Outcomes of rapid deployment aortic valve replacement with concomitant cardiac procedures

Background

Rapid deployment aortic valve replacement (RD-AVR) has been recently introduced with encouraging results. Outcomes of isolated RD-AVR include good hemodynamic profile, facilitation of minimally invasive techniques, and reduction of surgical times. However, role of this prosthesis in concomitant surgery is not well known.

Methods

In 2016, we formed a registry to monitor the introduction of this prosthesis, RApid Deployment Aortic Replacement (RADAR). We aim to report mid-term outcomes focusing on patients who had RD-AVR combined with other surgical procedures.

Results

Between July 2012 and February 2021, 370 patients were included in this registry (mean age, 75.8±8.0 years; 64.32% male; mean EuroSCORE II, 3.5±2.8). Of these, 128 (34.59%) had concomitant procedures including myocardial revascularization surgery in 69 patients (53.91%), surgery on the ascending aorta in 34 (26.56%), and procedures on other valves in 10 patients (7.81%). There were no significant differences between the isolated AVR and concomitant AVR groups in postoperative complications, in-hospital mortality (4.72% vs. 3.32%, P=0.524), or hemodynamic behavior of these prostheses. Three-year survival was 83.73% and 89.89% in the isolated and concomitant AVR group respectively. There was no difference in survival between the two groups (log-rank test, P=0.4124).

Conclusions

Our results support the safety and efficacy of the Edwards INTUITY valve system even in complex aortic valve disease with additional cardiac procedures. RD-AVR could become a useful tool for concomitant surgeries where surgical times are expected to be prolonged.

Acute acquired immune thrombocytopenia after cardiac surgery: A challenging case

Thrombocytopenia is a common condition that recognizes an infinite number of possible causes, especially in specific settings like the one covered in this case report: the postoperative period of cardiac surgery. We report a case of an old male with multiple comorbidities who underwent a coronary angioplasty procedure and aortic valve replacement. He showed severe thrombocytopenia in the postoperative days. Differential diagnosis required a big effort, also for the experts in the field. Our goal was to aggressively treat the patient with prednisolone, platelets, and intravenous immunoglobulins to maximize the prognosis. Our patient developed no complications and was discharged successfully.

Pathology-related changes in cardiac energy metabolites, inflammatory response and reperfusion injury following cardioplegic arrest in patients undergoing open-heart surgery

Introduction

Changes in cardiac metabolites in adult patients undergoing open-heart surgery using ischemic cardioplegic arrest have largely been reported for non-ventricular tissue or diseased left ventricular tissue, with few studies attempting to assess such changes in both ventricular chambers. It is also unknown whether such changes are altered in different pathologies or linked to the degree of reperfusion injury and inflammatory response. The aim of the present work was to address these issues by monitoring myocardial metabolites in both ventricles and to establish whether these changes are linked to reperfusion injury and inflammatory/stress response in patients undergoing surgery using cold blood cardioplegia for either coronary artery bypass graft (CABG, n = 25) or aortic valve replacement (AVR, n = 16).

Methods

Ventricular biopsies from both left (LV) and right (RV) ventricles were collected before ischemic cardioplegic arrest and 20 min after reperfusion. The biopsies were processed for measuring selected metabolites (adenine nucleotides, purines, and amino acids) using HPLC. Blood markers of cardiac injury (Troponin I, cTnI), inflammation (IL- 6, IL-8, Il-10, and TNFα, measured using Multiplex) and oxidative stress (Myeloperoxidase, MPO) were measured pre- and up to 72 hours post-operatively.

Results

The CABG group had a significantly shorter ischemic cardioplegic arrest time (38.6 ± 2.3 min) compared to AVR group (63.0 ± 4.9 min, p = 2 x 10-6). Cardiac injury (cTnI release) was similar for both CABG and AVR groups. The inflammatory markers IL-6 and Il-8 were significantly higher in CABG patients compared to AVR patients. Metabolic markers of cardiac ischemic stress were relatively and significantly more altered in the LV of CABG patients. Comparing diabetic and non-diabetic CABG patients shows that only the RV of diabetic patients sustained major ischemic stress during reperfusion and that diabetic patients had a significantly higher inflammatory response.

Discussion

CABG patients sustain relatively more ischemic stress, systemic inflammatory response and similar injury and oxidative stress compared to AVR patients despite having significantly shorter cross-clamp time. The higher inflammatory response in CABG patients appears to be at least partly driven by a higher incidence of diabetes amongst CABG patients. In addition to pathology, the use of cold blood cardioplegic arrest may underlie these differences.

Gender differences in bicuspid aortic valve Sievers types, valvulopathy, aortopathy, and outcome of aortic valve replacement

BACKGROUND

The gender difference of the bicuspid aortic valve (BAV) is not well understood.

OBJECTIVES

We evaluated the impact of gender on the Sievers types, valvulopathy, aortopathy, and outcomes of aortic valve replacement (AVR) of BAV patients in a cohort of Chinese patients.

METHODS

Among 992 BAV patients without aortic dissection nor congenital heart disease, 658 underwent AVR. The demography, Sievers types, valvulopathy, aortopathy, and outcomes of AVR were compared between genders.

RESULTS

Aortic regurgitation (AR ≥ 2+) (39.0% vs. 12.8%, p < .001), aortic root dilation only (3.8% vs. .8%, p = .014), and diffuse dilation (25.3% vs. 4.3%, p < .001) were more common in men, while moderate to severe aortic stenosis (AS) (21.3% vs. 45.7%, p < .001) and ascending dilation only (46.2% vs. 61.2%, p < .001) were more common in women. Men were more prone to develop preoperative AR ≥ 2+ (OR = 5.15, p < .001), moderate to severe AS + AR ≥ 2 + (OR = 2.95, p = .001), and Diffuse aortic dilation (OR = 3.91, p < .001). Sievers types did not have a significant effect on valvular dysfunction. Gender didn't predict early adverse events after AVR (n = 90) (HR = 1.21, p = .44), but male gender predicted a left ventricular ejection fraction <50% after AVR (OR = 3.07, p = .03).

CONCLUSIONS

In this BAV series of Chinese patients, gender didn't differ significantly in Sievers types of BAV but showed significant differences in valvulopathy, aortopathy, and LV function after AVR. In addition, the male patients developed more severe conditions at a younger age.

Operative mortality in adult cardiac surgery: is the currently utilized definition justified?

Background

This study evaluated operative mortalities following adult cardiac surgical operations to determine if this metric remains appropriate for the modern era.

