cardiorespiratory failure with subsequent transport to a tertiary care center has been introduced successfully into the medical practice. However, due to the very specific and resource intensive nature of this therapeutic concept, it seems important to generate algorithms for adequate patient selection. The aim of our study was to analyze the impact of patients’ gender on early clinical outcome in this specific therapeutic scenario. Methods: Ninety-seven consecutive patients treated by out-of-center ECMO/ECLS implantation and subsequent transport and treatment in our tertiary care cardiovascular center within the Hallesche Extracorporeal Life Support Program (HELP) retrospectively were analyzed, regarding the impact of patients’ gender on early clinical outcome. Results: Mechanical circulatory support successfully was weaned in two-thirds of the male patients. This result was achieved in only one-third of the female patients (59.4% in male vs. 33.3% in female, P = .0267). Overall survival significantly was higher in the male group (62.5% in male versus 30.3% in female, P = .0052). In uni- and multivariate logistic regression analysis, female gender was an independent predictor of in-hospital mortality (uni: OR:3.833, CI:1.597-9.745, P = .0034; multi: OR:3.477, CI:1.146-11.494, P = .0322). Worse outcome also was associated with following independent predictors, age, SOFA score, lactate and ventilation time pre-ECMO/ECLS implantation. Conclusion: The current study demonstrates a worse early survival for women, following emergent out-of-center ECMO/ECLS implantation and subsequent transport and treatment in our tertiary care cardiovascular center. Gender should be included in patient selection algorithms while basic research approaches are needed to better understand the mechanisms underlying these gender-specific outcome disparities.

The role of transcatheter mitral valve therapy in heart failure

Mitral valve regurgitation is detected in up to 75% of patients with heart failure. Interventional mitral valve therapies can be used to treat mitral regurgitation with very low morbidity and mortality rates and minimal invasiveness. Devices intended for the replacement of the mitral valve still require significant development and refinement before entering clinical practice on a large scale. The derived benefit of these therapies, the priority (repair over replacement) and the therapeutic role in patients with secondary mitral regurgitation due to heart failure remain to be investigated.

Transcatheter aortic valve implantation utilizing a non-occlusive balloon for predilatation

BACKGROUND

Balloon aortic valvuloplasty (BAV) is routinely performed preceding transcatheter aortic valve implantation (TAVI). Among risks inherent in BAV is low cardiac output due to rapid ventricular pacing (RVP), especially in patients with severely impaired left ventricular function. We herein report early experience utilizing a non-occlusive balloon for BAV (TrueFlow™, BARD, Peripheral Vascular, Tempe, AZ, US), which does not require RVP.

METHODS

Between 11/2016 and 10/2017, 27 consecutive patients received TAVI using a non-occlusive balloon valvuloplasty catheter for predilatation and a self-expandable transcatheter heart valve (77.8% female, 81.7 ± 6.6 years, logEuroSCORE I 15.8 ± 10.3%, STS Prom Score 2.5 ± 0.5%). Hemodynamic measurements and acute outcome data were analyzed according to updated Valve Academic Research Consortium definitions.

RESULTS

Procedure time, fluoroscopy time and amount of contrast agent were 74.5 ± 17.4 min, 16.7 ± 6.9 min and 156.9 ± 92.7 ml. Device success and early combined safety were 100% and 92.6% (25/27). Effective BAV without RVP after the first inflation was achieved in 92.6% of the patients (25/27). Continuous recording of hemodynamics documented no relevant systemic pressure drop during BAV. Postdilatation with a regular balloon was required in 10/27 patients. No death was observed during 30-day follow-up. Resultant mean transvalvular gradient was 6.0 ± 3.5 mm Hg. In one patient a moderate paravalvular leakage was seen.

CONCLUSIONS

In this series of TAVI utilizing a novel non-occlusive balloon, safety and efficacy were demonstrated. Adequate predilatation was achieved in all cases without need for RVP and with stable hemodynamics. These results will have to be confirmed in larger patient cohorts.

