Amine Mazine

Long-Term Outcomes of the Ross Procedure Versus Mechanical Aortic Valve Replacement: Propensity-Matched Cohort Study.

Background: The ideal aortic valve substitute in young and middle-aged adults remains unknown. We sought to compare the long-term outcomes of patients undergoing the Ross procedure and those receiving a mechanical aortic valve replacement (AVR). Methods: From 1990 to 2014, 258 patients underwent a Ross procedure and 1444 had a mechanical AVR at a single institution. Patients were matched into 208 pairs through the use of a propensity score. Mean age was 37.2±10.2 years, and 63% were male. Mean follow-up was 14.2±6.5 years. Results: Overall survival was equivalent (Ross versus AVR: hazard ratio, 0.91, 95% confidence interval, 0.38–2.16; P=0.83), although freedom from cardiac- and valve-related mortality was improved in the Ross group (Ross versus AVR: hazard ratio, 0.22; 95% confidence interval, 0.034–0.86; P=0.03). Freedom from reintervention was equivalent after both procedures (Ross versus AVR: hazard ratio, 1.86; 95% confidence interval, 0.76–4.94; P=0.18). Long-term freedom from stroke or major bleeding was superior after the Ross procedure (Ross versus AVR: hazard ratio, 0.09; 95% confidence interval, 0.02–0.31; P<0.001). Conclusions: Long-term survival and freedom from reintervention were comparable between the Ross procedure and mechanical AVR. However, the Ross procedure was associated with improved freedom from cardiac- and valve-related mortality and a significant reduction in the incidence of stroke and major bleeding. In specialized centers, the Ross procedure represents an excellent option and should be considered for young and middle-aged adults undergoing AVR.

A systematic review and meta-analysis of in situ versus composite bilateral internal thoracic artery grafting

Objectives: This meta‐analysis examines whether there is any advantage of coronary artery bypass graft with bilateral internal thoracic artery (BITA) as an in situ versus composite graft. Methods: We searched MEDLINE and EMBASE Databases from 1996 to 2016 for studies that compared coronary artery bypass graft with BITA as in situ versus composite graft. Data were extracted by 2 independent investigators and meta‐analyzed with the use of random effects. Results: Two randomized controlled trials (RCTs; n = 705), 2 matched (n = 1688), and 4 unadjusted observational studies (n = 3517) met inclusion criteria. Composite grafting trended towards greater distal anastomoses (+0.22, 95% confidence interval, −0.01 to +0.45 anastomoses/patient; P = .06 [4 unadjusted observational studies]) and greater distal anastomoses using an internal thoracic artery (+0.80, 95% confidence interval, 0.41‐1.18 anastomoses/patient; P < .001 [1 RCT]). There were no differences in perioperative or longer‐term composite cardiovascular outcomes comparing in situ versus composite BITA or individual outcomes of mortality, repeat revascularization, myocardial infarction, and cardiovascular mortality. Pooled results differed by study type with pooled results from lower‐risk‐of‐bias RCTs typically showing increases in events rates, and pooled results from higher‐risk‐of‐bias unadjusted observational studies typically showing decreases in event rates of in situ versus composite BITA. Post hoc subgroup analysis suggested possible improvements in all‐cause mortality and revascularization for in situ BITA in studies with short‐term (<5 years) versus longer‐term follow‐up, regardless of study type. Conclusions: Our meta‐analysis found that use of BITA as a composite graft configuration facilitated greater internal thoracic artery revascularization but both grafting strategies offer similar clinical outcomes. Our study supports the use of in situ and composite BITA for select patients but high‐quality, long‐term prospective trials are needed.

The Ross procedure in adults: which patients, which disease?

Purpose of review The purpose of this article is to review the contemporary evidence surrounding the use of the Ross procedure in young and middle-aged adults and to identify the subset patients who are most likely to derive a benefit from this operation. Recent findings In appropriately selected young and middle-aged adults undergoing aortic valve replacement (AVR), the Ross procedure is currently the only operation that can restore long-term survival that is equivalent to that of the age-matched healthy general population. The ideal patient for the Ross procedure is a young, otherwise healthy adult with aortic stenosis and a small or normal size aortic annulus. In addition, this operation is particularly valuable in women contemplating pregnancy and patients with high level of physical activity, as well as those who wish to avoid the burden of lifelong anticoagulation. When carried out in expert centers with adequate surgical volumes, the Ross procedure is associated with superior long-term outcomes compared with prosthetic AVR, with minimal cost in terms of early morbidity and mortality. Summary Despite the expanding body of evidence demonstrating its long-term superiority over conventional prosthetic AVR in appropriately selected patients, the Ross operation remains largely underused. This situation mandates careful reexamination of current practice guidelines.

Sutureless aortic valves: who is the right patient?

Purpose of review Sutureless aortic valve replacement (AVR) has emerged as an alternative to traditional AVR for patients with aortic stenosis who present a higher surgical risk, such as the elderly, or those with small or highly calcified aortic roots. With transcatheter aortic valve implantation – the other major AVR alternative – being used in increasingly lower-risk patients, the place of sutureless valves in the AVR landscape needs to be defined. In this review, we discuss recent data and expert opinion as it pertains to the subject of sutureless AVR. Recent findings Several recent studies have evaluated the performance of sutureless valves in a variety of clinical contexts, including minimally invasive operations and high-risk surgical procedures. The optimal surgical technique for sutureless AVR has been refined through the publication of several reports addressing technical considerations. Reduction in operative times represents the main advantage of sutureless valves over conventional surgical prostheses, and the possibility of complete annular decalcification – and hence a reduced incidence of paravalvular leak – is the primary advantage over TAVI. Summary Sutureless valves have emerged as an attractive option for high-risk patients or for complex surgeries where a minimization of bypass time is critical. However, there is limited data regarding long-term outcomes, durability or reoperation.

