Fernando Ramirez-Del Val

Reconstruction of Right Ventricular Outflow and Pulmonary Artery with a Composite Pericardial Monocusp Patch: An Experimental Study

A composite bovine pericardial monocusp patch was implanted in the right ventricular outflow tract of 30 dogs. The monocusp patch incorporates a molded sinus of Valsalva designed according to a computer-analyzed study of the normal anatomy. Twenty-two dogs survived the operation and were killed between 1 and 34 months postoperatively (mean, 19.5 +/- 3.5 months). Two implants showed signs of infective endocarditis 2 and 2.5 months, respectively, after operation; 1 was thrombosed at 7 months, and 1 was calcified 8 months postoperatively. In the remaining 18 animals, there was no stenosis, thrombosis, or degeneration of tissue in the monocusp. Macroscopic and microscopic studies of these grafts showed normal structure and pliability of the monocusp valve up to 34 months after operation.

Impact of flow, gradient, and left ventricular function on outcomes after transcatheter aortic valve replacement

To assess the impact of low flow with and without preserved left ventricular ejection fraction (LVEF) on outcomes after transcatheter aortic valve replacement (TAVR).

Outcomes of repeat mitral valve replacement in patients with prior mitral surgery: A benchmark for transcatheter approaches

Objectives With the emergence of transcatheter mitral valve‐in‐valve/ring replacement for deteriorated bioprostheses or failed repair, comparative clinical benchmarks for surgical repeat mitral valve replacement (re‐MVR) are needed. We present in‐hospital and survival outcomes of a 24‐year experience with re‐MVR. Methods From January 1992 to June 2015, 520 adult patients underwent re‐MVR; 273 had undergone prior mitral valve repair (pMVP) and 247 had undergone prior MVR (pMVR). A benchmark cohort of isolated re‐MVR was defined based on potential eligibility for transcatheter mitral valve‐in‐valve/ring replacement, resulting in 73 pMVPs with previous annuloplasty rings and 74 pMVRs with previous bioprosthetic valves for comparison. Results For the entire cohort, mean age was 64 ± 12 years for pMVP patients and 63 ± 15 years for pMVR patients (P = .281), which was similar for the benchmark cohort. Overall operative mortality was 14 out of 273 (5%) for pMVP versus 23 out of 247 (9%) for pMVR (P = .087). There were 3 operative deaths (4.1%) in both groups of the benchmark cohort (P = 1.0). For the benchmark cohort, median time to reoperation was 9.8 years for pMVP and 9.1 years for pMVR. Cox proportional hazard analysis showed that chronic kidney disease (hazard ratio [HR], 2.47; 95% CI, 1.77‐3.44), endocarditis (HR, 1.49; 95% CI, 1.07‐2.07), pMVR (HR, 1.45; 95% CI, 1.12‐1.89), early reoperation ≤ 1 year (HR, 1.49; 95% CI, 1.02‐2.17), and age (HR, 1.04/y; 95% CI, 1.03‐1.05) were associated with decreased survival after re‐MVR. Conclusions A re‐MVR is a high‐risk operation, but in carefully selected patients such as our benchmark population, it can be performed with acceptable results. Patients undergoing pMVP also have better long‐term survival compared with patients undergoing pMVR. These results will serve as a benchmark for transcatheter mitral valve‐in‐valve/ring replacement.

