Giovanni Concistrè

Minimally invasive aortic valve replacement with Perceval S sutureless valve: early outcomes and one-year survival from two European centers.

OBJECTIVE The aim of our study was to evaluate the early outcomes and 1-year survival of patients undergoing minimally invasive aortic valve replacement with the Perceval S sutureless valve for severe aortic stenosis. METHODS From March 2010 to March 2013, 281 high-risk patients underwent minimally invasive aortic valve replacement with the Perceval S sutureless valve through either right anterior minithoracotomy (n = 164) or upper ministernotomy (n = 117) at 2 cardiac centers. RESULTS The overall in-hospital mortality was 0.7% (2 patients). The overall median cardiopulmonary bypass and crossclamp time was 81 minutes (interquartile range, 68-98) and 48 minutes (interquartile range, 37-60), respectively. Postoperative stroke occurred in 5 patients (1.8%). The incidence of paravalvular leak greater than 1 of 4 and atrioventricular block requiring pacemaker implantation was 1.8% (5 patients) and 4.2% (12 patients), respectively. No migration occurred, and the mean postoperative gradient was 13 ± 4 mm Hg. At a median follow-up of 8 months (interquartile range, 4-14), the overall survival was 90%. CONCLUSIONS Minimally invasive aortic valve replacement with the Perceval S sutureless valve in high-risk patients is a safe and reproducible procedure associated with excellent hemodynamic results, postoperative outcomes, and 1-year survival.

The Perceval S Aortic Valve Has the Potential of Shortening Surgical Time: Does It Also Result in Improved Outcome?

BACKGROUND Sutureless aortic valve prostheses have the potential of shortening surgical time. However, whether shorter operative times may also result in improved patient outcomes remains to be established. METHODS One hundred patients underwent minimally invasive isolated aortic valve replacement. Of these, 50 patients received a Perceval (Sorin Group, Saluggia, Italy) bioprosthesis (group P) and 50 patients received a non-Perceval valve (group NP). RESULTS The group P patients were older (77.5 ± 5.3 versus 71.7 ± 10 years, p = 0.001) and at higher risk (logistic European System for Cardiac Operative Risk Evaluation [EuroSCORE] 9.9 ± 6.5 versus 4.3 ± 1, p = 0.001) than group NP patients. One implant failure occurred in group P (p = 0.5), and conversion to full sternotomy was necessary in 1 patient from each group. Aortic cross-clamp and cardiopulmonary bypass times were 39.4% and 34% shorter in group P (both p < 0.001). Within 30 days, a total of 5 patients died (2 in group P and 3 in group NP, p = 0.5). No significant differences were observed between groups in postoperative arrhythmias and need for pacemaker implantation (p = 0.3 and p = 0.5, respectively). Despite the higher surgical risk, group P patients less frequently required blood transfusion (1.1 ± 1.1 units versus 2.3 ± 2.8 units, p = 0.007), and had a shorter intensive care unit stay (1.9 ± 0.7 versus 2.8 ± 1.9 days, p = 0.002) and a shorter intubation time (9.2 ± 3.6 hours versus 15 ± 13.8 hours, p = 0.01). Group NP patients had a mean prosthesis size significantly smaller than for group P (23 ± 2 mm versus 23.9 ± 1.1 mm, p = 0.01). The Perceval valve provided comparable hemodynamic performance to that of non-Perceval valves (mean gradient 8.4 ± 6 mm Hg versus 10 ± 4.9 mm Hg, p = 0.24). CONCLUSIONS Sutureless implantation of the Perceval valve is associated with shorter cross-clamp and cardiopulmonary bypass times, resulting in improved clinical outcome. In addition, it compares favorably with conventional valves in terms of mortality and outcome variables.