Methods

This was a retrospective review of Society of Thoracic Surgeons (STS) indexed adult cardiac operations that included coronary artery bypass grafting (CABG), aortic valve replacement (AVR), CABG + AVR, mitral valve repair (MVr), CABG + MVr, mitral valve replacement (MVR) and CABG + MVR, performed at a single institution between 2011 and 2017. The primary outcome was the timing and relatedness of operation mortality, as defined by the STS as mortality within 30-day or during the index hospitalization, compared to the index operation. The secondary outcomes evaluated cause of death and the rates of postoperative complications.

Results

A total of 11,190 index cardiac operations were performed during the study period and operative mortality occurred in 246 (2.2%) of patients. The distribution of operative mortalities included 83.7% (n=206) who expired within 30-day while an inpatient, 6.9% (n=17) died within 30-day as an outpatient, 11.2% (n=23) expired after 30-day. The most common causes of operative mortality were cardiac (38.7%, n=92), renal failure (15.6%, n=37), and strokes (13.9%, n=33). Furthermore, 98.4% (n=242) of deaths were attributable to the index operation. Postoperative complications occurred frequently in those with operative mortality, with blood transfusions (80.1%), reoperations (65.0%) and prolonged ventilation (62.2%) being most common.

Conclusions

Most of the operative mortalities seemed to be attributable to the index cardiac operation. We believe that the current definition of mortality remains appropriate in the modern era.

The surgical outcomes of aortic valve replacement in patients with aortic valve lesions caused by Behcet's disease: lessons we learned

Background

For Behcet’s disease patients with aortic root lesions, the disease often manifests as aortic valve regurgitation (AR). Following aortic valve replacement (AVR), many of these patients often suffer perivalvular leakage and valve dehiscence, requiring a second or third operation. In this study, we report the outcomes of 20 patients who underwent AVR to manage aortic root lesions caused by Behcet’s disease, and the lessons we learned.

Methods

From October 2013 to September 2019, a total of 50 patients with Behcet’s disease underwent AVR at our institution. Among them, isolated AVR was performed in 15 preoperatively undiagnosed cases. The other 5 patients were preoperatively diagnosed and underwent modified AVR. All patients were contacted for a follow-up. Valve function was evaluated using echocardiography.

Results

The 15 preoperatively undiagnosed patients [age: 38.4±12.6 years (range, 24–63 years); 9 males, 6 females] underwent isolated AVR as their primary procedure. Echocardiography revealed that valve dehiscence occurred in 13 (86.7%) patients postoperatively after a mean interval of 10.8±8.4 months. These patients accepted a second operation, and 1 of them accepted a third operation because of a pseudoaneurysm of the distal anastomosis site. For the other 5 patients [age: 38.8±9.5 years (range, 27–55 years); 4 males, 1 female] who underwent modified AVR, neither AR nor prosthetic valve detachment were observed during the echocardiography follow-up, and none required a secondary operation.

Conclusions

For behcet’s disease patients with AR, there was a high rate of valve dehiscence after isolated AVR. When compared with traditional AVR, we found that modified AVR was the optimal choice for patients who received standardized preoperative treatment.

Trends in Mortality From Aortic Stenosis in Europe: 2000-2017

Background: Trends in mortality from aortic stenosis across European countries are not well-understood, especially given the significant growth in transcatheter aortic valve implantation (TAVI) in the last 10 years. Methods: Age-standardised death rates were extracted from the World Health Organisation Mortality Database, using the International Classification of Diseases 10th edition code for non-rheumatic aortic stenosis for those aged > 45 years between 2000 and 2017. The UK and countries from the European Union with at least 1,000,000 inhabitants and at least 50% available datapoints over the study period were included: a total of 23 countries. Trends were described using Joinpoint regression analysis. Results: No reductions in mortality were demonstrated across all countries 2000-2017. Large increases in mortality were found for Croatia, Poland and Slovakia for both sexes (>300% change). Mortality plateaued in Germany from 2008 in females and 2012 in males, whilst mortality in the Netherlands declined for both sexes from 2007. Mortality differences between the sexes were observed, with greater mortality for males than females across most countries. Conclusions: Mortality from aortic stenosis has increased across Europe from 2000 to 2017. There are, however, sizable differences in mortality trends between Eastern and Western European countries. The need for health resource planning strategies to specifically target AS, particularly given the expected increase with ageing populations, is highlighted.

Ross operation after failure of aortic valve repair

Background

Repair failure remains one of the most important complications of aortic valve reconstruction. Young patients might benefit from a Ross procedure in such a scenario, provided it can be performed safely and with adequate durability. The aim of this study was to assess the safety and clinical outcomes of a Ross operation following a failed repair.

Methods

Between 1996 and 2019, 80 patients (male, 76%; mean age, 31±13 years) underwent a Ross procedure after a median of 6.6 (1.7-15.9) years following an initial aortic valve repair. The previous valve repair was performed for unicuspid (53%), bicuspid (39%), tricuspid (7%), and quadricuspid morphology (1%). Median follow-up after the Ross operation was 2.8 (0.964-13.25) years, mean 5±5 years (92% complete).

Results

Median cardiopulmonary bypass and cross-clamp times were 144 [106-154] minutes and 98 [79-113] minutes, respectively. Thirty-two patients (40%) required a concomitant procedure, most commonly, an ascending aortic replacement (n=23). There were no peri-operative deaths, myocardial infarctions, or neurological complications. There was one late death from a non-cardiac cause. At 10 years, overall survival was 99%±1%, similar to that of an age- and gender-matched population. Nine patients required re-intervention after their Ross procedure (five on the autograft and four on the pulmonary conduit). The autograft re-interventions were valve-sparing procedures in all patients. The cumulative incidence of re-intervention on the autograft at 8 years was 5.1%±3.1%.

Conclusions

The stepwise strategy of an initial valve repair followed by Ross operation represents a safe and valid option for failed aortic valve repair. It is associated with low peri-operative morbidity. Mid-term survival is excellent, similar to that of a matched general population. The probability of re-intervention after the Ross procedure appears similar to that of a primary Ross operation, deeming it a warranted consideration in cases of failed aortic valve repair.

The Ross procedure in children: a systematic review

Background

The Ross procedure involves autograft transplantation of the native pulmonary valve into the aortic position and reconstruction of the right ventricular outflow tract (RVOT) with a homograft. The operation offers the advantages of a native valve with excellent hemodynamic performance, the avoidance of anticoagulation, and growth potential. Conversely, the operation is technically demanding and imposes the risk of turning single-valve disease into double-valve disease. This systematic review reports outcomes of pediatric patients undergoing the Ross procedure.

Methods

An electronic search identified studies reporting outcomes on pediatric patients (mean age <18 years, max age <21 years) undergoing the Ross procedure. Long-term outcomes, including early mortality, late mortality, sudden unexpected unexplained death, reoperation due to failure of the pulmonary autograft or RVOT reconstruction, thromboembolic events, bleeding events, and endocarditis-related complications, were evaluated.