Rotational Thromboelastometry for Assessing Bleeding Complications and Factor XIII Deficiency in Cardiac Surgery Patients

We aimed to detect alterations and deficits in hemostasis during cardiac surgery with cardiopulmonary bypass (CPB) using point-of-care-supported coagulation analysis (rotational thromboelastometry, impedance aggregometry), in addition to single factor assays for the measurement of fibrinogen (FI) and factor XIII (FXIII) levels. Forty-one patients scheduled for elective cardiac surgery with CPB were enrolled in this observational study. Perioperative measurement (pre-, postheparin, 30-minutes before the end of bypass, 1-hourpostoperatively) of standard laboratory variables, additional rotational thromboelastometry (ROTEM; International GmbH, Munich, Germany), Multiplate analysis (Roche, Switzerland), and an assay of FXIII activity were performed as well as the collection of epidemiological data and blood loss. The FI and FXIII levels as well as the measured ROTEM and Multiplate parameters correlated weakly with the blood loss. Clotting time and maximum clot firmness (MCF) of the intrinsically activated ROTEM showed a good correlation (r_CT-INTEM = 0.378; P < .05, r_MCF-INTEM = 0.305; P < .05) with postoperative drainage loss, suggesting a dependence of blood loss on the initial intrinsic activity. Additionally, perioperative FI or FIBTEM levels and the FXIII levels correlated with each other. Intrinsically activated ROTEM showed a good correlation with postoperative drainage loss, thus suggesting a dependence of blood loss on the initial intrinsic activity and therefore facilitating clinicians to assess postoperative bleeding complications. Based on the FI level or the MCF_FIBTEM measured by ROTEM, it may also be possible to assess the FXIII concentration. Especially in chronically ill and massive bleeding cardiac surgery patients with significantly decreased FXIII levels, the knowledge of FXIII deficiency may help clinicians to treat coagulation disorders more adequately.

Predictors for quality of life of patients with a portable out-of-centre-implanted extracorporeal membrane oxygenation device

Objectives

Despite progress in the treatment of cardiopulmonary organ failure, the mortality rate for patients with acute respiratory distress syndrome (ARDS) and cardiogenic shock remains high. Extracorporeal membrane oxygenation (ECMO) is a promising treatment option, but long-term outcomes and health-related quality of life (HRQOL) are unknown.

Methods

Detailed information related to pre- and post-device data and outcomes from a consecutive sample of 71 patients treated with ECMO was analysed. Long-term survivors were given a detailed follow-up examination after a median time of 31 months that included multiple scoring systems for HRQOL assessment.

Results

Seventy-one patients received a portable out-of-centre-implanted ECMO system. The survival rate at hospital discharge was 48%. Median HRQOL scores were 80% on the Karnofsky index (normal ≥80%), 80% on the Euroqol-5D (normal ≥75%) and 73.1% on the quality-of-life index (normal ≥70%). Mental scores were 96.7% on the Mini-Mental State Examination (normal ≥90.0%), 77.8% on the DemTect (normal ≥72.0%), 87.0% on the test for early detection of dementia with depression demarcation (TFDD; normal ≥74.0%) and confirmed good mental state and HRQOL for patients at follow-up. Univariate analysis for in-hospital mortality indicated that ventilation time before device implantation, higher Acute Physiology and Chronic Health Evaluation (APACHE) II score, higher lactate level at the time of ECMO implantation and female gender were associated with adverse outcomes.

Conclusions

In our cohort of patients, survivors of out-of-hospital ECMO implantation demonstrated good mental and quality-of-life conditions with well-recovered cardiopulmonary function during long-term follow-up. The indicators for adverse outcomes, pre-implantation lactate levels, pre-ventilation time and APACHE II score, should be considered before implantation of an ECMO device.

Clinical trial

This study is registered at DRKS (Deutsches Register Klinischer Studien) under the code DRKS00009735 and was submitted to the WHO.

Preoperative plasma growth-differentiation factor-15 for prediction of acute kidney injury in patients undergoing cardiac surgery

Background

Growth-differentiation factor-15 (GDF-15) is an emerging humoral marker for risk stratification in cardiovascular disease. Cardiac-surgery-associated acute kidney injury (CSA-AKI), an important complication in patients undergoing cardiac surgery, is associated with poor prognosis. The present secondary analysis of an observational cohort study aimed to determine the role of GDF-15 in predicting CSA-AKI compared with the Cleveland-Clinic Acute Renal Failure (CC-ARF) score and a logistic regression model including variables associated with renal dysfunction.