Reoperation After Surgical Correction of Acute Type A Aortic Dissection: Risk Factor Analysis

BACKGROUND Aortic dissection is an evolving process that may require one or several reoperations after its initial repair. We conducted a study to evaluate risk factors and define the incidence and locations of reoperations after surgical correction of acute type A aortic dissection (AAD). METHODS Between 1998 and 2008, 250 consecutive patients (mean age 62.5±12.4 years) underwent surgery for AAD at our institution. Replacement of the ascending aorta was done in 173 cases, composite graft replacement in 61 cases, separate aortic valve and ascending aorta replacement in 2 cases, and arch replacement required by distal repair in 14 cases. Mean follow-up time was 4.7±5.6 years. RESULTS Freedom from reoperation was 99%, 82%, and 79% at 1, 5, and 10 years, respectively. Twenty-five patients required 25 reoperations at a mean interval of 4.7 years after initial surgery for the correction of AAD. Reoperations included 21 procedures on the proximal aorta (ascending aorta, aortic root, or valve) and 4 procedures on the distal aorta (arch or descending aorta). Cox regression analysis identified the use of gelatin-resorcinol-formaldehyde (GRF) glue (p=0.0270), and nonreplacement of the aortic root at the time of initial AAD repair (p=0.0004), as a significant risk factor for proximal reoperation, and a patent false lumen (p=0.0107) as a significant risk factor for distal reoperation. CONCLUSIONS A patent false lumen, the use of GRF glue, and aortic root preservation at initial operation influence the risk for surgical correction in patients undergoing surgery for AAD. These patients need long-term follow-up.

Outcomes After Surgical Treatment for Type A Acute Aortic Dissection in Octogenarians: A Multicenter Study

BACKGROUND Management of octogenarian patients with acute type A acute aortic dissection is controversial. This study analyzed the surgical outcomes to identify patients who should undergo operations. METHODS Beginning January 2000, we established a registry including all octogenarian patients operated on for type A acute aortic dissection. We evaluated 57 consecutive patients enrolled up to December 2006. Their median age was 82 (range, 80 to 89 years). Compassionate indication operations were attempted in 2 moribund patients and in 5 presenting with shock associated with neurologic symptoms or renal failure, or both. Operations followed the standard procedure recommended in younger patients. Follow-up was 100% complete (mean, 3.9 +/- 2 years; range, 5 months to 8 years). RESULTS There were 26 (45.6%) in-hospital and 6 late deaths. Multivariate analysis identified compassionate indication (p < or = 0.0001) and total arch replacement (p = 0.0060) as risk factors for in-hospital mortality. Postoperative complications occurred in 36 patients (69.2%) and were associated with a higher mortality (p = 0.0001). Overall survival was 51% at 1 year and 44% at 5 years. Excluding patients with compassionate indication and those who underwent total arch replacement, or both, overall survival was 66% at 1 year and 57% at 5 years. CONCLUSIONS Surgical treatment for type A acute aortic dissection in octogenarians shows satisfactory midterm results among survivors. However, the high mortality rate imposes a requirement for better perioperative management. Compassionate cases should be managed medically. A less aggressive approach should improve outcomes of surgical treatment.

Perceval S aortic valve implantation in mini-invasive surgery: the simple sutureless solution

The Perceval S bioprosthesis (21 and 23 mm) was approved for clinical use in December 2010 and it is now routinely used. This bioprosthesis is suggested for the treatment of patients undergoing minimally-invasive surgery for reasons of safety and reduction in implantation time. Here we describe the use of the Perceval bioprosthesis in patients undergoing minimally invasive cardiac surgery.

Sutureless aortic bioprosthesis in severe aortic root calcification: an innovative approach

Aortic valve replacement (AVR) in patients with severe aortic root calcification is technically a very difficult procedure which requires a long cardiopulmonary bypass (CPB) time, especially in patients undergoing complex procedures such as multivalve or valve and coronary surgery. We report a case of successful AVR with an innovative approach in a patient with an extensively calcified aortic root and concomitant tricuspid valve regurgitation who underwent mitral valve replacement 20 years ago.

Delayed dislocation of a sutureless aortic bioprosthesis: the first case.

Sutureless aortic bioprosthesis implantation is an alternative technique in high-risk patients undergoing aortic valve replacement with a possible reduction in the extracorporeal circuit time and reliable haemodynamic features. A 3F Enable (ATS Medical-Medtronic, Inc., Minneapolis, MN, USA) has shown very good results. We report the first upward displacement of 3F Enable three months post implantation.