Results

Upon review of 2,035 publications, 30 studies and 3,156 pediatric patients were included. Patients had a median age of 9.5 years and median follow-up period of 5.7 years. Early mortality rates varied from 0.0 to 17.0% and were increased in the neonatal population. Late mortality rates were much lower (0.04-1.83%/year). Reoperation due to pulmonary autograft failure occurred at rates of 0.37-2.81%/year and reoperation due to RVOT reconstruction failure was required at rates of 0.34-4.76%/year. Thromboembolic, bleeding, and endocarditis events were reported to occur at rates of 0.00-0.58, 0.00-0.39, and 0.00-1.68%/year, respectively.

Conclusions

The Ross operation offers a durable aortic valve replacement (AVR) option in the pediatric population that offers favorable survival, excellent hemodynamics, growth potential, decreased risk of complications, and avoidance of anticoagulation. Larger multi-institutional registries focusing on pediatric patients are necessary to provide more robust evidence to further support use of the Ross procedure in this population.

Need for permanent pacemaker implantation following implantation of the rapid deployment valve in combined procedures: a single centre cohort study

Background

Rapid deployment aortic valves may interfere with the cardiac conduction system. We investigated the need for permanent pacemaker implantation (PPI) following the implantation of Edwards INTUITY valve (Edwards Lifesciences, Irvine, CA).

Methods

One hundred twenty patients underwent aortic valve replacement (AVR) with the INTUITY valve in a combined procedure at the German Heart Centre Munich between April 2016 and December 2019. Twenty-four patients with prior PPI or concomitant ablation procedures (24/120, 20%) were excluded. Patient-specific, procedural and post-procedural outcomes were assessed in the remaining 96 cases.

Results

AVR was successful in all cases. Seventy-four percent of the study population were men. Mean age was 69.5±7.6 years. EuroSCORE II was 3.2±2.9. Forty-six patients (46/96, 47.9%) presented with pre-operative conduction disorders, right bundle branch block (RBBB) (17/96, 17.7%) and first-degree or second degree atrio-ventricular block (AVB) (18/96, 18.8%), in particular. In total, 9 patients (9/96, 9.4%) underwent PPI. PPI was required in 3 patients (3/50, 6.0%) who did not have a pre-existing conduction disorder due to new high degree AVB. 6 patients with pre-operative conduction disorders (6/46, 13%) needed PPI. Timing of PPI was 5.2±1.5 days (median 5). Independent predictors of PPI were preoperative RBBB [odds ratio (OR) =4.554, P=0.049] and large valve size (#27) (OR =5.527, P=0.031).

Conclusions

The analysis of the data collected enabled us to identify patient factors associated with higher risk for post-operative PPI following AVR with the INTUITY valve. Patient factors associated with post-operative PPI, were RBBB and large valve size. These patients should be closely monitored following the procedure, in particular.

Minimally-invasive versus transcatheter aortic valve implantation: systematic review with meta-analysis of propensity-matched studies

Background

Minimally invasive aortic valve replacement (MiAVR) and transcatheter aortic valve implantation (TAVI) provide aortic valve replacement (AVR) by less invasive methods than conventional surgical AVR, by avoiding complete sternotomy. This study directly compares and analyses the available evidence for early outcomes between these two AVR methods.

Methods

Electronic databases were searched from inception until August 2019 for studies comparing MiAVR to TAVI, according to predefined search criteria. Propensity-matched studies with sufficient data were included in a meta-analysis.

Results

Eight studies with 9,744 patients were included in the quantitative analysis. Analysis of risk-matched patients showed no difference in early mortality (RR 0.76, 95% CI, 0.37–1.54, P=0.44). MiAVR had a signal towards lower rate of postoperative stroke, although this did not reach statistical significance (OR 0.42, 95% CI, 0.13–1.29, P=0.13). MiAVR had significantly lower rates of new pacemaker (PPM) requirement (OR 0.29, 95% CI, 0.16–0.52, P<0.0001) and postoperative aortic insufficiency (AI) or paravalvular leak (PVL) (OR 0.05, 95% CI, 0.01–0.20, P<0.0001) compared to TAVI, (OR 0.42, 95% CI, 0.13–1.29, P=0.13), while acute kidney injury (AKI) was higher in MiAVR compared to TAVI (11.1% vs. 5.2%, OR 2.28, 95% CI, 1.25–4.16, P=0.007).

Conclusions

In patients of equivalent surgical risk scores, MiAVR may be performed with lower rates of postoperative PPM requirement and AI/PVL, higher rates of AKI and no statistical difference in postoperative stroke or short-term mortality, compared to TAVI. Further prospective trials are needed to validate these results.

Outcome of reoperative aortic root or ascending aorta replacement after prior aortic valve replacement

Background

There are limited data regarding the clinical outcomes of reoperative aortic root or ascending aorta replacement after prior aortic valve replacement (AVR). We aimed to analyze outcomes of reoperative aortic root or ascending aorta replacement after prior AVR.

Methods

Eighty patients with prior AVR underwent reoperative aortic root or ascending aorta replacement in our hospital. The indications were root or ascending aortic aneurysm in 36 patients, root or ascending aortic dissection in 37, root false aneurysm in 2, prosthesis valve endocarditis (PVE) with root abscess in 2, Behçet’s disease (BD) with root destruction in 3 patients. An elective surgery was performed in 63 patients and an emergent surgery in 17. The survival and freedom from aortic events during the follow-up were evaluated with the Kaplan-Meier survival curve and the log-rank test.

Results

The operative techniques included ascending aorta replacement in 14 patients, ascending aorta replacement with AVR in 3, prosthesis-sparing root replacement (PSRR) in 35, Bentall procedure in 24, and Cabrol procedure in 4 patients. Operative mortality was 1.3% (1/80). A composite of adverse events occurred in 5 patients, including 1 operative death, 2 stroke and 3 renal failure necessitating hemodialysis. The mean follow-up was 35.5±22.1 months. Five late deaths occurred. The Kaplan-Meier survival at 1 year, 3 years and 6 years were 97.5%, 91.1% and 84.1%, respectively. Aortic events developed in 3 patients. The freedom from aortic events at 1-year, 3-year, and 6-year were 100%, 96.3% and 88.9%, respectively. There were no differences in survival and freedom from aortic events between the elective group and the emergent group.

Conclusions

Reoperative aortic root or ascending aorta replacement after prior AVR could be performed to treat the root or ascending pathologies after AVR, with satisfactory early and midterm outcomes.

Conduction disorders after aortic valve replacement: what is the real impact of sutureless and rapid deployment valves?

Background

Although sutureless and rapid deployment aortic valve replacement (SURD-AVR) has been associated with an increased rate of permanent pacemaker (PPM) implantation compared to conventional AVR (c-AVR), the predictors of new conduction abnormalities remain to be clarified. This study aimed to identify risk factors for conduction disorders in patients undergoing AVR surgery.

