Hardy Baumbach

Transcatheter Aortic Valve Replacement: Does Kidney Function Affect Outcome?

BACKGROUNDnChronic kidney disease is a significant risk factor for mortality as well as acute kidney injury in cardiac surgery. The impact of contrast agent application on outcome is not well described in patients undergoing transcatheter aortic valve implantation.nnnMETHODSnWe analyzed data of 270 patients who underwent transcatheter aortic valve implantation (TAVI) between September 2008 and March 2012. Acute kidney injury was defined according to modified risk, injury, failure, loss and end-stage renal failure criteria. Patients on chronic hemodialysis were analyzed separately (n = 15). In 129 (47.8%) patients chronic kidney disease was apparent preoperatively. On average, 83.7 (± 32.4) mL of contrast agent were used per patient.nnnRESULTSnPostoperatively, 41 patients (15.2%) developed acute kidney injury. In 19 patients (7.1%) transient renal replacement therapy was necessary; no chronic hemodialysis was required. Thirty-day-mortality did not differ between patients with or without chronic kidney disease (7.0% vs 7.1%, p = 0.97). Additionally, chronic kidney disease had no influence on the incidence of postoperative acute kidney injury (12.8% vs 20.2%, p = 0.07) or postoperative hemodialysis (5.0% vs 10.5%, p = 0.08). No correlation between the amount of contrast agent applied and the incidence of acute kidney injury could be verified (p = 0.57).nnnCONCLUSIONSnPreoperative chronic kidney disease does not increase the risk of mortality and acute kidney injury after transcatheter aortic valve implantation. Acute kidney injury after TAVI is associated with an elevated risk of mortality. The amount of contrast agent applied intra-procedurally does not affect the risk of acute kidney injury.

Severe Aortic Insufficiency After Transapical Aortic Valve Implantation

We report the dislocation of a stented aortic valve prosthesis two weeks after the uneventful transapical implantation in a female who had underwent mitral valve replacement and CABG six years before. The initial implantation of the Edwards Sapien aortic valve prosthesis (Edwards Lifesciences, Irvine, CA), as well as the postoperative recovery, was uneventfully. At the sixth postoperative day, the patient developed a progressive heart failure due to a severe aortic insufficiency. During conventional aortic valve replacement, the dislocated prosthesis was found in the left ventricle. After uncomplicated postoperative recovery, the patient could be discharged in a good physical condition. Preexisting mitral valve prosthesis seems to be an important, complicating goal for transcatheter aortic valve implantation.

Minimally Invasive Extracorporeal Bypass in Minimally Invasive Heart Valve Operations: A Prospective Randomized Trial

BACKGROUNDnMinimally invasive extracorporeal circulation (MECC) is predominantly used in coronary operations. Data supporting the benefits of MECC in minimally invasive valve operations are still absent.nnnMETHODSnPatients undergoing either isolated minimally invasive mitral or aortic valve procedures were prospectively randomized to a minimally invasive group (MECC; nxa0= 101) or a conventional extracorporeal circulation group (CECC; nxa0= 99). The procedural and postoperative outcomes were compared, including the levels of inflammation factors (procalcitonin, interleukin [IL]-6, IL-8, and IL-10), tumor necrosis factor-α [TNF-α], and interferon-gamma [IFN-γ]).nnnRESULTSnThe demographics were comparable between the groups regarding age (MECC versus CECC, 70.5 ± 10.2 years versus 73.1 ± 8.9 years; Pxa0= 0.086), left ventricular function (59.2% ± 13.4% versus 62.1% ± 14.0%; pxa0= 0.302), EuroSCORE (7.4% ± 7.9% versus 6.8% ± 4.0%; pxa0= 0.256), and other comorbidities. Hospital mortality (nxa0= 1 versus nxa0= 3; pxa0= 0.339) and other complications were similar. However, hemoglobin level (111.9 ± 19.0 g/L versus 103.8 ± 14.6 g/L; pxa0= 0.001), the number of packed red blood cells (PRBCs) (1.1 ± 1.9 versus 1.7 ± 1.8; pxa0= 0.003), the levels of ILs (IL-6, 194.0 ± 131.8 pg/mL versus 289.2 ± 62.5 pg/mL; pxa0= 0.020; IL-8, 38.1 ± 27.3 pg/mL versus 45.8 ± 43.4 pg/mL; pxa0= 0.012; IL-10, 29.0 ± 123.9 pg/mL versus 49.9 ± 85.6 pg/mL; pxa0= 0.012), TNF-α (3.8 ± 6.7 ng/mL versus 10.8 ± 47.7 ng/mL; pxa0= 0.049), and IFN-γ (1.9 ± 1.9 pg/mL versus 4.5 ± 2.7 pg/mL; pxa0= 0.027) were in favor of patients in the MECC group. Additionally, those patients had shorter postoperative ventilation time (7.7 ± 8.4 hours versus 9.3 ± 12.9 hours; pxa0= 0.010) and intensive care unit (ICU) stay (1.2 ± 1.2 days versus 2.2 ± 3.8 days; pxa0= 0.047).nnnCONCLUSIONSnThe intraprocedural data were excellent and comparable in the groups, but postoperative outcomes were better in the MECC group. Thus MECC is preferable to CECC even for minimally invasive valve procedures. These findings strongly support a combined strategy of minimally invasive valve operations and minimally invasive extracorporeal circulation.