Impact of pulmonary hypertension on mortality after operation for isolated aortic valve stenosis

BACKGROUND Pulmonary hypertension (PH) is a well-known independent risk factor for mortality and morbidity after cardiac surgery. However, no weight is given to PH in the current guidelines for the management of patients with aortic stenosis (AS) undergoing aortic valve replacement (AVR). The aim of our study was to evaluate the impact of preoperative PH on early and five-year survival in patients with severe AS undergoing isolated AVR. METHODS From January 2005 to July 2010, 422 consecutive patients with severe AS underwent isolated AVR. According to systolic pulmonary artery pressure (sPAP), PH was classified as none (sPAPS<35 mmHg, N=224), mild-moderate (35≤sPAP<50 mmHg, N=159) and severe (sPAP≥50 mmHg, N=39). RESULTS Overall in-hospital mortality was 2.8%. Unadjusted mortality was 0.9%, 3.8% and 10.2% for patients with normal, mild-moderate and severe PH (p=0.003). In multivariable analysis, severe PH (OR 4.1, 95 CI 1.1-15.3, p=0.04) and New York Heart Association class III-IV (OR 14.9, 95% CI 1.8-117.8, p=0.01) were independent risk factors of in-hospital mortality. Multivariable predictors of five-year survival were extracardiac arteriopathy (HR 2.8, 95%CI 1.6-4.9, p<0.0001), severe PH (HR 2.4, 95%CI 1.2-4.6 p=0.01), NHYA III-IV class (HR 2.3, 95% CI 1.3-4, p=0.003), preoperative serum creatinine (HR 2.2, 95%CI, 1.6-3.1,p<0.0001) and age (HR 1.08, 95%CI 1.03-1.13, p=0.01). Five-year survival was 86%±3% with normal sPAP, 81%±4% with mild-moderate PH and 63±10% with severe PH (p<0.001). CONCLUSIONS In patients undergoing isolated AVR with severe AS, severe PH is an independent predictor of in-hospital mortality and five-year survival.

Aortic Valve Replacement with Smaller Prostheses in Elderly Patients: Does Patient Prosthetic Mismatch Affect Outcomes?

To evaluate the influence of patient‐prosthesis mismatch (PPM) on survival, and quality of life (QOL) after aortic valve replacement (AVR) in elderly patients with small prosthesis size.

Minimally invasive aortic valve replacement with Perceval valves: first clinical experience.

Aim Although minimally invasive aortic valve replacement (MIAVR) has been shown to cause less morbidity than conventional surgery, it has not yet received broad application. The purpose of this study was to evaluate sutureless implantation using the Perceval S aortic valve bioprosthesis (Sorin Group, Saluggia, Italy) via ministernotomy. Methods Seventy-two patients (43 women, 29 men; mean age 77.4 ± 5.3 years) with isolated aortic valve stenosis (mean gradient of 52 ± 14 mmHg) underwent aortic valve implantation with the sutureless Perceval S bioprosthesis, following cardiopulmonary bypass (CPB), aortic cross-clamping (ACC), cardioplegic arrest and removal of the calcified native valve. The mean logistic EuroSCORE was 9.7 ± 6.2%. Results The prosthetic valve was successfully deployed in all patients. Thirty-day mortality was 1.4% (n = 1). Mean CBP, ACC, and implantation times were 68 ± 18, 40 ± 13 and 8.9 ± 4 min, respectively. Perioperative echocardiography revealed significant paravalvular leakage in one patient. Postoperative mean gradient was 11.6 ± 5.1 mmHg. At a mean follow-up of 13 ± 6.7 months, no significant paravalvular leakage or valvular regurgitation was observed, and no migration or dislodgement of the prosthesis occurred. Conclusion This study shows that sutureless implantation of the Perceval S aortic valve bioprosthesis provides a simple and reproducible alternative for MIAVR. As the valve does not need to be sutured, it may also result in reduced ACC and CPB times. This self-anchoring valve may also allow the application of MIAVR to a broader spectrum of patients. This new technology needs a long-term follow-up.