Methods

Data from 243 patients receiving minimally invasive AVR were prospectively collected. SURD-AVR was performed in 103 (42.4%) patients and c-AVR in 140 (57.6%). The primary endpoint was the occurrence of new-onset conduction disorders, defined as first degree atrioventricular (AV) block, advanced AV block requiring PPM implantation, left anterior fascicular block (LAFB), left bundle branch block (LBBB) and right bundle branch block (RBBB).

Results

The unadjusted comparison revealed that SURD-AVR was associated with a higher rate of advanced AV block requiring PPM when compared with c-AVR (10.5% vs. 2.1%, P=0.01). After adjusting for other measured covariates (OR: 1.6, P=0.58) and for the estimated propensity of SURD-AVR (OR: 5.1, P=0.1), no significant relationship between type of AVR and PPM implantation emerged. On multivariable analysis, preoperative first-degree AV block (OR: 6.9, P=0.04) and RBBB (OR: 6.9, P=0.03) were independent risk factors for PPM. Subgroup analysis of patients with normal preoperative conduction revealed similar incidence of PPM between SURD-AVR and c-AVR (1.3% vs. 1.9%, P=0.6). When compared with c-AVR, SURD-AVR was associated with a greater incidence of postoperative new onset LBBB (18.1% vs. 3.2%, P<0.001). This finding was confirmed after adjusting for the estimated propensity of SURD-AVR (OR: 6.3, P=0.009).

Conclusions

Our study revealed that the risk of PPM implantation in patients receiving surgical AVR is heavily influenced by the presence of pre-existing conduction disturbances rather than the type of valve prosthesis. Conversely, SURD-AVR emerged as an independent predictor for LBBB and was associated with an increased risk of PPM in patients presenting with RBBB.

Sutureless and rapid deployment implantation in bicuspid aortic valve: results from the sutureless and rapid-deployment aortic valve replacement international registry

Background

Benefits of sutureless and rapid deployment (SURD) bioprostheses in bicuspid aortic valves (BAV) are controversial. The aim of this study is to report the outcomes of patients undergoing aortic valve replacement (AVR) for BAV from the Sutureless and Rapid-Deployment Aortic Valve Replacement International Registry (SURD-IR).

Methods

Of the 4,636 patients who received primary isolated SURD-AVR between 2007 and 2018, 191 (4.1%) BAV patients underwent AVR with SURD valve.

Results

Overall 30-day mortality was 1.6%. The Intuity valve was implanted in 53.9% of cases, whereas the Perceval was implanted in 46.1%. Rate of stroke for isolated AVR was 4.2%. No case of endocarditis, thromboembolism, myocardial infarction, valve dislocation or structural valve deterioration was reported in the early phase. Rate of pacemaker implantation and moderate-severe aortic regurgitation (AR) were 7.9% and 3.7%, respectively.

Conclusions

BAV is not considered a contraindication for the implantation of SURD valves. However, detailed information of aortic root geometry as well as the knowledge of some technical considerations are mandatory for a good outcome.

The sutureless and rapid-deployment aortic valve replacement international registry: lessons learned from more than 4,500 patients

The treatment options for patients with aortic valve disease have considerably expanded over the last decade. The remarkable advances in catheter-based technology, the popularizing of minimally invasive (MI) surgery, and the introduction of new valve technologies, such as sutureless and rapid-deployment (SURD) valves have led to a paradigm shift in the management of aortic valve pathologies. Yet, given their recent introduction, the current evidence on sutureless and rapid-deployment aortic valve replacement (SURD-AVR) has been limited thus far. The Sutureless and Rapid-Deployment Aortic Valve Replacement International Registry (SURD-IR) was established in 2015 by a consortium of 18 research centers to assess safety, efficacy, short- and long-term outcomes of SURD-AVR interventions. The present keynote lecture aims to assess and comment on the real-world evidence for SURD-AVR surgery generated from the SURD-IR.

Long-term outcomes of sutureless and rapid-deployment aortic valve replacement: a systematic review and meta-analysis

Background

Sutureless and rapid-deployment aortic valve replacement (SURD-AVR) has become a prominent area of research as the medical community evaluate its place amongst other aortic valve interventions. The main advantages of SURD-AVR established to date are the reduced cross-clamp and cardiopulmonary bypass (CPB) times, as well as facilitating minimally invasive surgery in high-risk surgical patients. This current systematic review and meta-analysis, to our knowledge, is the first focusing on long-term outcomes regarding safety, efficacy and durability of SURD-AVR from available current literature.

Methods

A literature search via six electronic databases was performed from their inception to November 2019. Inclusion criteria for this systematic review included survival and postoperative echocardiographic outcomes greater than five years in patients who underwent SURD-AVR with either Perceval or Intuity valves. Studies were identified and data extracted by two independent reviewers. Long-term survival outcomes were aggregated using digitized Kaplan-Meier curves where available.

Results

After applying predefined inclusion and exclusion criteria, four studies were identified for review. All four studies were observational and in total reported data for 1,998 patients. Almost half (42.4%) of patients underwent SURD-AVR via full sternotomy, with almost one third (30.1%) also undergoing concomitant cardiac procedures. Aggregate overall survival rates at 1-, 2-, 3-, and 5-year follow-up were 94.9%, 91.2%, 89.0%, and 84.2%, respectively. Incidence of strokes (4.8%), severe paravalvular leaks (PVLs) (1.5%) and permanent pacemaker (PPM) insertion (8.2%) at up to 5-year follow-up were acceptable. At 5-year follow-up hemodynamic outcomes were also acceptable for mean pressure gradient (MPG) (range, 8.8-13.6 mmHg), peak pressure gradient (PPG) (range, 18.9-21.1 mmHg) and effective orifice area (EOA) (range, 1.5-1.8 cm²).

Conclusions

Evaluation of the evidence reporting long-term outcomes of SURD-AVR suggests that it is a safe procedure for AVR with low rates of complications. Long-term outcomes presented in this review show that not only does SURD-AVR have acceptable survival rates, but also good hemodynamic performance at 5-year follow-up.

Surgical Complexity and Outcome of Patients Undergoing Re-do Aortic Valve Surgery

Objectives

Re-do aortic valve surgery carries a higher mortality and morbidity compared with first time aortic valve replacement (AVR) and often requires concomitant complex procedures. Transcatheter aortic valve replacement (TAVR) is an option for selective patients. The aim of this study is to present our experience with re-do aortic valve procedures and give an insight into the characteristics of these patients and their outcomes.

Methods

Retrospective review of 80 consecutive re-do aortic valve procedures.

