Fanar Mourad

Minimal access versus conventional aortic valve replacement: a meta-analysis of propensity-matched studies

Conventional aortic valve replacement (CAVR) via a full sternotomy is the standard surgical approach for aortic valve replacement. Minimal access aortic valve replacement (MAAVR) is commonly performed via a partial sternotomy and a right minithoracotomy. Such procedures aim not only to reduce the invasiveness but to offer the same quality, safety and results of the conventional approach. Our goal was to compare both procedures by performing a meta-analysis of reports with risk adjustment that performed a propensity-matched analysis. Relevant articles were searched for in Medline, the Cochrane Database of Systematic Reviews and the Scopus database based on predefined criteria and end-points. The early and late outcomes and complications were compared in the selected studies. A total of 4558 patients from 9 studies were enrolled; 2279 (50%) underwent CAVR and 2279 (50%) underwent MAAVR. There was a significantly lower rate of postoperative low output syndrome (1.4% vs 2.3%, P = 0.05) and atrial fibrillation (11.7% vs 15.9%, P = 0.01) in the MAAVR than in the CAVR group, respectively. In contrast, aortic cross-clamp and cardiopulmonary bypass times were significantly longer in the MAAVR group (P < 0.05). Finally, the incidence of early deaths (1.5% vs 2.2%, P = 0.14), stroke (1.4% vs 2%, P = 0.20), myocardial infarction (0.4% vs 0.5%, P = 0.65), renal injury (4.5% vs 6%, P = 0.71), respiratory complications (9% vs 10.1%, P = 0.45), re-exploration for bleeding (4.9% vs 4.1%, P = 0.27) and pacemaker implantation (3.3% vs 4.1%, P = 0.31) was similar in both groups, respectively. In summary, even though MAAVR procedure, either through partial sternotomy or right minithoracotomy, provides patient satisfaction due to the smaller incision and better cosmetics, MAAVR is as safe as the CAVR procedure. Although MAAVR takes slightly longer, it was not associated with greater cardiopulmonary bypass-related adverse effects. Interestingly, MAAVR shows a lower incidence of low cardiac output syndrome and atrial fibrillation.

Comparison of ascending aortic cohesion between patients with bicuspid aortic valve stenosis and regurgitation

OBJECTIVES A bicuspid aortic valve (BAV) is commonly associated with aortic wall abnormalities, including dilatation of the ascending aorta and increased potential for aortic dissection. We compared the mechanical properties of the aortic wall of BAV patients with aortic valve stenosis (AS) and regurgitation (AR) using a dissectometer, a device mimicking transverse aortic wall shear stress. METHODS Between March 2010 and February 2013, 85 consecutive patients with bicuspid aortic valve undergoing open aortic valve replacement at our institution were prospectively enrolled, presenting either with stenosis (Group 1, n = 58) or regurgitation (Group 2, n = 27). Aortic wall cohesion measured by the dissectometer (Parameters P7, P8 and P9), aortic diameters measured by transoesophageal echocardiography (TOE) and thickness of the wall were compared. One patient presenting with the Marfan syndrome was excluded from the study. RESULTS Patients with aortic regurgitation were significantly younger (48.2 ± 15.8 vs 64.7 ± 10.7, P < 0.001), and had a significantly thicker aortic wall (2.30 ± 0.49 mm vs 2.06 ± 0.35 mm, P = 0.029). Transoesophageal echocardiography diameters (annulus, aortic sinuses and sinotubular junction) were significantly larger in the AR group (27.3 ± 3.6 vs 25.5 ± 2.4, P = 0.008; 41.1 ± 7.7 vs 36.7 ± 8.0, P = 0.011; 37.6 ± 9.7 vs 33.8 ± 9.1, P = 0.049). The ascending aortic diameter did not differ (43.2 ± 10.6 vs 40.3 ± 9.1, P = 0.292). Patients with AR had significantly worse aortic cohesion, as measured by shear stress testing (P7: 97.2 ± 45.0 vs 145.5 ± 84.9, P = 0.015; P8: 2.00 ± 0.65 vs 3.82 ± 1.56, P < 0.001; P9: 2.96 ± 0.82 vs 4.98 ± 1.80, P < 0.001) compared with those with AS. CONCLUSIONS We observed significantly worse aortic wall cohesion, a thicker aortic wall and a larger aortic root in patients presenting with bicuspid AR compared with patients with AS. These results suggest that bicuspid AR represents a different disease process with possible involvement of the ascending aorta, as demonstrated by dissectometer examination.

David Procedure—Reconstruction of the Native Insufficient Valve

Abstract Aortic valve (AV)–sparing procedures were devolved and rapidly improved the morbidity of patients suffering from aortic aneurysm of either the aortic root or the ascending aorta and in cases of AV regurgitation. Reimplantation of the AV and remodeling of the aortic root are the known types of AV-sparing procedures. The aim of this chapter is to describe the reimplantation of AV during valve-sparing procedure. The key point of a successful procedure with a long-term stability of the valve is usually attributed to choosing the appropriate prosthesis size and the accuracy of the reimplantation technique. The new technique modification describes the reimplantation of a normal tricuspid valve, AV with prolapsed cusp(s), and cases of bicuspid valve with pitfalls of reimplantation.

