Herbert De Praetere

Early and intermediate outcome after aortic valve replacement with a sutureless bioprosthesis: Results of a multicenter study

OBJECTIVE The aim of this study was to evaluate the outcome of aortic valve replacement with the sutureless Perceval S aortic valve bioprosthesis (Sorin Biomedica Cardio Srl, Saluggia, Italy). METHODS This is a retrospective analysis of 314 patients (mean age, 77.9 ± 5.0 years, mean European System for Cardiac Operative Risk Evaluation II, 9.0% ± 7.6%) who underwent aortic valve replacement with the Perceval S valve with (94 patients) or without (220 patients) concomitant coronary artery bypass surgery at 5 European centers. RESULTS The Perceval S valve was successfully implanted in all but 1 patient (99.7%). The mean aortic crossclamping time was 43 ± 20 minutes (isolated procedure, 39 ± 15 minutes; concomitant coronary surgery, 52 ± 26 minutes). Severe paravalvular leak occurred in 2 patients (0.6%). In-hospital mortality was 3.2% (1.4% after isolated procedure and 7.4% after concomitant coronary surgery). In-hospital mortality was 2.8% and 4.0% among patients with a European System for Cardiac Operative Risk Evaluation II less than 10% and 10% or greater, respectively (P = .558). Octogenarians had slightly higher in-hospital mortality (5.2% vs 2.0%, P = .125; after isolated procedure: 2.7% vs 0.7%, P = .223; after concomitant coronary surgery: 9.5% vs 5.8%, P = .491) compared with younger patients. Full sternotomy did not increase the in-hospital mortality risk compared with ministernotomy or minithoracotomy access (1.3% vs 1.4%, when adjusted for baseline covariates: P = .921; odds ratio, 0.886; 95% confidence interval, 0.064-12.346). One-year survival was 90.5%. Freedom from valve-related mortality, stroke, endocarditis, and reoperation was 99.0%, 98.1%, 99.2%, and 98.3%, respectively. CONCLUSIONS The sutureless Perceval S valve is associated with excellent early survival in high-risk patients, particularly among those undergoing an isolated procedure. Further studies are needed to prove the durability of this bioprosthesis.

Aortic valve replacement through full sternotomy with a stented bioprosthesis versus minimally invasive sternotomy with a sutureless bioprosthesis

OBJECTIVES The aim of this study was to analyse early postoperative outcomes and 2-year survival after aortic valve replacement (AVR) through a ministernotomy with a sutureless bioprosthesis implantation compared with a full sternotomy with implantation of a stented bioprosthesis. METHODS Patients who underwent primary isolated non-emergent AVR at six European centres were included in the study. Of these, 182 (32%) underwent a ministernotomy with a sutureless bioprosthesis (ministernotomy sutureless group) and 383 (68%) a full sternotomy with a stented bioprosthesis (full sternotomy stented group). Propensity score matching was used to reduce selection bias. RESULTS In the overall cohort, 30-day mortality was 1.6 and 2.1%, and 2-year survival was 92 and 92% in the ministernotomy sutureless group and in the full sternotomy stented group, respectively. Propensity score matching resulted in 171 pairs with similar characteristics and operative risk. Aortic cross-clamp (40 vs 65 min, P < 0.001) and cardiopulmonary bypass time (69 vs 87 min, P < 0.001) were shorter in the ministernotomy sutureless group. Patients undergoing ministernotomy received less packed red blood cells but the risk for postoperative permanent pacemaker implantation was higher. There were no differences regarding 30-day mortality or 2-year survival between the two groups. CONCLUSIONS AVR through a ministernotomy with implantation of a sutureless bioprosthesis was associated with shorter aortic cross-clamp and cardiopulmonary bypass time and less transfusion of packed red blood cells, but a higher risk for postoperative permanent pacemaker implantation compared with a full sternotomy with a stented bioprosthesis.