Results

Mean patients’ age was 51.80±18.73 years. Aortic regurgitation (AR) was present in 51 (65.4%) patients and aortic stenosis (AS) in 38 (48.7%). Indications for reoperation were: infective endocarditis (IE) (23.8%), bioprosthetic degeneration (12.5%), mechanical valve dysfunction (5%), paravalvular leak (6.2%), patient–prosthesis mismatch (3.8%), native valve disease (25%), aortic aneurysm, pseudoaneurysm and dissection (35%), aortic root/homograft degeneration (27.5%). Forty-one (51.2%) patients underwent re-do AVR, 39 (48.8%) re-do complex aortic valve surgery (28 root, 23 ascending aorta and 6 hemiarch procedures) and 37.5% concomitant procedures. A bioprosthesis was implanted in 43.8%, a mechanical valve in 37.5%, a composite graft in 2.5%, a Biovalsalva graft in 6.2% and a homograft in 10% of patients. In-hospital mortality was 3.8% and incidence of major complications was low.

Conclusions

A significant proportion of patients were young (61%<60 y), required complex aortic procedures (49%) or presented with contraindications for TAVR (mechanical valve, AR, IE, proximal aortic disease, need for concomitant surgery). Re-do aortic surgery remains the only treatment for such challenging cases and can be performed with acceptable mortality and morbidity in a specialised aortic centre.

Selection of prosthetic aortic valves in the United States among elderly Medicare patients from 2006 to 2015

BACKGROUND

Both biological and mechanical prosthetic valves are treatment choices for aortic valve replacement. We aimed to characterize the selection of prosthetic aortic valves among elderly Medicare patients.

METHODS

This was a retrospective analysis of patients aged 65 years or older who underwent aortic valve replacement alone or in combination with other procedures in the 2006-2015 Medicare databases. Patients were continuously enrolled in Medicare Part A and B. We characterized the trends and regional variation of the selection of prosthetic valves. Multivariable logistic regression was used to evaluate the determinants that influenced the selection of prosthetic valves.

RESULTS

During the study period, there were 272,921 Medicare patients aged 65 years or older who underwent aortic valve replacement and met the inclusion and exclusion criteria. The selection of mechanical aortic valves decreased from 32.0% in 2006 to 24.3% in 2015 (P < .01). In comparison with 18.5% from northeastern states, 34.6% of patients from southern states selected mechanical valves (P < .01). Major determinants of the selection of prosthetic valves include age, gender, region, hospital characteristics, and physician experience. Patients being older, male, living in the northeast region, operated on in a high-volume hospital, and by more experienced physicians were more likely to receive biological valves.

CONCLUSIONS

A 24.1% decrease in the selection of mechanical aortic valves was observed among elderly Medicare patients from 2006 to 2015. A dramatic regional difference was observed in the choice of prosthetic valves across the nation.

Ten-year experience with the Perceval S sutureless prosthesis: lessons learned and future perspectives

Aortic stenosis has traditionally been addressed with surgical aortic valve replacement (AVR). In recent years, several technologies have emerged as alternative treatment methods for aortic valve disease. Among them, the Perceval (LivaNova, London, UK) is a sutureless valve that has been used in clinical practice for over 10 years. It has been implanted in over 20,000 patients worldwide. With nearly 600 Perceval implants since 2011, the Montreal Heart Institute has developed a worldwide expertise with this technology. In this article, we provide an overview of the clinical data currently available in the literature and discuss the lessons we have learned from our experience with the Perceval prosthesis.

Ochronosis of the aortic valve

Ochronosis is the bluish-black discolouration of connective tissue, including heart valves, joints, kidney and the skin. It is due to the deposition of homogentisic acid (HGA) commonly found in alkaptonuria. Ochronosis in the aortic valve is a rare occurrence and there is limited data available on the most appropriate choice of valve prosthesis in these patients. This case involves a 72-year-old male with symptomatic aortic stenosis and on echocardiogram a severe calcific trileaflet aortic stenosis with normal ejection fraction. Intraoperative aortic cannulation was routine and uncomplicated, and bluish-black discolouration of aortic valve was noted. Thorough decalcification was undertaken and a bioprosthetic valve was chosen in accordance with patient's age and preference. There were no complications post-operatively and the patient reported being well. Ochronosis affecting the aortic valve is a rare condition and there is limited data on the recurrence rate as well as the natural history of the disease. This case reports aims to provide data to facilitate further research to better understand the natural history of aortic valve ochronosis and rates of recurrence following bioprosthetic aortic valve replacement (AVR).

Transcatheter aortic valve implantation for patients with lung cancer and aortic valve stenosis

Many patients who require lung resection have cardiovascular and cerebrovascular comorbidities. It has been recommended that surgical aortic valve replacement (SAVR) should precede lung resection in patients with severe aortic valve stenosis (AS). However, by first undergoing transcatheter aortic valve implantation (TAVI), the patient may undergo lung resection more safely. We present two patients with both severe AS and lung cancer who underwent TAVI and lung resection without any complications.

A technique of minimally invasive aortic valve replacement: an alternative to transcatheter aortic valve replacement (TAVR)

Minimally invasive aortic valve replacement (AVR) is increasingly being adopted worldwide, in which a right mini-thoracotomy (RT) approach plays an important role. Here we reported a novel technique of AVR via RT using sutureless prosthesis, without rib division or groin incision. Surgical access was performed through an anterior right thoracotomy with 5-cm skin incision placed in the third intercostal space. Percutaneous femoral-femoral cardio-pulmonary bypass (CPB) was applied under fluoroscopy guidance to avoid groin incision. A 5-mm stab incision was made in the right chest wall for aortic cross-clamping. A sutureless bioprosthetic valve was utilized in the limited operative field, which reduced the cross-clamp and CPB time. The patient was discharged on post-operative day 2, without obvious cross-valvar gradient, and with no pain or other complication. This report offers a more minimally invasive approach to AVR with proven durable valves, which can benefit high-risk patients.

Routine aortic valve replacement followed by a myriad of complications: role of 3D printing in a difficult cardiac surgical case

Aortic valve replacement (AVR) is a routine cardiac surgical intervention that is rarely associated with severe complications. In this report, we present a complex and unique case following AVR in a middle-aged woman. We show the growing necessity for a strong cooperation between interventional cardiologists and cardiac surgeons, together with the emerging role of cardiac tomography based three-dimensional printing technique in planning and executing precision surgery within the chest.

Should sinus of Valsalva be preserved in patients with bicuspid aortic valve and aortic dilation?

Background

It is recommended that dilated ascending aortas (≥45 mm) should be replaced at the time of aortic valve replacement (AVR) for bicuspid aortic valve (BAV). The risk of progressive sinus of Valsalva dilatation after AVR and ascending aorta replacement is less clear.