Methods

Preoperative plasma GDF-15 was determined in 1176 consecutive patients undergoing elective cardiac surgery. Patients with chronic kidney disease stage 5 were excluded. AKI was defined according to Kidney-Disease-Improving-Global-Outcomes (KDIGO) - creatinine criteria. The following variables were screened for association with development of postoperative AKI: age, gender, additive Euroscore, serum creatinine, duration of cardiopulmonary bypass, duration of surgery, type of surgery, total circulatory arrest, preoperative hemoglobin, preoperative oxygen-supplemented cerebral oxygen saturation, diabetes mellitus, hemofiltration during ECC, plasma GDF-15, high sensitivity troponin T (hsTNT), and N-terminal prohormone of B-type natriuretic peptide (NTproBNP).

Results

There were 258 patients (21.9 %) with AKI (AKI stage 1 (AKI-1), n = 175 (14.9 %); AKI-2, n = 6 (0.5 %); AKI-3, n = 77 (6.5 %)). The incidence of AKI-1 and AKI-3 increased significantly from the lowest to the highest tertiles of GDF-15. In logistic regression, preoperative GDF-15, additive Euroscore, age, plasma creatinine, diabetes mellitus, and duration of cardiopulmonary bypass were independently associated with AKI. Inclusion of GDF-15 in a logistic regression model comprising these variables significantly increased the area under the curve (AUC 0.738 without and 0.750 with GDF-15 included) and the net reclassification ability to predict AKI. Comparably, in receiver operating characteristic analysis the predictive capacity of the CC-ARF score (AUC 0.628) was improved by adding GDF-15 (AUC 0.684) but this score also had lower predictability than the logistic regression model. In random forest analyses the predictive capacity of GDF-15 was especially pronounced in patients with normal plasma creatinine.

Conclusion

This suggests that preoperative plasma GDF-15 independently predicts postoperative AKI in patients undergoing elective cardiac surgery and is particularly helpful for risk stratification in patients with normal creatinine.

Trial registration

NCT01166360 on July 20, 2010.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-016-1482-3) contains supplementary material, which is available to authorized users.

Data Science Meets the Clinician: Challenges and Future Directions

In the last three decades a profound transformation of the medical profession has taken place. The modern clinician is required to consume vast amounts of information from clinical studies, critically reviewing evidence that may or may not lead to changes in clinical practice. The present article presents some challenges that this era of information poses to clinicians and patients.

Does Undersizing of Transcatheter Aortic Valve Bioprostheses during Valve-in-Valve Implantation Avoid Coronary Obstruction? An In Vitro Study

Background The transcatheter aortic valve-in-valve implantation (TAViVI) is an evolving treatment strategy for degenerated surgical aortic valve bioprostheses (SAVBs) in patients with high operative risk. Although hemodynamics is excellent, there is some concern regarding coronary obstruction, especially in SAVB with externally mounted leaflet tissue, such as the Trifecta (St. Jude Medical Inc., St. Paul, Minnesota, United States). We investigated coronary flow and hydrodynamics before and after TAViVI in a SAVB with externally mounted leaflet tissue (St. Jude Medical, Trifecta) with an undersized transcatheter aortic valve bioprosthesis (Edwards Sapien XT; Edwards Lifesciences LLC, Irvine, California, United States) in an in vitro study. Materials and Methods An aortic root model was constructed incorporating geometric dimensions known as risk factors for coronary obstruction. Investigating the validity of this model, we primarily performed recommended TAViVI with the Sapien XT (size 26 mm) in a Trifecta (size 25 mm) in a mock circulation. Thereafter, hydrodynamic performance and coronary flow (left/right coronary diastolic flow [lCF/rCF]) after TAViVI with an undersized Sapien XT (size 23 mm) in a Trifecta (size 25 mm) were investigated at two different coronary ostia heights (COHs, 8 and 10 mm). Results Validation of the model led to significant coronary obstruction (p < 0.001). Undersized TAViVI showed no significant reduction with respect to coronary flow (lCF: COH 8 mm, 0.90-0.87 mL/stroke; COH 10 mm, 0.89-0.82 mL/stroke and rCF: COH 8 mm, 0.64-0.60 mL/stroke; COH 10 mm, 0.62-0.58 mL/stroke). Mean transvalvular gradients (4-5 mm Hg, p < 0.001) increased significantly after TAViVI. Conclusions In our in vitro model, undersized TAViVI with the balloon-expandable Sapien XT into a modern generation SAVB (Trifecta) successfully avoided coronary flow obstruction.