Ministernotomy Versus Full Sternotomy Aortic Valve Replacement With a Sutureless Bioprosthesis: A Multicenter Study

BACKGROUND The aim of this study was to analyze early postoperative outcomes and 2-year survival after aortic valve replacement (AVR) with the sutureless Perceval bioprosthesis (Sorin Biomedica Cardio Srl, Salluggia, Italy) performed through ministernotomy compared with full sternotomy. METHODS This was a study of 267 consecutive patients who underwent isolated AVR with the sutureless Perceval bioprosthesis between 2007 and 2014 at 6 European centers. Of these, 189 (70.8%) were performed through ministernotomy and 78 through a full sternotomy. Propensity score matching was used to reduce selection bias. RESULTS In the overall cohort of ministernotomy and full sternotomy patients, in-hospital mortality was 1.1% and 2.6% and 2-year survival was 92% and 91%, respectively. Propensity score matching resulted in 56 pairs with similar characteristics and operative risk. Aortic cross-clamp (44 minutes in both groups, p = 0.931) and cardiopulmonary bypass time (69 vs 74 minutes, p = 0.363) did not differ between the groups. Apart from higher values in the ministernotomy group for postoperative peak gradients (28.1 vs 23.3 mm Hg, p = 0.026) and mean aortic valve gradients (15.2 vs 11.7 mm Hg, p = 0.011), early postoperative outcomes did not differ in the propensity-matched cohort. There were no differences in the in-hospital mortality rate or 2-year survival between the groups. CONCLUSIONS AVR with the sutureless Perceval bioprosthesis through a ministernotomy was a safe and reproducible procedure that was not associated with prolonged aortic cross-clamp or cardiopulmonary bypass time compared with a full sternotomy. Early postoperative outcomes and 2-year survival were comparable between patients undergoing ministernotomy and full sternotomy.

Esophageal Necrosis After Endoprosthesis for Ruptured Thoracoabdominal Aneurysm Type I: Can Long-Segment Stent Grafting of the Thoracoabdominal Aorta Induce Transmural Necrosis?

BACKGROUND To study the pathophysiology of esophageal necrosis after endoprosthesis was performed for a ruptured aneurysm and to define preventive measures and possible treatment options. METHOD A 72-year-old man with thoracoabdominal aneurysm type I and dysphagia underwent an emergent carotico-carotid bypass in combination with thoracic endovascular aortic aneurysm repair starting at a point distal to the brachiocephalic trunk and ending proximal to the superior mesenteric artery. On day 12, a decortication was performed for treating an infection in the remaining hematoma. However, further deterioration occurred as a result of mediastinitis secondary to the transmural necrosis of the middle third of the esophagus combined with accompanying mediastinitis. The patients family refused to give consent for further treatment by esophagectomy. He died 24 days after the initial operation. CONCLUSION Dysphagia aortica, mucosal abnormalities on esophagogastroscopy, and mediastinal compression by hematoma at the time of rupture draws our attention toward ischemia of the esophagus after thoracic endovascular aortic aneurysm repair. Repeated esophagoscopy can provide us with the opportunity to act before full thickness necrosis and mediastinitis occur.

Robust Catheter and Guidewire Tracking Using B-Spline Tube Model and Pixel-Wise Posteriors

In endovascular surgery and cardiology, robotic catheters are emerging as a promising technology for enhanced catheter manipulation and navigation while reducing radiation exposure. For robotic catheter systems especially with tendon actuation, a key challenge is the localisation of the catheter shape and position within the anatomy. An effective approach is through image-based catheter/guidewire detection and tracking. However, these are difficult problems due to the thin appearance of the instruments in the image and the low signal-to-noise ratio of fluoroscopy. In this letter, we propose a deformable B-spline tube model, which can effectively represent the shape of a catheter and guidewire. The model allows fitting using a region-based probabilistic algorithm, which does not rely on intensity gradients but exploits a signed distance function and the nonparametric distributions of measurements. Unlike previous B-spline fitting approaches, which optimise the spline with respect to control points, we propose a knot-driven scheme with an equidistance prior to better fit complex curves. Our probabilistic framework shows promising results for catheter and guidewire tracking in different procedures even with handling overlapping instrument segments. We present empirical studies using phantom model data and in vivo fluoroscopic sequences with annotated ground truth. Our results indicate that the proposed approach can precisely model the catheter and guidewire contours in near real time, and this information can be embedded in a robotic catheter control loop or utilised for image-guidance.