Methods

We identified 156 patients (age 56.2±10.8 years, 46 females) who underwent AVR and ascending aorta replacement in our institution from 2010-2014, 124 (79%) of whom had BAV. Aortic root and ascending aorta sizes were determined from preoperative and the most recent echocardiograms. The mean follow-up time was 34.4±22.3 months, and 97% of patients completed the follow-up.

Results

The operative mortality rate was 1.3%. During a follow-up of up to 75.2 months, there were no late reoperations for aortic root dissection or rupture. The mean preoperative aortic root diameters in the tricuspid aortic valve (TAV) and BAV groups were 42.2±5.4 and 37.5±5.4 mm, respectively (P=0.69). After operation, most of the patients had reduced aortic root sizes, as the mean postoperative root diameters in the TAV and BAV groups were 39.6±5.2 and 35.7±5.1 mm, respectively (P=0.99).

Conclusions

To avoid the risks associated with aortic root replacement, it is reasonable to spare the aortic roots in the setting of AVR and ascending aorta replacement for BAV with a dilated ascending aorta and relatively normal sinuses of Valsalva.

Transcatheter aortic valve implantation in nonagenarians: selectively feasible or extravagantly futile?

A growing number of nonagenarians is recorded as life expectancy increases. Unfortunately, this extreme-aged group is plagued by increased prevalence of aortic stenosis amidst a higher occurrence of comorbidities that pose dilemmas to cardiologists and cardiac surgeons when having to choose a conservative or interventional treatment modality, and a surgical or transcatheter aortic valve implantation (TAVI) approach. TAVI is an expensive procedure, which also confers a higher mortality and morbidity risk in nonagenarians, compared to younger patients. Considering the physiologic rather the chronologic age alone, and adopting a shared-decision making approach (participatory medicine), it may be more realistic to determine a patient's candidacy for this non-surgical therapeutic modality. Thus, it comes down to the patient selection process by having the heart team review each nonagenarian case individually and getting the patient and the family involved, always aiming to prolong and improve patient's quality of life (QoL), but also taking into consideration patient preferences and values, sharing and respecting goals, realistic expectations, and end-of-life views and ideas. One should keep in mind that there is always the possibility that TAVI may be clinically futile for patients who have a multitude of comorbidities and extreme frailty, for whom a transition to palliative care might be prudent. Selecting nonagenarian patients with low comorbidity index and with no extreme frailty, adopting a minimalistic approach and paying attention to vascular access hemostasis may provide the elements that may lead to a successful, desirable and hopefully cost-effective outcome.

Transcatheter aortic valve implantation economics: a grisly reality

Transcatheter aortic valve implantation (TAVI), an established treatment for inoperable and high-risk operable symptomatic patients with severe aortic stenosis with growing numbers of procedures and expanding indications, is an expensive therapy. Cost-effectiveness analyses rely on the value of the incremental cost-effectiveness ratio (ICER), which is the difference in cost between two possible interventions, divided by the difference in their effect. Several analyses have demonstrated that TAVI is cost-effective with an acceptable ICER for the inoperable patient alone and only via the iliofemoral route, while TAVI is more costly and is either less or equally effective as surgery in high-risk operable patients. When use of TAVI is extended to include a larger number of patients suitable for surgery, the overall results become less favorable. Acceptable ICERs should practically equate to the value of the gross domestic product (GDP) per capita in each country; however, the cost of the TAVI kit alone already exceeds the GDP per capita of all moderate- and low-income countries. An overview of the current cost-efficacy issues of TAVI is presented and this grisly reality is discussed, which may hopefully be improved in the future.

The Ross procedure: time for a hard look at current practices and a reexamination of the guidelines

The ideal aortic valve substitute for young adults requiring aortic valve replacement (AVR) remains elusive. Young and middle-aged patients have a longer anticipated life expectancy and a higher level of physical activity than their elderly counterparts. In recent years, there has been a growing focus on long-term outcomes following AVR in this specific patient population. These studies highlight the direct impact of the choice of prosthesis on long-term survival, quality of life and rates of valve-related complications in younger adults. Although conventional AVR using a biological or mechanical prosthesis significantly improve the natural history of the disease, there are many inherent limitations, which need to be addressed. Despite declining use of the Ross procedure in recent years, several long-term registry, cohort and comparative studies in the last decade, indicate a clear role for this operation in young and middle-aged adults requiring AVR. These advantages are manifest in terms of long-term survival, freedom from valve-related complications and quality of life. In this Perspective article, we discuss findings from a recently published propensity-matched analysis of long-term outcomes following mechanical AVR versus the Ross procedure, showing better cardiac- and valve-related survival in the Ross cohort, lower rates of stroke and major bleeding and equal rates of reoperation at 20 years. These data are placed in the broader context of currently available evidence regarding the Ross procedure and a broader discussion pertaining to its role in today's practice and the need to reexamine current valvular guidelines so they are more reflective of the actual evidence.

Delayed aortic rupture resulting from postoperative superficial sternal wound infection

While deep sternal wound infection (DSWI) after cardiac surgery is a significant contributor to patient morbidity and mortality, superficial sternal wound infection (SSWI) mostly has a benign course. We report a mortality case of aortic rupture resulting from SSWI after cardiac surgery. A 50-year-old male underwent an aortic valve replacement (AVR). Three months after the valve operation, he presented with severe dyspnea, which had never before been observed, and chest computed tomography revealed an ascending aortic rupture with large hematoma compressing the main pulmonary artery. We performed an emergent operation for aortic rupture that possibly originated from the SSWI. Postoperatively, the patient died of hypovolemic shock due to recurrent aortic rupture despite efforts to resuscitate him.

Sutureless aortic valve replacement

The increasing incidence of aortic stenosis and greater co-morbidities and risk profiles of the contemporary patient population has driven the development of minimally invasive aortic valve surgery and percutaneous transcatheter aortic valve implantation (TAVI) techniques to reduce surgical trauma. Recent technological developments have led to an alternative minimally invasive option which avoids the placement and tying of sutures, known as "sutureless" or rapid deployment aortic valves. Potential advantages for sutureless aortic prostheses include reducing cross-clamp and cardiopulmonary bypass (CPB) duration, facilitating minimally invasive surgery and complex cardiac interventions, whilst maintaining satisfactory hemodynamic outcomes and low paravalvular leak rates. However, given its recent developments, the majority of evidence regarding sutureless aortic valve replacement (SU-AVR) is limited to observational studies and there is a paucity of adequately-powered randomized studies. Recently, the International Valvular Surgery Study Group (IVSSG) has formulated to conduct the Sutureless Projects, set to be the largest international collaborative group to investigate this technology. This keynote lecture will overview the use, the potential advantages, the caveats, and current evidence of sutureless and rapid deployment aortic valve replacement (AVR).

