Low-Risk Surgical Aortic Valve Replacement in the Era of Transcatheter Aortic Valve Implantation

Open surgical aortic valve replacement (SAVR) is a viable alternative to transcatheter implantation in low-risk patients. In this light, we evaluated the safety and effectiveness of SAVR performed through conventional and less invasive surgical approaches in a high-volume center.

We retrospectively reviewed the records of 395 consecutive patients who underwent open SAVR from January 2019 through December 2019 in our center. We evaluated and compared the operative results and postoperative major adverse outcomes of 3 surgical approaches: full median sternotomy (n=267), upper ministernotomy (ministernotomy) (n=106), and right anterior thoracotomy (minithoracotomy) (n=22).

Overall, the 30-day all-cause mortality rate was 0.8% (3 patients). Stroke occurred in 8 patients (2%), disabling stroke in 4 patients (1%), myocardial infarction in 1 (0.2%), and surgical site infection in 13 (3.2%). There was no difference in 30-day mortality rate or incidence of postoperative major adverse events among the 3 surgical groups. Stroke and surgical site infection occurred more frequently, but not significantly so, in the full-sternotomy group. The mean hospital stay was longer after full sternotomy (9.1 ± 5.5 d) than after ministernotomy (7.5 ± 2.9 d) or minithoracotomy (7.4 ± 1.9 d) (P=0.012).

Our findings suggest that open SAVR performed in a high-volume center is associated with a low early mortality rate and that less invasive approaches result in faster postoperative recovery and shorter hospital stays.

Prediction value of EuroSCORE II in total arterial revascularization and its usage in the evaluation of postoperative complications: Single-center experience

BACKGROUND

Total arterial revascularization is the most durable and technically the most demanding type of coronary artery bypass grafting procedure. It has proven long-term supremacy in comparison to conventional coronary artery bypass grafting. In our study, we investigated the reliability of EuroSCORE II as a predictor of intrahospital death. We showed its impact on adverse perioperative events.

METHODS

In this nonrandomized prospective study, we analyzed 116 consecutive patients who underwent the total arterial revascularization procedure at our Institute from January 2011 until the present. For myocardial revascularization, the most suitable combinations with left internal mammary artery, right internal mammary artery, and radial artery grafts were used. Main fact in this research was intrahospital mortality value in comparison with the value predicted.

RESULTS

There were 104 (89.7%) males and 12 (10.3%) females. Mean preoperative EuroSCORE II prediction value was 1.98% and postoperative we obtained 1.72%. Postoperative redo for bleeding was 6%. Positive correlation was proven between the EuoroSCORE II value and intensive care unit stay (0.452; p < 0.001). Among patients who received two internal mammary arteries, the highest EuroSCORE II was among those with presternal wound infection (p = 0.005). Patients with bilateral internal mammary arteries and diabetes showed that they have the highest values of EuroSCORE II and, at the same time, that they are extremely prone to wound problems.

CONCLUSIONS

We achieved a lower intrahospital mortality level than it was predicted with preoperative EuroSCORE II value. This tool is a reliable method for preoperative death risk calculation in this group of patients.

The role of transapical cannulation in the operative management of acute aortic dissection

OBJECTIVES

The aim of the study was to investigate the usefulness of transapical cannulation as the routine cannulation site in patients with acute aortic dissection and to compare it with other cannulation methods.

METHODS

Between January 2010 and December 2013, emergency surgery was performed in 111 consecutive patients with acute type A aortic dissection. Patients were divided into two groups: transapical cannulation group and other cannulation sites group (including femoral and axillary artery cannulation). Pre-, intra- and postoperative data were compared between these two groups of patients.

RESULTS

Transapical cannulation was the most frequent cannulation site (78 patients, 70.3%), the femoral artery was selected in 24 patients (21.6%) and the axillary artery in 9 patients (8.1%). The mortality rate in the transapical group was 16.7% and 18.2% when other cannulation sites were chosen (p=0.85). No difference in postoperative stroke rate (6.4% vs 9.1%, p=0.62, transapical vs other cannulation sites group, respectively), myocardial infarction (6.4% vs 6.1%, p=0.94) and postoperative acute renal insufficiency incidence (9% vs 6.1%, p=0.61) was found.

CONCLUSIONS

Routine transapical cannulation in patients with acute type A aortic dissection is a fast and safe way to establish cardiopulmonary bypass. There is no difference in major operative outcomes after transapical cannulation when compared to the other cannulation sites.

Steroids and statins: an old and a new anti-inflammatory strategy compared

OBJECTIVES

This study compared the anti-inflammatory effects of methylprednisolone (MP) and atorvastatin and analysed their influences on clinical variables in patients undergoing coronary revascularization.

METHODS

Ninety patients with compromised left ventricular ejection fraction (≤30%) undergoing elective coronary surgery were equally randomized to one of three groups: statin group, treatment with atorvastatin (20 mg/day) 3 weeks before surgery; methylprednisolone group, a single shot of methylpredniosolone (10mg/kg); and control group.