The risk of reoperative cardiac surgery in radiation-induced valvular disease

Objective: Mediastinal radiation therapy (MRT) increases the risk for adverse outcomes after cardiac surgery and is not incorporated in the Society of Thoracic Surgeons (STS) risk algorithm. We aimed to quantify the surgical risk conferred by MRT in patients undergoing primary and reoperative valvular operations. Methods: A retrospective analysis of 261 consecutive patients with prior MRT who underwent valvular operations between January 2002 and May 2015. Short‐ and long‐term outcomes were compared for STS predicted risk of mortality, surgery type, gender, year of surgery, and age‐matched patients stratified by reoperative status. Results: Mean age was 62.6 ± 12.1 years and 174 (67%) were women. The majority had received MRT for Hodgkin lymphoma (48.2%) and breast cancer (36%). Overall, 214 (82%) were primary and 47 (18%) were reoperative procedures. Reoperation carried a higher operative mortality than primary cases (17% vs 3.7%; P = .003). Compared with the 836 nonradiated matches, operative mortality and observed‐to‐expected STS mortality ratios were higher in primary (3.8% [1.4] vs 0.8% [0.32]; P = .004) and reoperative (17% [3.35] vs 2.3% [0.45]; P = .001) patients with prior MRT. Cox proportional hazard modeling revealed that in patients with previous MRT, primary (hazard ratio, 2.24; 95% confidence interval, 1.73–2.91) and reoperative status (hazard ratio, 3.19; 95% confidence interval, 1.95–5.21) adversely affected long‐term survival compared with nonradiated matches. Conclusions: Surgery for radiation‐induced valvular heart disease has a higher operative mortality than predicted by STS predicted risk of mortality. Reoperations are associated with increased morbidity and mortality compared with primary cases. Careful patient selection is paramount and expanded indications for transcatheter therapies should be considered, especially in reoperative patients.

Proximal aortic surgery in the elderly population: Is advanced age a contraindication for surgery?

Objective: The study objective was to describe the clinical outcomes of elderly patients undergoing ascending aortic surgery. Methods: Patients aged 70 years or older who underwent ascending aortic surgery between January 2002 and December 2013 were examined. Of 415 included patients, 285 were elderly patients (age 70‐79 years) and 130 were very elderly (age ≥80 years). Logistic regression and Cox proportional hazards models were used to evaluate operative mortality and long‐term survival, respectively. Results: Surgical indications included aortic aneurysm (63.1%), calcified aorta with need for other cardiac procedure (26.4%), and type A dissection (10.5%). Compared with elderly patients, the very elderly patients had a higher burden of comorbidities and operative mortality (13% vs 7%, P < .04). The very elderly patients were also more likely to be discharged to a rehabilitation facility than home (P < .001). However, risk‐adjusted operative mortality and 30‐day readmissions rates were similar (P > .05). Kaplan–Meier estimates of survival at 1 and 5 years were 85.6% and 72.6% for elderly patients versus 79.2% and 57.1% for the very elderly patients. Age was a strong risk variable for late mortality in the unadjusted and adjusted analyses. Conclusions: After adjusting for these comorbidities, the cause of aortic disease, and the type of procedure, age was not an independent predictor of operative mortality, but was strongly associated with reduced late survival. Thus, advanced age alone should not be an absolute contraindication for ascending aortic surgery.

Surgical pulmonary embolectomy and catheter-directed thrombolysis for treatment of submassive pulmonary embolism

Acute pulmonary embolism (PE) with preserved hemodynamics but right ventricular dysfunction, classified as submassive PE, carries a high risk of mortality. We report the results for patients who did not qualify for medical therapy and required treatment of submassive PE with surgical pulmonary embolectomy and catheter‐directed thrombolysis (CDT).

Minimally invasive versus full sternotomy aortic valve replacement in low-risk patients: Which will stand against transcatheter aortic valve replacement?

Background: Minimally invasive aortic valve replacement using upper‐hemisternotomy has been associated with improved results compared to full sternotomy aortic valve replacement. Given the likely expansion of transcatheter aortic valve replacement to low‐risk patients, we examine contemporary outcomes after full sternotomy and minimally invasive aortic valve replacement in low‐risk patients using our 15‐year experience. Methods: Two thousand ninety‐five low‐risk patients (Society of Thoracic Surgeons Predicted Risk of Mortality score <4) underwent elective isolated aortic valve replacement, including 1,029 (49%) minimally invasive and 1,066 (51%) full sternotomy, from 2002 to 2015. Results: Compared to minimally invasive aortic valve replacement patients, full sternotomy aortic valve replacement patients had a greater burden of comorbidities, including diabetes, stroke, congestive heart failure, and predicted risk of mortality (all P ≤ .05). Operative mortality, stroke, and reoperation rates for bleeding were similar. There was a clinical trend toward shorter median intensive care unit stay and significantly shorter hospital length of stay among minimally invasive aortic valve replacement patients. Adjusted survival analysis identified age, chronic kidney disease, prior sternotomy, and congestive heart failure as predictors of decreased survival (all P ≤ .05), while type of intervention approach was nonsignificantly different. Conclusion: In low‐risk patients, minimally invasive aortic valve replacement results in similar mortality, stroke, reoperation rates for bleeding, and midterm survival (after adjusting for confounders), but shorter hospital length of stay and a trend (P=.075) toward shorter intensive care unit stay, compared to full sternotomy aortic valve replacement. Therefore, minimally invasive aortic valve replacement should stand as a benchmark against transcatheter aortic valve replacement in these patients.