Long-term outcomes after surgical ablation for atrial fibrillation in patients with continuous heart rhythm monitoring devices

OBJECTIVES

Surgical ablation for atrial fibrillation (AF) is an established therapy for the treatment of concomitant AF in cardiac surgery patients. We aim to present our prospective experience with 99 continuously monitored patients and investigate whether enhanced monitoring can identify patterns and factors influencing AF recurrence after surgical AF ablation.

METHODS

Ninety-nine patients (73 males; age: 68.0 ± 9.2 years) with documented preoperative AF (paroxysmal: 29; persistent: 18; long-lasting persistent: 52, mean preoperative duration: 46 ± 53 months) underwent concomitant biatrial surgical ablation (Cox Maze III: 29), full set left atrial cryoablation (n = 22), high-intensity focused ultrasound (HIFU) box lesion (n = 46) or right-sided ablation (n = 2). Postoperative rhythm disclosure was provided via an implantable device. Scheduled follow-up was performed quarterly (mean ± standard deviation: 1.75 ± 1.16 years, 173.7 patient-years).

RESULTS

The mean postoperative AF burden during the follow-up was 7 ± 19% (median: 0.2%). Seventy-one and 82 patients had AF burden <1% and <5%, respectively. The preoperative AF duration, preoperative ejection fraction, mitral valve surgery and HIFU in patients with more persistent AF were associated with statistically significant higher postoperative AF burdens. The pattern of AF recurrence during the 3-month blanking period was associated with the amount of later AF recurrence.

CONCLUSIONS

Continuous rhythm disclosure reveals that very small amounts of AF burden after surgical ablation are common. The preoperative duration of AF and the use of a box lesion only in patients with longer AF persistence history were independently associated with higher postoperative AF burden recurrence. The temporal AF pattern during the blanking period after ablation should be considered for further patient management and might serve as a prognostic factor.

New insights in the association between bicuspid aortic valve phenotype, aortic configuration and valve haemodynamics

OBJECTIVES

Patients with a bicuspid aortic valve (BAV) present with various phenotypes of the valve, the aortic root (AoR) and/or the ascending aorta (AAo) and various valve haemodynamics (vHs). The aim of the present study was to investigate the association between the above parameters.

METHODS

Between February 1999 and April 2014, the preoperative aortographies of 828 surgical patients with BAV were evaluated. The exact BAV type was classified intraoperatively according to the number and spatial orientation of the raphes.

RESULTS

On analysis of BAV phenotypes and aortic configurations, a weak pattern was revealed (P = 0.01) only for BAV type 0 and AoR dilatation. Including haemodynamics, certain significant patterns emerged: in insufficient BAVs, AoR dilatation was significantly more frequent in type 0, type 1 LR and type 1 RN, whereas AoR + AAo dilatation was more frequent in BAV type 1 LR. In stenotic BAVs, AAo dilatation alone was observed significantly more frequently in BAV type 1 LR and type 0. Combined vHs were associated with AAo and AoR + AAo dilatation in BAV type 2/unicuspid only.

CONCLUSIONS

Associations between the two parameters, BAV type and aortic configuration, were only weak. With the inclusion of haemodynamics significant associations emerged but were not exclusive. In stenotic BAVs, aortic dilatation was more localized to AAo only, supporting the valve-related flow turbulence theory. Insufficient (even trace insufficient) BAVs and also combined lesions in BAV type 2/unicuspid were associated with a more extensive aortopathy (AoR + AAo) in younger patients, indicating a more aggressive gene-related aortopathy.