Infections after transcatheter versus surgical aortic valve replacement: mid-term results of 200 consecutive patients

Background Transcatheter aortic valve implantation (TAVI) is the standard therapy for high-risk patients with aortic stenosis (AS). TAVI-outcomes are widely investigated in comparison to surgical aortic valve replacement (SAVR), but less is known about infectious complications after TAVI. We aimed to compare early and mid-term infectious outcomes of patients undergoing TAVI or SAVR. Methods The present study is a prospective single-centre study including 200 consecutive patients between 06/2014-03/2015 undergoing TAVI (either transfemoral or transapical and transaortic, n=47+53=100) or SAVR (either isolated or concomitant with CABG, n=52+48=100). The mean age and log. EuroSCORE were significantly different between both groups (81±6 versus 69±11 years, P<0.001 and 23.1%±13.8% versus 8.7%±9.5%, P<0.001). Primary endpoints included wound healing disorders, respiratory and urinary tract infections and incidence of endocarditis or sepsis within hospital stay. Secondary endpoints included infectious parameters, infectious related rehospitalisation and 2-year mortality. Results Primary endpoints showed no difference in overall TAVI- versus SAVR-groups regarding respiratory- (14% versus 19%, P=0.45), urinary-tract (7% versus 4%, P=0.54) infections, sepsis (5% versus 6%, P=1.0), endocarditis (0% versus 1%, P=1.0) or 30-day mortality (10% versus 4%, P=0.09), except for wound disorders, which were significantly lower in the TAVI-group (1% versus 8%, P=0.035), respectively. Secondary endpoints reported no difference regarding infectious related rehospitalisation (4% versus 4%, P=1.0), but significantly higher 2-year mortality (28% versus 16%, P=0.048) in the TAVI-group. Conclusions So far, little has been studied about infectious complications after TAVI. This study reports no difference between the overall TAVI and SAVR groups regarding infectious complications. However, SAVR group show more wound healing disorders but less mortality than TAVI group.

Endoscopy in aortic valve repair: does it worth it?

Background Aortic valve repair (AVR) is a technically challenging procedure. Usually, the repaired valve is checked after weaning from cardiopulmonary bypass (CPB). We aimed to evaluate intraoperative and clinical outcomes of AVR patients in whom intraoperative aortic root endoscopy was applied. Methods The present study was a retrospective single-center study. An autoclavable video-scope was used to evaluate aortic valve. During endoscopy, crystalloid cardioplegia was administered to pressurize the aortic root. Primary endpoints were: need for Re-CPB after weaning from bypass and early postoperative aortic valve regurgitation. Secondary endpoints included: 30-day mortality and freedom from aortic regurgitation/reoperation during follow-up. Results A total of 66 consecutive patients who underwent AVR (05/2014-03/2017) were evaluated. Patients mean age was 53.5±14.5 years and 74.2% were male. Seventy-three percent of the patients were in New York Heart Association (NYHA) functional class III/IV. The main underlying aortic valve pathology was aortic valve regurgitation in 83.3%, 9.1% aortic stenosis and combination of both in 7.6%. A tricuspid or bicuspid aortic valve was observed in 48.5% and 43.9%, respectively, whereas 7.6% showed a functional unicuspid aortic valve. Intraoperative results revealed endoscopy as a helpful tool, where second time cross-clamp was avoided in most (58, 87.9%) of patients. Thirty-day mortality was 3.0%. During follow-up (28±10 months), 2 patients required re-operation due to recurrent aortic valve regurgitation. Conclusions The present analysis showed, that intraoperative aortic valve endoscopy is a helpful tool to evaluate AVR before weaning from bypass. This easy-to-use tool gives real-time information about the intraoperative result and might provide additional guidance to achieve optimal results after AVR.

Aortic valve construction using pericardial tissue: short-term single-centre outcomes†

OBJECTIVES Aortic valve construction using pericardial tissue has been known since the late 1960s. The procedure was re-introduced by Ozaki in 2010 and is currently used to treat specific aortic valve diseases. The exact sizing of the neo-cusps and the insertion of the commissures remain the keys to success when performing this procedure. We evaluated our experience using modified custom-made templates. METHODS In this prospective single-centre study, we evaluated 52 consecutive patients who underwent aortic valve construction between September 2015 and March 2017 using either autologous (16 patients, 30.8%) or tissue-engineered pericardium (36 patients, 69.2%). Most patients (34, 65.4%) presented with aortic stenosis or endocarditis (5, 9.6%). Twenty patients had bicuspid and 5 had unicuspid valves. A modified sizing technique with specially designed templates was used. The primary end point was early death; the secondary end points were major adverse cardiac and cerebrovascular events, freedom from reoperation and overall mortality rate. Echocardiographic follow-up was performed intraoperatively and at 12-month intervals. RESULTS The mean age was 60 ± 14 years; 63.5% were men; and 34 (65.4%) patients had combined procedures. The mean cross-clamp time was 99 ± 17 min. Early outcomes included 1 stroke, 2 patients needing short-term dialysis and 1 death. During follow-up (mean 11.2 ± 4.8 months), trace aortic regurgitation was observed in 4 patients; the mean pressure gradient was 6.8 ± 2.9 mmHg. Three patients died later (of non-cardiac reasons), and 5 patients needed reoperation due to endocarditis. CONCLUSIONS Aortic valve construction using pericardial tissue could be an alternative in middle-age patients presenting with aortic valve disease in whom valve repair was not possible. The newly designed templates allow exact sizing of the neo-cusps and optimal commissure implantation; however, long-term follow-up in a larger cohort is warranted to assess the durability of the neo-valves.