Sutureless Aortic Valve Replacement International Registry (SU-AVR-IR): design and rationale from the International Valvular Surgery Study Group (IVSSG)

BACKGROUND

Sutureless aortic valve replacement (SU-AVR) is an innovative approach which shortens cardiopulmonary bypass and cross-clamp durations and may facilitate minimally invasive approach. Evidence outlining its safety, efficacy, hemodynamic profile and potential complications is replete with small-volume observational studies and few comparative publications.

METHODS

Minimally invasive aortic valve surgery and high-volume SU-AVR replacement centers were contacted for recruitment into a global collaborative coalition dedicated to sutureless valve research. A Research Steering Committee was formulated to direct research and support the mission of providing registry evidence warranted for SU-AVR.

RESULTS

The International Valvular Surgery Study Group (IVSSG) was formed under the auspices of the Research Steering Committee, comprised of 36 expert valvular surgeons from 27 major centers across the globe. IVSSG Sutureless Projects currently proceeding include the Retrospective and Prospective Phases of the SU-AVR International Registry (SU-AVR-IR).

CONCLUSIONS

The global pooling of data by the IVSSG Sutureless Projects will provide required robust clinical evidence on the safety, efficacy and hemodynamic outcomes of SU-AVR.

Sutureless aortic valve replacement: a systematic review and meta-analysis

BACKGROUND

Sutureless aortic valve replacement (SU-AVR) has emerged as an innovative alternative for treatment of aortic stenosis. By avoiding the placement of sutures, this approach aims to reduce cross-clamp and cardiopulmonary bypass (CPB) duration and thereby improve surgical outcomes and facilitate a minimally invasive approach suitable for higher risk patients. The present systematic review and meta-analysis aims to assess the safety and efficacy of SU-AVR approach in the current literature.

METHODS

Electronic searches were performed using six databases from their inception to January 2014. Relevant studies utilizing sutureless valves for aortic valve implantation were identified. Data were extracted and analyzed according to predefined clinical endpoints.

RESULTS

Twelve studies were identified for inclusion of qualitative and quantitative analyses, all of which were observational reports. The minimally invasive approach was used in 40.4% of included patients, while 22.8% underwent concomitant coronary bypass surgery. Pooled cross-clamp and CPB duration for isolated AVR was 56.7 and 46.5 minutes, respectively. Pooled 30-day and 1-year mortality rates were 2.1% and 4.9%, respectively, while the incidences of strokes (1.5%), valve degenerations (0.4%) and paravalvular leaks (PVL) (3.0%) were acceptable.

CONCLUSIONS

The evaluation of current observational evidence suggests that sutureless aortic valve implantation is a safe procedure associated with shorter cross-clamp and CPB duration, and comparable complication rates to the conventional approach in the short-term.

Minimally invasive aortic valve surgery: Cleveland Clinic experience

BACKGROUND

Minimally invasive surgery has become a routine approach for aortic valve disease over the last 18 years at the Cleveland Clinic. It is performed in isolation or in combination with other procedures. The objective of this study is to review trends and outcomes in these patients.

METHODS

Cleveland Clinic Cardiovascular Information Registry (CVIR) was searched for aortic valve procedures from 1996 to 2013. All patients undergoing isolated or combined aortic valve operations were included for analysis. The incision type and procedure type were reviewed and trends were evaluated over time. Cleveland Clinic outcomes with minimally invasive approaches to the aortic valve are reviewed.

RESULTS

A total of 22,766 aortic valve surgical procedures were performed in this 18-year timeframe. Of these, 3,385 (14.9%) were minimally invasive procedures (MIPs) and 2,379 (10.5%) were isolated minimally invasive aortic valves. MIPs increased from 12.4% to 29.6% of the total aortic valve volume over the period of the study. Combined procedures, including concomitant surgery on the aorta, mitral valve, tricuspid valve, and arrhythmia surgery increased over time as well. Overall mortality for primary and reoperative aortic valve operations continues to decline and has consistently been less than 1% for several years.

CONCLUSIONS

A programmed approach to minimally invasive aortic valve surgery (MIAVS) with careful patient selection, appropriate use of preoperative imaging, and selective conversion to sternotomy when necessary, allows for aortic valve replacement (AVR) and a wide range of concomitant procedures to be performed safely in a large number of patients.

Minimally invasive aortic valve replacement versus aortic valve replacement through full sternotomy: the Brigham and Women's Hospital experience

BACKGROUND

Minimally invasive aortic valve surgery (mini AVR) is a safe and effective treatment option at many hospital centers, but there has not been widespread adoption of the procedure. Critics of mini AVR have called for additional evidence with direct comparison to aortic valve replacement (AVR) via full sternotomy (FS).

METHODS

Our mini AVR approach is through a hemi-sternotomy (HS). We performed a propensity-score matched analysis of all patients undergoing isolated AVR via FS or HS at our institution since 2002, resulting in 552 matched pairs. Baseline characteristics were similar. Operative characteristics, transfusion rates, in-hospital outcomes as well as short and long term survival were compared between groups.

RESULTS

Median cardiopulmonary bypass and cross clamp times were shorter in the HS group: 106 minutes [inter-quartile ranges (IQR) 87-135] vs. 124 minutes (IQR 90-169), P≤0.001, and 76 minutes (IQR 63-97) vs. 80 minutes (IQR 62-114), P≤0.005, respectively. HS patients had shorter ventilation times (median 5.7 hours, IQR 3.5-10.3 vs. 6.3 hours, IQR 3.9-11.2, P≤0.022), shorter intensive care unit stay (median 42 hours, IQR 24-71 vs. 45 hours, IQR 24-87, P≤0.039), and shorter hospital length of stay (median 6 days, IQR 5-8 vs. 7 days, IQR 5-10, P≤0.001) compared with the FS group. Intraoperative transfusions were more common in FS group: 27.9% vs. 20.0%, P≤0.003. No differences were seen in short or long term survival, or time to aortic valve re-intervention.

CONCLUSIONS

Our study confirms the clinical benefits of minimally invasive AVR via HS, which includes decreased transfusion requirements, ventilation times, intensive care unit and hospital length of stay without compromising short and long term survival compared to conventional AVR via FS.

Minimally invasive aortic valve replacement: the "Miami Method"

For patients undergoing aortic valve replacement (AVR), a minimally invasive approach performed via a right anterior thoracotomy is the preferred method at our institution. This method has evolved over a 10-year span, being applied to over 1,500 patients with the commitment of one surgeon seeking to offer a simplistic and reproducible minimally invasive alternative. We believe that this is truly the least invasive approach to the aortic valve since it avoids sternal invasion. By virtue of being less traumatic, the morbidity is diminished and therefore the recovery is enhanced. We believe that this approach is most beneficial in the high risk patient such as the elderly, the obese, those with chronic obstructive pulmonary, chronic kidney disease and those requiring re-operative surgery. This method has proven to be safe and effective in all patients requiring isolated AVR surgery. The only relative exclusion criteria would be a porcelain aorta with the inability to cannulate the patient.

