Christian Rustenbach

Minimally invasive Ross procedure through partial upper sternotomy

The Ross procedure has gained increasing interest for therapy of aortic valve pathologies in young adults because of excellent long-term results. This case report describes the first published experiences of the Ross procedure performed through a minimally invasive access in two consecutive patients. The limited access is associated with only a slightly prolonged aortic cross-clamp time. Consequently, a minimal access method does not result in an increased risk for patients.

Prognostic Implications of Pre-Procedural High-Sensitivity Cardiac Troponin T in Patients Undergoing Transcatheter Aortic Valve Replacement

High-sensitivity cardiac troponin T (hs-cTnT) is increasingly recognized as a marker for adverse outcomes in patients with cardiovascular diseases. However, its role for individual risk assessment in patients transcatheter aortic valve replacement (TAVR) is uncertain [(1–3)][1]. Therefore, we

Concomitant therapy: off-pump coronary revascularization and transcatheter aortic valve implantation

OBJECTIVES Significant coronary artery disease (CAD) is common among patients evaluated for transcatheter aortic valve implantation (TAVI). Only little data exist on outcome of patients undergoing concomitant off-pump coronary revascularization and TAVI. The goal of this study was to analyse the impact of concomitant off-pump revascularization on early clinical outcome and 2-year follow-up of patients undergoing TAVI. METHODS A total of 70 patients with significant CAD and aortic valve stenosis were included between January 2011 and January 2016. Decision to perform concomitant off-pump coronary revascularization and TAVI was made by the interdisciplinary heart team according to the SYNTAX score. Prospectively assigned data were analysed retrospectively and follow-up was performed up to 2 years. RESULTS Mean age was 82.2 ± 4.0 years and 43 (61.4%) patients were male. Mean logistic European system for cardiac operative risk evaluation and Society of Thoracic Surgeons European system for cardiac operative risk evaluation score were 35.9 ± 21.9% and 12.2 ± 7.9%, respectively. SYNTAX score was 29.0 ± 12.9. Access site for TAVI was transapical in 60.0% and transaortic in 40.0%. Procedural success was 94.3%. Eighty percent of the patients had none or trace paravalvular leakage after TAVI. Severe complications requiring consecutive surgical aortic valve replacement occurred in 2 patients (2.9%). The use of cardiopulmonary bypass due to haemodynamic instability or conversion to surgical aortic valve replacement was necessary in 7 patients (10.0%). Stroke occurred in 1 patient (1.4%). Re-exploration for bleeding was necessary in 6 patients (8.6%). Thirty-day mortality was 14.3%. Two-year survival was 68.4% (95% confidence interval: 55.7-81.1%). CONCLUSIONS Simultaneously performed complete off-pump coronary revascularization is a feasible and valid option in patients with significant CAD undergoing TAVI.

Minimally Invasive Versus Conventional Extracorporeal Circulation in Minimally Invasive Cardiac Valve Surgery

BACKGROUND Minimally invasive extracorporeal circulation (MECC) technology was applied predominantly in coronary surgery. Data regarding the application of MECC in minimally invasive valve surgery are missing largely. PATIENTS AND METHODS Patients undergoing isolated minimally invasive mitral or aortic valve procedures were allocated either to conventional extracorporeal circulation (CECC) group (n = 63) or MECC group (n = 105), and their prospectively generated data were analyzed. RESULTS Demographic data were comparable between the groups regarding age (CECC vs. MECC: 71.0 ± 7.5 vs. 66.2 ± 10.1 years, p = 0.091) and logistic EuroSCORE I (6.2 ± 2.5 vs. 5.4 ± 3.0, p = 0.707). Hospital mortality was one patient in each group (1.6 vs. 1.0%, p = 0.688). The levels of leukocytes were lower in the MECC group (11.6 ± 3.2 vs. 9.4 ± 4.3 109/L, p = 0.040). Levels of platelets (137.2 ± 45.5 vs. 152.4 ± 50.3 109/L, p = 0.015) and hemoglobin (103.3 ± 11.3 vs. 107.3 ± 14.7 g/L, p = 0.017) were higher in the MECC group. Renal function was better preserved (creatinine: 1.1 ± 0.4 vs. 0.9 ± 0.2 mg/dL, p = 0.019). We were able to validate shorter time of postoperative ventilation (9.5 ± 15.1 vs. 6.3 ± 3.4 h, p = 0.054) as well as significantly shorter intensive care unit (ICU) stay (1.8 ± 1.3 vs. 1.2 ± 1.0 d, p = 0.005) for MECC patients. The course of C-reactive protein did not differ between the groups. CONCLUSION We were able to prove the feasibility of MECC even in minimally invasive performed mitral and aortic valve procedures. In addition, the use of MECC provides decreased platelet consumption and less hemodilution. The use of MECC in these selected patients lead to a shorter ventilation time and ICU stay.

Transcatheter Aortic Valve Implantation

Abstract Aortic valve stenosis is the most common valvular heart disease, with surgical aortic valve replacement being the therapeutic gold standard in the past. Transcatheter aortic valve implantation (TAVI) has developed to be a valid therapy option for patients with symptomatic severe aortic valve stenosis and high surgical risk, as it is deemed to be less invasive and traumatic. Since the first implantation in 2002, rapid developments took place in recent years, not only in regard to technical aspects—new devices and new access sites—but also in indications and patient selection. Currently, it is conflicting if TAVI should also be a therapy option for intermediate- and low-risk patients. However, complications such as paravalvular leakage, stroke, and bleeding events need to be kept in mind and should be addressed in further progressions.

Prognostic implications of psoas muscle area in patients undergoing transcatheter aortic valve implantation

OBJECTIVES This study sought to assess the incremental prognostic value of the psoas muscle area in patients scheduled for transcatheter aortic valve implantation (TAVI). METHODS A total of 1076 consecutive patients undergoing TAVI at 2 centres between 2010 and 2017 were prospectively included in this study. Computed tomography-derived cross-sectional area of the psoas muscle was measured at the superior border of the third (L3) and fourth (L4) lumbar vertebra and indexed to body surface area (PMAi) as well as stratified into tertiles. Multivariable logistic regression and Cox regression analyses were performed to investigate the value of PMAi as a predictor of 30-day and cumulative mortality. The incremental prognostic value of PMAi over the Society of Thoracic Surgeons (STS) score was assessed using a net reclassification analysis. RESULTS The rate of 30-day mortality was 5.8% (n = 62). PMAi at the level of L3 [odds ratio 0.082, 95% confidence interval (CI) 0.011-0.589; P = 0.013] and L4 (odds ratio 0.049, 95% CI 0.005-0.536; P = 0.013) was independently associated with 30-day mortality. During a median follow-up of 435 days (interquartile range 139-904), 292 patients (27.1%) died. PMAi of L3 (hazard ratio 0.200, 95% CI 0.083-0.482; P < 0.001) and L4 (hazard ratio 0.083, 95% CI 0.029-0.235; P < 0.001) was independently associated with mortality during follow-up. The addition of PMAi to the STS score led to a net reclassification improvement for 30-day and cumulative mortality. CONCLUSIONS PMAi emerged as a valuable outcome predictor in patients undergoing TAVI. The addition of PMAi to the established STS score led to an increase in its prognostic ability.