Complex Cusp Repair in Patients Undergoing the David Procedure: Is It Worth It?

BACKGROUNDnValve-sparing aortic root replacement has already proven its excellent long-term results, with low valve-related complications comparable with conventional aortic valve replacement. The aim of this study was to investigate whether additional expanded cusp repair is an alternative with comparable results.nnnMETHODSnData of 192 elective patients undergoing valve-sparing aortic root replacement were prospectively recorded: 58 patients (30.2%) received an isolated aortic root replacement (group I, isolated David), and 134 patients (69.8%) received additional cusp repair (group II, complex David), such as plication of the free margin (nxa0=xa077), decalcification (nxa0= 45), or pericardial patch (nxa0= 39). Cumulative follow-up was 480 patient-years, with a mean of 2.5 ± 1.5 years.nnnRESULTSnMean age was 60 years, and 76.6% were men. In hospital mortality was 3.4% in group I and 0.0% in group II. Freedom from cardiac death at 5 years (by Kaplan-Meier estimation) was 83% vs 98% (pxa0= 0.058). Freedom from moderate or severe aortic insufficiency at 5xa0years was 100% in group I vs 93% (95% confidence interval, 86% to 97%) in group II (pxa0= 0.110). Seven patients required reoperation for aortic insufficiency or stenosis: repeat repair (nxa0= 3), Ross procedure (nxa0= 2), and biologicical aortic valve replacement (nxa0= 2). Freedom from reoperation at 5 years was 96% (95% confidence interval, 76% to 99%) in group I vs 89% (95% confidence interval, 71% to 96%) in group II (pxa0= 0.305).nnnCONCLUSIONSnOverall survival and freedom from reoperation after valve-sparing aortic root replacement, even with additional complex cusp repair, provides excellent midterm results. Low risk of valve-related complications and absence of anticoagulation therapy are distinctive advantages of this complex procedure.

Transapical aortic valve implantation and minimally invasive off-pump bypass surgery

Transcatheter aortic valve implantation (TAVI) has gained increasing popularity for high-risk patients with symptomatic aortic valve stenosis. A concomitant coronary artery disease leads to a complicated management and an increased perioperative risk. This case report describes the successful total arterial coronary revascularization of the left anterior descending and the left marginal branch of the circumflex artery utilizing the left internal mammary artery (LIMA) and left radial artery in off-pump technique in combination with the transapical transcatheter aortic valve implantation via minimally invasive anterolateral access in the fifth intercostal space.

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.

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

OBJECTIVESnSignificant 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.nnnMETHODSnA 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.nnnRESULTSnMean age was 82.2u2009±u20094.0 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 35.9u2009±u200921.9% and 12.2u2009±u20097.9%, respectively. SYNTAX score was 29.0u2009±u200912.9. 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%).nnnCONCLUSIONSnSimultaneously performed complete off-pump coronary revascularization is a feasible and valid option in patients with significant CAD undergoing TAVI.