Emergent surgical removal of a migrated left atrial appendage occluder

Occlusion of the left atrial appendage (LAA) in patients with atrial fibrillation has become a standard therapy to prevent thromboembolic complications. We aim to present 3 cases of LAA occluder embolization after percutaneous WATCHMAN™ device implantation, which required emergent surgical retrieval. The device was dislocated in the left atrium, introducing LAA perforation and resulting in pericardial effusion and later tamponade in 1 patient who developed multiorgan failure and died 8 days postoperatively. Other patients were successfully operated and discharged. Hence, LAA occluder embolization may occur asymptomatically with immediate/late serious complications, which indicates emergent surgery.

Transcatheter versus Surgical Aortic Valve Replacement after Previous Cardiac Surgery: A Systematic Review and Meta-Analysis

Aim Aortic valve replacement (AVR) in patients with prior cardiac surgery might be challenging. Transcatheter aortic valve replacement (TAVR) offers a promising alternative in such patients. We therefore aimed at comparing the outcomes of patients with aortic valve diseases undergoing TAVR versus those undergoing surgical AVR (SAVR) after previous cardiac surgery. Methods and Results MEDLINE, EMBASE, and the Cochrane Central Register were searched. Seven relevant studies were identified, published between 01/2011 and 12/2015, enrolling a total of 1148 patients with prior cardiac surgery (97.6% prior CABG): 49.2% underwent TAVR, whereas 50.8% underwent SAVR. Incidence of stroke (3.8 versus 7.9%, p=0.04) and major bleeding (8.3 versus 15.3%, p=0.04) was significantly lower in the TAVR group. Incidence of mild/severe paravalvular leakage (14.4/10.9 versus 0%, p < 0.0001) and pacemaker implantation (11.3 versus 3.9%, p=0.01) was significantly higher in the TAVR group. There were no significant differences in the incidence of acute kidney injury (9.7 versus 8.7%, p=0.99), major adverse cardiovascular events (8.7 versus 12.3%, p=0.21), 30-day mortality (5.1 versus 5.5%, p=0.7), or 1-year mortality (11.6 versus 11.8%, p=0.97) between the TAVR and SAVR group. Conclusions TAVR as a redo procedure offers a safe alternative for patients presenting with aortic valve diseases after previous cardiac surgery especially those with prior CABG.

Role of regional aortic wall properties in the pathogenesis of thoracic aortic dissection

Abstract Objectives. The mechanisms of the location and extension of acute aortic dissection (AD) are only poorly understood. The aim of this study was to compare the cohesion of the non-coronary aortic sinus (NAS) and the ascending aortic wall (AA) using the Dissectometer – a new device for analyses of the mechanical properties of the aorta. Design. The properties of the aortic wall were analyzed with the “Dissectometer” (parameters P7, P8 and P9) in adult patients undergoing aortic root (AR) replacement in two different segments: NAS and AA. The aortic wall thickness (AWT) was measured with a micrometer. Results. Thirty-three adult patients (mean age 65 ± 14 years, 80% male) were included in this study. The aortic wall of the NAS was significantly thinner than that of the AA (1.9 ± 0.4 vs. 2.3 ± 0.4, p < 0.01). In contrast, mechanical stability assessed by cohesion testing was diminished in AA samples compared to NAS samples (P7: 86.0 ± 55.0 vs. 152.3 ± 89.2, p < 0.01; P8: 2.5 ± 1.3 vs. 6.0 ± 3.1, p < 0.01; P9: 3.6 ± 1.4 vs. 7.8 ± 3.2, p < 0.01). Conclusions. This study shows that the wall of the AR is characterized by a thin but stable wall, whereas AA was found to be weaker despite its greater thickness. This difference might be involved in the development and spreading of aortic dissections.

Minimally invasive David reimplantation of bicuspid aortic valve.

In this video article, we present the technical details of the minimally invasive aortic valve reimplantation operation through a partial upper “J” ministernotomy using novel sizing of the Valsalva graft. Stability of the aortic annulus is achieved with the use of a purse string suture at the bottom of the Valsalva prosthesis. The key factors crucial for achieving long-term stability of aortic valve reimplantation include symmetrical heights of both commissures in 180° orientation, coaptation above the annulus, and adequate length of coaptation.