A multicentre evaluation of the autograft procedure for young patients undergoing aortic valve replacement: update on the German Ross Registry†

OBJECTIVES

Conventional aortic valve replacement (AVR) in young, active patients represents a suboptimal solution in terms of long-term survival, durability and quality of life. The aim of the present work is to present an update on the multicentre experience with the pulmonary autograft procedure in young, adult patients.

METHODS

Between 1990-2013, 1779 adult patients (1339 males; 44.7 ± 11.6 years) underwent the pulmonary autograft procedure in 8 centres. All patients underwent prospective clinical and echocardiographic examinations annually. The mean follow-up was 8.3 ± 5.1 years (range 0-24.3 years) with a total cumulative follow-up of 14 288 years and 662 patients having a follow-up of at least 10 years.

RESULTS

The early (30-day) mortality rate was 1.1% (n = 19). Late (>30 day) survival of the adult population was comparable with the age- and gender-matched general population (observed deaths: 101, expected deaths: 91; P = 0.29). Freedom from autograft reoperation at 5, 10 and 15 years was 96.8, 94.7 and 86.7%, respectively, whereas freedom from homograft reoperation was 97.6, 95.5 and 92.3%, respectively. The overall freedom from reoperation was 94.9, 91.1 and 82.7%, respectively. Longitudinal modelling of functional valve performance revealed a low (<5%) probability of a patient being in higher autograft regurgitation grades throughout the first decade. Similarly, excellent homograft function was observed throughout the first 15 years.

CONCLUSION

The autograft principle results in postoperative long-term survival comparable with that of the age- and gender-matched general population and reoperation rates within the 1%/patient-year boundaries and should be considered in young, active patients who want to avoid the shortcomings of conventional prostheses.

Postoperative intubation time is associated with acute kidney injury in cardiac surgical patients

INTRODUCTION

Acute kidney injury (AKI) is a frequent complication after cardiac surgery and is associated with a poor prognosis. Mechanical ventilation is an important risk factor for developing AKI in critically ill patients. Ventilation with high tidal volumes has been associated with postoperative organ dysfunction in cardiac surgical patients. No data are available about the effects of the duration of postoperative respiratory support in the immediate postoperative period on the incidence of AKI in patients after cardiac surgery.

METHOD

We performed a secondary analysis of 584 elective cardiac surgical patients enrolled in an observational trial on the association between preoperative cerebral oxygen saturation and postoperative organ dysfunction and analyzed the incidence of AKI in patients with different times to extubation. The latter variable was graded in 4 h intervals (if below 16 h) or equal to or greater than 16 h. AKI was staged according to the AKI Network criteria.

RESULTS

Overall, 165 (28.3%) patients developed AKI (any stage), 43 (7.4%) patients needed renal replacement therapy. Patients developing AKI had a significantly (P <0.001) lower renal perfusion pressure (RPP) in the first 8 hours after surgery (57.4 mmHg (95% CI: 56.0 to 59.0 mmHg)) than patients with a postoperatively preserved renal function (60.5 mmHg ((95% CI: 59.9 to 61.4 mmHg). The rate of AKI increased from 17.0% in patients extubated within 4 h postoperatively to 62.3% in patients ventilated for more than 16 h (P <0.001). Multivariate logistic regression analysis of variables significantly associated with AKI in the univariate analysis revealed that the time to the first extubation (OR: 1.024/hour, 95% CI: 1.011 to 1.044/hour; P <0.001) and RPP (OR: 0.963/mmHg; 95% CI: 0.934 to 0.992; P <0.001) were independently associated with AKI.

CONCLUSION

Without taking into account potentially unmeasured confounders, these findings are suggestive that the duration of postoperative positive pressure ventilation is an important and previously unrecognized risk factor for AKI in cardiac surgical patients, independent from low RPP as an established AKI trigger, and that even a moderate delay of extubation increases AKI risk. If replicated independently, these findings may have relevant implications for clinical care and for further studies aiming at the prevention of cardiac surgery associated AKI.