TCT-670 Optimal Transcatheter Heart Valve Sizing in Aortic Valve in Valve Implantation: Insights from the Valve in Valve International Data (VIVID) Registry

Optimal transcatheter heart valve (THV) sizing is crucial to optimize procedural outcomes. Larger THV oversizing is shown to decrease paravalvular leakage post transcatheter aortic valve replacement but its role in Valve in Valve implantation (ViV) is not well established.nnFor each surgical type

Transapical aortic valve implantation in patients with pre-existing mitral valve prostheses: a case report

BackgroundTranscatheter aortic valve implantation (TAVI) has proven to be a valid option for patients with severe aortic stenosis who are at high perioperative risk, particularly in patients with previous cardiac surgery. Several patients with previous mitral valve surgery were reported to have been successfully treated with TAVI.Case presentationTwo patients, one with mechanical and one with biological mitral valve prosthesis, presented with symptomatic severe aortic stenosis. After discussion among our multidisciplinary heart team transapical approach and a JenaValve™ prosthesis was used for TAVI. Main reasons were to decrease the perioperative risk, avoid a re-opening of the chest via median sternotomy, and discuss the possible superiority of the JenaValve™ device due to its design. The patients were successfully treated and discharged on the 11th and 14th post-operative day, respectively. Echocardiographic follow up before discharge and up to 2.8xa0years post-operatively showed excellent results.ConclusionsIn conclusion, TAVI in patients with preexisting mitral prostheses-mechanical or biological-is feasible, safe, and effective and offers a valid alternative to conventional aortic valve replacement in this particular re-operation scenario. The JenaValve™ device does not interact with the mitral prosthesis and offers therefore due to its unique design a potential advantage.

Feasibility and clinical outcome after minimally invasive valve-sparing aortic root replacement

ObjectivesnThis study aims to examine the feasibility and clinical course after minimally invasive David procedure compared with those via a conventional median sternotomy.nnnMethodsnOne hundred and ninety-two consecutive patients who underwent elective valve-sparing aortic root replacement (David procedure) with or without additional cusp repair for aortic regurgitation ( n u2009=u200917, 8.9%), dilatation of the aortic root ( n u2009=u200995, 49.5%) or a combination of both pathologies ( n u2009=u200980, 41.7%) were included. Patients with systemic disorders, such as Marfans syndrome, and emergency cases were excluded. Assessment of quality of life was performed by modified Short Form Health Survey (SF-36) questionnaire. To minimize baseline differences, a matched pair analysis was conducted.nnnResultsnOne hundred and seventeen patients (60.9%) received a minimally invasive hemisternotomy (Group 1), 75 patients a conventional median sternotomy (39.1%, Group 2). Patients of Group 1 were significantly younger (56.5u2009±u200913.6 vs 64.8u2009±u200911.6, P u2009<u20090.001). Understandably, concomitant cardiac procedures were more frequent in Group 2 ( n u2009=u20097 [6.0%] vs n u2009=u200948 [64.0%], P u2009<u20090.001). In hospital, mortality was 0.9% in Group 1 (1/117) and 2.7% in Group 2 (2/75; P u2009=u20090.562). Blood loss was significantly less in Group 1 (542.6u2009±u2009441.8 vs 996.7u2009±u2009822.6u2009ml, P u2009<u20090.001). Duration of mechanical ventilation (10.2u2009±u200921.8 vs 26.9u2009±u2009109.0u2009h, P u2009<u20090.001) and ICU-stay (1.9u2009±u20093.6 vs 3.2u2009±u20095.6 days, P u2009<u20090.001) were significantly shorter in the minimally invasive group, but this differences did not remain after matching. According to SF-36 questionnaire, patients in the minimally invasive group tend to have a higher quality of life.nnnConclusionsnMinimally invasive valve-sparing aortic root replacement can be done safely via an upper partial sternotomy in experienced hands even if additional cusp repair is required.