Minimally invasive reoperative aortic valve replacement: a systematic review and meta-analysis

BACKGROUND

With prolonged life expectancy and more frequent use of biological prostheses, an increasingly higher proportion of patients are undergoing aortic valve replacement (AVR) after previous sternotomy. We critically appraised the quantity and quality of evidence to demonstrate the efficacy and safety of the minimally invasive (MIrAVR) versus conventional (CrAVR) approaches for reoperative AVR.

METHODS

Electronic searches were performed using six databases from their inception to April 2014. Relevant studies utilizing a MIrAVR were identified. Data were extracted and analyzed according to predefined clinical endpoints.

RESULTS

Four single-arm and seven comparative observational studies including a total of 441 MIrAVR patients were included for quality assessment, data extraction and analysis. In-hospital mortality ranged from 0-9.5%, and was similar between the MIrAVR and CrAVR groups (RR, 0.77; 95% CI, 0.39-1.54; P=0.46). Stroke rates ranged from 2.6-8% and were also similar between the two cohorts. The rates of pacemaker implantation, renal failure and reoperation for bleeding were not significantly different between the two groups. There were no reports of myocardial infarctions in the included studies. No significant difference in hospital stay was observed for the MIrAVR versus CrAVR group.

CONCLUSIONS

The current literature suggests that MIrAVR has similar efficacy and mortality outcomes compared to CrAVR without compromise to myocardial protection or hospitalization duration. It appears to be a valid alternative option for patients requiring reoperative AVR.

Minimally invasive aortic valve replacement: the Leipzig experience

BACKGROUND

Minimally invasive techniques are progressively challenging traditional approaches in cardiothoracic surgery. Minimally invasive aortic valve replacement (AVR) has become a routine procedure at our institution.

METHODS

We retrospectively analyzed all patients undergoing minimally invasive isolated AVR between January 2003 and March 2014, at our institution. Mean follow-up was 4.7±4.3 years (range: 0-18 years) and was 99.8% complete.

RESULTS

There were 1,714 patients who received an isolated minimally invasive AVR. The mean (± SD) patient age was 65±12.8 years, ejection fraction 60%±12% and log EuroSCORE 5.3%±5.1%. Mean cross-clamp time was 58±18 minutes and mean cardiopulmonary bypass (CPB) time was 82.9±26.7 minutes. Thirty-day survival was 97.8%±0.4%, and 69.4%±1.7% at 10-years. The multivariate analysis revealed age at surgery [P=0.016; odds ratio (OR), 1.1], length of surgery time (P=0.002; OR, 1.01), female gender (P=0.023; OR, 3.54), preoperative myocardial infarction (MI) (P=0.006; OR, 7.87), preoperative stroke (P=0.001; OR, 13.76) and preoperative liver failure (P=0.015; OR, 10.28) as independent risk factors for mortality. Cox-regression analysis revealed the following predictors for long term mortality: age over 75 years (P<0.001; OR, 3.5), preoperative dialysis (P<0.01; OR, 2.14), ejection fraction less than 30% (P=0.003; OR, 3.28) and urgent or emergency operation (P<0.001; OR, 2.3).

CONCLUSIONS

Minimally invasive AVR can be performed safely and effectively with very few perioperative complications. The early and long-term outcomes in these patients are acceptable.

Minimally invasive aortic valve surgery: state of the art and future directions

Minimally invasive aortic valve replacement (MIAVR) is defined as an aortic valve replacement (AVR) procedure that involves a small chest wall incision as opposed to conventional full sternotomy (FS). The MIAVR approach is increasingly being used with the aim of reducing the "invasiveness" of the surgical procedure, while maintaining the same efficacy, quality and safety of a conventional approach. The most common MIAVR techniques are ministernotomy (MS) and right anterior minithoracotomy (RT) approaches. Compared with conventional surgery, MIAVR has been shown to reduce postoperative mortality and morbidity, providing faster recovery, shorter hospital stay and better cosmetics results, requires less rehabilitations resources and consequently cost reduction. Despite these advantages, MIAVR is limited by the longer cross-clamp and cardiopulmonary bypass (CPB) times, which have raised some concerns in fragile and high risk patients. However, with the introduction of sutureless and fast deployment valves, operative times have dramatically reduced by 35-40%, standardizing this procedure. According to these results, the MIAVR approach using sutureless valves may be the "real alternative" to the transcatheter aortic valve implantation (TAVI) procedures in high risk patients "operable" patients. Prospective randomized trials are required to confirm this hypothesis.

Exercise stress echocardiography in patients with aortic stenosis: impact of baseline diastolic dysfunction and functional capacity on mortality and aortic valve replacement

BACKGROUND

Patients with aortic stenosis (AS) often undergo exercise echocardiography. Diastolic dysfunction (DD) is frequently associated with AS but little is known about its impact on functional capacity (FC). We sought to determine the relationship between DD and FC and their impact on mortality and need for aortic valve replacement (AVR) in patients with AS.

METHODS AND RESULTS

Data was analyzed for consecutive patients with any degree of AS undergoing exercise stress echocardiography between 2000 and 2010 at our institution. The primary endpoint was a composite of death or need for AVR. We identified 1,267 patients [mean age 67±11 years, ejection fraction (56±7)%, mean aortic valve gradient 19±12 mmHg, mean maximal metabolic equivalents (METs) achieved 8±2.6]. The proportion with normal, stage 1, and ≥ stage 2 diastology was 195 (15%), 928 (73%), 144 (12%). A total of 475 (37.5%) patients had a primary outcome with 164 deaths (mean follow up 5.6±4.1 years) and 341 AVR (mean follow up 2.4±2.6 years). Predictors of FC were age, gender, body mass index, Bruce protocol, heart rate recovery (HRR), ejection fraction, mean aortic valve gradient, and diabetes but not baseline DD. Baseline DD [HR 1.82, 95% CI (1.17, 2.82), P=0.008] and FC [HR 0.93, 95% CI (0.88, 0.98), P=0.003] were independent predictors of death or AVR.

CONCLUSIONS

For patients with AS undergoing exercise echocardiography, baseline DD was not predictive of FC. However, both baseline DD and FC were independent predictors of death or need for AVR.

Reoperative minimal access aortic valve replacement

Reoperative minimal access aortic valve replacement (AVR) is performed through an upper hemisternotomy with peripheral cannulation. This approach limits dissection of mediastinum and especially the left internal mammary artery (LIMA) graft in patients with previous coronary artery bypass grafting (CABG) thus minimizing trauma to the patient. This approach is safe and feasible and may have some benefit over conventional full sternotomy in terms of mortality and morbidity.