Clinical outcomes and lessons learned with aortic valve repair in 508 patients

BACKGROUND AND AIM OF THE STUDY

Aortic valve repair is an attractive alternative to valve replacement. Herein is presented the authors' single-center experience and lessons learned from 508 patients undergoing AVR, in three different groups.

METHODS

Between 1993 and 2010, a total of 508 patients (148 females, 360 males; mean age 54 ± 17 years) underwent aortic valve repair. Operations included valve-sparing surgery (n = 253), isolated leaflet intervention (n = 158), and sinotubular junction (STJ) remodeling (n = 97). Aortic valve repair was defined as any primary or concomitant procedure performed at the level of the aortic valve or root for the restoration of function and/or anatomy of the valve. The mean follow up was 6.9 ± 3.8 years (range: 0-18 years; median: 6.3 years; total: 3,477 patient-years). The completeness of clinical follow up was 95%.

RESULTS

The 30-day mortality with and without dissection was 4.4% (8/180) and 1.8% (6/328), respectively. Late survival without dissection, although statistically inferior, followed closely the expected general population. In total, 53 patients required a cardiac, valve-related reoperation. Among the valve-sparing group, no significant difference in freedom from reoperation at 10 years was observed between the David and Yacoub types (n = 147 (89%) versus n = 113 (79%); p = 0.373, respectively). Among patients who underwent isolated leaflet interventions, the number required to restore valve function (repair score) significantly affected the durability and incidence of reoperations (hazard ratio 1.47; 95% CI 1.1-2.0; p = 0.01), with the risk for failure being higher early after the operation. Patients with functional aortic insufficiency (AI) requiring only STJ remodeling resulted in the most durable outcome (freedom from reoperation 97.5% at 10 years). At the latest echocardiographic follow up (448 patients; total: 2,755 pt-yr; mean: 6.4 ± 3.7 years; completeness 88%), 97% of patients had AI of grade ≤ 2.

CONCLUSION

Aortic valve repair is an attractive alternative to conventional replacement in many patients and pathologies. In particular, pathologies requiring multiple leaflet interventions and repair techniques may lead to suboptimal results. Leaflet quality and leaflet-adjusted root stabilization/reconstruction are key elements for durable results.

Toward individualized management of the ascending aorta in bicuspid aortic valve surgery: the role of valve phenotype in 1362 patients

OBJECTIVE

Decision making regarding the management of the ascending aorta (AA) in patients with a bicuspid aortic valve (BAV) undergoing valve surgery has hardly been individualized and remains controversial. We analyzed our individualized, multifactorial approach, focusing on the BAV phenotype.

METHODS

In 1362 patients (1044 men) undergoing aortic valve surgery, the BAV phenotypes were intraoperatively classified and retrospectively analyzed. The mean follow-up was 5.4±3.6 years (range, 0-14; 7334 patient-years), and the data were 96.5% complete. The individualized AA management decision process mainly included the AA diameter, age, body surface area, macroscopic AA configuration, and the perceived tissue strength of the aortic wall resulting in 3 AA treatment groups: no intervention, aortoplasty (AoP), and AA replacement (AAR).

RESULTS

In 906 patients (66.5%), no intervention was performed and 172 (12.6%) and 284 (20.9%) underwent AoP and AAR, respectively. The hospital mortality was 1.1% for no intervention, 0.6% for AoP, and 0.4% for AAR (P=.4). The 10-year survival was similar for all 3 groups and comparable to that of the general population. Five reoperations on the AA occurred, 4 in the no intervention and 1 in the AoP group. BAV type 2/unicuspid patients were younger and more had undergone AAR in absolute numbers and after allowing for the AA diameter. Also, in patients with BAV type 1 LR and regurgitation, AAR was performed more often.

CONCLUSIONS

The individualized, multifactorial management of AA in patients with BAV during aortic valve surgery leads to excellent results. The threshold AA diameter for intervention (AoP or AAR) varied from 34 to 51 mm (mean, 43.9). BAV type 2/unicuspid and BAV type 1 LR with regurgitation emerged as determinants for more liberal AAR in our practice. Longer term follow-up is necessary to confirm our conclusions.