Novel fast-track recovery protocol for alternative access transcatheter aortic valve replacement: application to non-femoral approaches

OBJECTIVES Although the transfemoral approach for transcatheter aortic valve replacement is the preferred choice, alternative access remains indicated for inadequate iliofemoral vessels. We report the successful implementation of a novel fast-track (FT) protocol for patients undergoing alternative access transcatheter aortic valve replacement compared with conventional controls. METHODS Between September 2014 and January 2017, 31 and 23 patients underwent alternative access transcatheter aortic valve replacement under FT and pre-fast-track (p-FT) protocols, respectively. Comparisons of outcomes (in terms of mortality, complications, readmissions and resource utilization) were made before and after the implantation of the FT protocol in September 2015. RESULTS Overall, mean age was 78.7 years in FT and 79.6 years in p-FT patients (P = 0.71). There were no significant differences in procedural (3.2% vs 13.0%, P = 0.301) or 90-day mortality (3.2% vs 17.4%, P = 0.151) between the FT and p-FT groups, respectively. Compared with p-FT patients, FT patients had significantly shorter intensive care unit stays (12 h vs 27 h, P = 0.006) and a trend towards more discharges within 3 days (41.9% vs 17.4%, P = 0.081). Resource utilization analyses projected a 56% and 17% reduction in the mean intensive care unit time (hours) per 100 patients and the total length of stay (days) per 100 patients, respectively, with respect to the FT approach. CONCLUSIONS This pilot study demonstrates the feasibility and safety of the novel FT protocol for alternative access transcatheter aortic valve replacement, resulting in shorter intensive care unit stays, without increasing procedural complications or readmissions. With the expected increase in transcatheter aortic valve replacement utilization, FT protocols should be integrated with a multidisciplinary heart team approach to enhance patient recovery and optimize resource utilization.

Effectiveness and Safety of Transcatheter Aortic Valve Implantation for Aortic Stenosis in Patients With “Porcelain” Aorta

Surgical aortic valve replacement (SAVR) in patients with porcelain aorta is considered a high-risk procedure. Hence, transcatheter aortic valve implantation (TAVI) is emerging as the intervention of choice. However, there is a paucity of data directly comparing TAVI with SAVR in patients with porcelain aorta. We compared outcomes of TAVI versus SAVR in high-risk patients with porcelain between March 2012 and June 2015. The TAVI group included 54 patients, whereas 130 SAVR patients with porcelain aorta were identified (operated on between 2004 and 2015). Both groups were matched 1:1 based on the Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) score with a 0.5% a priori caliper, resulting in 52 matched pairs. The mean STS-PROM was 7.3 ± 3.9 for both groups (p = 0.98), whereas mean age was 77.5 years for TAVI and 78.8 years for SAVR (p = 0.46). Compared with SAVR, TAVI patients had lower operative mortality (3.8% vs 17.3%; p = 0.052), significantly shorter median intensive care unit (40 vs 107 hours; p < 0.001) and hospital (5 vs. 7 days; p < 0.001) length of stay (LOS), but similar postoperative stroke rates (7.7% vs 11.5%; p = 0.74). One-year unadjusted survival was 81.7% (95% confidence interval [CI]: 69.8% to 93.5%) in the TAVI group versus 71.2% (95% CI: 61.0% to 85.1%) in the SAVR group, p = 0.093. Cox proportional hazard modeling identified preoperative chronic kidney disease (hazard ratio: 2.63 [95% CI: 1.03 to 6.70]; p = 0.043) and SAVR (hazard ratio: 2.641 [95% CI: 1.07 to 6.51]; p = 0.035) as significant predictors for decreased survival. Overall, TAVI was associated with reduced operative mortality, increased survival, and shorter intensive care unit and hospital length of stay compared with SAVR in patients with porcelain aorta. This study demonstrates that TAVI is a safe intervention in this high-risk population.