Subclinical bioprosthetic aortic valve thrombosis: clinical and translational implications

Purpose of review A recently published study has alerted the cardiovascular community to the existence of a significant and previously unrecognized risk of subclinical valve thrombosis following implantation of surgical and catheter-based bioprosthetic valves. The purpose of this article is to review our current understanding of this new clinical entity and to identify unanswered questions and areas for future research. Recent findings Subclinical bioprosthetic valve thrombosis (BPVT) is a more common phenomenon than previously appreciated. It appears that the incidence of BPVT is higher following transcatheter aortic valve replacement compared with surgical aortic valve replacement. Four-dimensional computed tomography (CT) is the most sensitive imaging modality for detection of leaflet immobility and subclinical BPVT. Certain echocardiographic findings, such as increasing transaortic gradients, increased cusp thickness and abnormal cusp mobility, predict the presence of BPVT on four-dimensional CT. There is a growing body of evidence linking subclinical BPVT with premature valvular hemodynamic deterioration and structural valve degeneration. Furthermore, subclinical leaflet thrombosis may constitute a nidus for unrecognized subacute cerebral or other thromboembolic events. Oral anticoagulation seems effective in both the prevention and treatment of BPVT. Summary Subclinical valve thrombosis is an important and underappreciated cause of early bioprosthetic valve failure. Although several recent studies have improved our understanding of this newly recognized clinical entity, a number of questions remain unanswered. Further studies are warranted to elucidate the true incidence of subclinical BPVT, its clinical consequences, as well as the optimal antithrombotic regimen following bioprosthetic valve implantation. The subgroups of patients at highest risk of BPVT will need to be identified for risk stratification purposes. Several ongoing clinical trials will shed some light on these important issues.

Surgery for Tumors of the Heart

Most surgeons will encounter only a handful of primary cardiac tumors outside of myxomas. Approximately 3 quarters of primary cardiac tumors are benign and 1 quarter is malignant. In most cases, cardiac tumors are silent but when symptoms do occur, they are primarily determined by tumor size and anatomical location, not by histopathology. The diagnosis and preoperative imaging relies heavily on multimodal imaging including echocardiography, computed tomography, magnetic resonance imaging, and coronary angiography. Surgical resection is the most common treatment for most simple primary cardiac tumors and for some complex benign tumors. Surgical resection of primary cardiac tumors frequently involves the need for complex cardiac reconstruction, particularly when malignant. Secondary tumors to the heart are 30 times more frequent than primary cardiac tumors, and their incidence is increasing, largely as a result of advances in cancer diagnosis and therapy. Surgical resection is feasible in only a small fraction of highly-selected patients with secondary tumors to the heart. For complex benign tumors-such as paraganglioma or large fibromas-and all primary and secondary malignant tumors, a multidisciplinary cardiac tumor team review in experienced centers of excellence is recommended.

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.

Year in review: complex valve reconstruction.

Purpose of review In recent years, great emphasis has been placed on reconstructive techniques for the surgical management of heart valve disease. In this review, we discuss recent data and current practice as it pertains to the subject of reconstructive valve surgery. Recent findings New techniques and an improved understanding of the mechanisms of aortic insufficiency have led to marked improvement in the early and late outcomes of aortic valve repair. While mitral valve repair is the established approach for the management of degenerative mitral valve disease, surgical technique continues to be refined, with valve reconstruction principles applied to increasingly challenging anatomy. Moreover, the introduction of novel biomaterials has allowed extension of the indication for valve reconstruction to circumstances of extensive tissue defect, including infective endocarditis. Summary Valve reconstruction is increasingly being recognized as an alternative to valve replacement. It alleviates the risks of prosthesis-related complications and is especially appealing in young and middle-aged adults. While early and midterm outcomes appear promising, further studies are warranted to assess the clinical benefit and long-term durability of complex valve reconstruction procedures.

Conservative Management of Extensive Iatrogenic Aortic Dissection

Iatrogenic aortic dissection (IAD) is a rare complication of percutaneous coronary interventions (PCI). There are no clear guidelines for IAD management, and limited data are available. Registry data and case series combined with extrapolations from our experience with spontaneous Type-A dissections suggest that very limited dissections are often managed conservatively with coronary stenting of the entry tear when possible, while more extensive dissections are managed surgically. We present a case report of a 50-year-old woman who underwent PCI for an ST-elevation myocardial infarction that resulted in an extensive IAD from the ostium of the right coronary artery to the aortic root, ascending aorta, and aortic arch. While the current evidence strongly supports surgical management of such extensive dissection, our patient was successfully managed conservatively with complete resolution according to short-term computed tomography imaging. This case suggests that conservative management may be a reasonable approach for select patients with extensive IAD.

Moderate mitral regurgitation at the time of coronary bypass surgery: repair or leave it?

Purpose of review Moderate ischemic mitral regurgitation (IMR) is a common finding in patients undergoing coronary artery bypass grafting (CABG). In this review, we summarize the current evidence on the optimal management of this condition. Recent findings In recent years, several randomized clinical trials have assessed the impact of concomitant restrictive mitral annuloplasty at the time of CABG on reverse left ventricular remodeling, IMR reduction and clinical outcomes. Summary Surgical revascularization alone is a conservative strategy that reduces IMR in a significant proportion of patients. Concomitant restrictive annuloplasty provides better relief of mitral regurgitation in the immediate postoperative period, at the cost of increased perioperative morbidity. The only major randomized trial on the issue of moderate IMR published to date showed no difference in reverse left ventricular remodeling at 1 year between these two approaches. There are insufficient data in the literature to support the routine addition of mitral valve repair to CABG in patients with moderate IMR.