RESULTS

Postoperative IL-6 was higher in the control group when compared to the methylprednisolone and statin groups (p<0.01). IL-6 was higher in the statin-treated patients (p<0.05 versus methylprednisolone). Administration of methylprednisolone as well as statin treatment increased postoperative cardiac index, left ventricular stroke work index, decreased postoperative atrial fibrilation rate and reduced ICU stay (p<0.05 versus control). The number of patients requiring inotropic support was lower in the methylprednisolone group when compared with the other two groups (p<0.01). Tracheal intubation time was reduced in patients who received methylprednisolone (p<0.01 versus control).

CONCLUSIONS

Preoperative administration of either methylprednisolone or atorvastatin reduced pro-inflammatory cytokine release, improved haemodynamics, decreased postoperative atrial fibrilation rate and reduced ICU stay in patients with significantly impaired cardiac function undergoing coronary revascularization. Treatment with methylprednisolone was associated with less inotropic support requirements and reduced mechanical ventilation time.

[The internal thoracic artery in myocardial revascularization in patients with severely depressed left ventricular function]

INTRODUCTION

In most prospective, randomized studies, severely depressed left ventricular function is found to be the independent predictor of increased morbidity and mortality after myocardial revascularization [3]. Surgical treatment in this particular group of patients results in superior long-term results [1, 2]. Internal thoracic artery (ITA) is considered to be superior compared to venous grafts in myocardial revascularization for the majority of patients with ischaemic heart disease. However, its value in patients with already severely depressed left ventricular function (EF < or = 30%) is still a matter of debate. There are no prospective, randomized studies, so far. In some studies it was shown that revascularization with ITA graft resulted in superior long-term results (10- and 15-year follow-up) in all subgroups of patients, including those with severely depressed left ventricular function [4, 5]. Some authors find it still unacceptable, if this result would be possible at the expense of higher early mortality (due to use of ITA). The purpose of this study is to analyze the early and long-term results of myocardial revascularization using ITA graft in patients with severely depressed left ventricular function (EF < 30%).

MATERIAL AND METHODS

Over the period from November 1986 through March 1999, 2860 pts have received ITA (alone or with additional vein grafts) for myocardial revascularization. In 431 pts EF was < or = 30% (15.1%), average EF being 25.7% (by echocardiography); 33 were women, 29 were diabetics, while average age was 56.7 +/- 8.4 years. The control group consisted of 430 pts, with similar preoperative characteristics, who received vein grafts alone.

RESULTS

Operative mortality in the ITA group was 2.55% (11/431), and postoperative morbidity was 7.4% (32/431). In the group with vein grafts only the mortality was 3.25% (14/430) and morbidity 6.7% (29/430)--Table 2. The average postoperative hospital stay was 9.1 days (range 7-32). There was no difference in operative and postoperative parameters (extracorporeal time, ischaemic time, duration of mechanical ventilation, need for inotropic support, mortality, morbidity and hospital stay) compared to the group with vein grafts alone, except for the blood drainage--significantly higher in the ITA group--p < 0.00001)--Table 3. Multivariate analysis showed that independent predictors of unfavorable outcome were the presence of peripheral vascular disease (beta--0.9; p = 0.02) and aortic cross-clamp time (beta--0.02; p = 0.01). Long-term results in 14 pts with ITA graft operated on from 1986 to 1992 (6-12 years of follow-up) showed the survival of 92.7%.

DISCUSSION

Superior long-term patency of ITA graft resulted in its practically routine use in myocardial revascularization. However, in some studies it was shown that ITA flow might be insufficient during the maximal effort [6]. This may result in hypoperfusion, low cardiac output syndrome and cardiac arrest. This frequently happens at the end of the operation, and may be accentuated with the use of vasopressors that can further decrease the ITA flow [9]. In patients with already severely depressed left ventricular function preoperatively, the use of vasopressors at the end of procedure when the myocardium may be quite vulnerable, is to be expected. Friesewinkel et al., [18] showed that there was an impairment of the regional contractility of the left ventricle early (up to 4 hours) after myocardial revascularization, when one or both ITA grafts were used. Since this was not the case if vein grafts were used, they advised to be careful in patients with "depressed left ventricular function". However, Elefteriades et al., [1] found no higher mortality in patients with "bad left ventricle" in whom ITA was used, but point out that patients with elective operation and without need for intensive care treatment preoperatively had much better outcome. Jagaden et al., [19] found very good results in these patients, after the routine use of ITA, during a 20-year follow-up. In our study EF < or = 30% was present in 861 patients, 431 with ITA graft and 430 with vein grafts only. There was no difference between groups considering all possible preoperative and operative factors of importance for the outcome. We found no increased early morbidity and mortality in patients in whom ITA was used compared to patients with vein grafts only. In patients operated on from 1986-1992 (follow-up of 6-12 years), we noted the survival of 92.7%. This was not statistically different compared to patients with vein grafts (survival of 88.9%). Despite the small number of patients, we found these long-term results very encouraging.

CONCLUSION

ITA graft is a very good and absolutely acceptable choice in patients with severely damaged left ventricular function, particularly if we consider its long-term superiority. These pts should not be deprived of the long-term benefit of ITA graft, since early results are very good.