Transapical transcatheter aortic valve implantation in a heart transplant recipient with severely depressed left ventricular function

Transcatheter aortic valve implantation (TAVI) is becoming a valuable alternative to surgical aortic valve replacement in non-operable and high-risk surgical patients. As the population of heart donors and recipients ages, the prevalence of degenerative valvular disease after transplantation will increase. The optimal treatment strategy of valvulopathies in these patients with extensive comorbidity is still unknown because of insufficient published experience. We present a heart transplant recipient with renal failure, systolic heart failure and severe aortic stenosis who was successfully treated with transapical TAVI.

Migration of a broken scalpel into the heart after spine surgery

Iatrogenic vascular problems during posterior lumbar interbody fusion are a rare entity. Migration of a broken scalpel towards the heart has, to our knowledge, never been reported. We present the successful surgical retrieval of a broken scalpel from the heart after posterior lumbar interbody fusion without the use of a cardiopulmonary bypass.

A novel tissue treatment to reduce mineralization of bovine pericardial heart valves

Objective: With the increasing use of bioprostheses worldwide, continuous efforts have been made to improve tissue durability. We introduce a new treatment for bovine pericardium combining octanediol‐ethanol based phospholipid removal with taurine‐based glutaraldehyde neutralization and storage in an aldehyde‐free solution (FREE). Methods: Treated tissues were evaluated by mechanical and biochemical characterization, phospholipid content, aldehyde levels, cell cultures on pericardial samples (L929 fibroblasts and human umbilical vein endothelial cells), rat subcutaneous implantations, and long‐term juvenile sheep mitral valve implantations (n = 3). Comparisons were made to glutaraldehyde‐fixed bovine pericardium or to samples from commercially available biological valves (ie, Trifecta [St Jude Medical, Saint Paul, Minn] and Perimount Magna Ease [Edwards Lifesciences, Irvine, Calif]). Results: FREE‐treated pericardium had similar mechanical strength and biochemical properties as commercially available valves. Compared with glutaraldehyde‐only samples, FREE‐treated samples showed lower phospholipid levels (P < .01), significantly better growth of L929 fibroblasts, and lower calcification levels in rat subcutaneous implants (P < .01). Compared with samples from Linx‐ (Trifecta) and ThermaFix‐treated (Perimount Magna Ease) valves, similar low levels of phospholipids were observed as were similar low calcification levels in subcutaneous implants, but tissue extractions from FREE‐treated samples showed the lowest levels of extracted aldehydes (P < .01). Mitral implants of FREE‐treated valves in juvenile sheep had excellent hemodynamic behavior without any sign of degeneration or calcification at 5 months. Conclusions: The new FREE treatment combines an adequate phospholipid reduction and aldehyde neutralization with storage in an aldehyde‐free solution. This combination enhances the anticalcification properties and may thereby improve long‐term durability of the tissue.

Starting minimally invasive valve surgery using endoclamp technology: safety and results of a starting surgeon

OBJECTIVES To critically review the learning curve, safety issues and outcome of a single surgeon while starting up minimally invasive mitral valve surgery (MIMVS). METHODS We performed a descriptive, retrospective study of 138 patients with minimally invasive mitral valve surgery between March 2004 and December 2010. The learning curve was assessed using a logarithmic curve-fit regression analysis of the cardiopulmonary bypass parameters and defined as the end of the steepest part. Complexity was assessed by the number of different techniques performed on the mitral valve and the number of concomitant procedures. Follow-up was obtained for embolic events, endocarditis, bleeding, reintervention, echocardiographic data and NYHA class. RESULTS The learning curve was found in the last 30 cases. There was a significant reduction in aortic cross-clamp time before and after the end of the learning curve [Patients 1-30: 120.77 (±28.28); Patients 31-138: 97.57 (±5.66); P <0.0001]. Operations during the learning curve did not correlate with intensive care unit (ICU) [1.77 (±0.97) vs 2.06 (±1.38)] and hospital stay [10.00 (±2.74) vs 9.10 (±3.36)]. In 104 patients, the valve was reconstructed, whereas in 34 it was replaced. The complexity of mitral valve reconstruction gradually increased and proportion of mitral valve replacement decreased, partly by expanding minimally invasive mitral valve surgery indications. Eighteen patients underwent 25 concomitant procedures and four conversions were necessary (after Patient 30). Minimal follow-up was 1 year with a mean follow-up of 1211 ± 651 days. No procedure-related mortality was encountered and mitral regurgitation after mitral valve repair was classified as Grade 1 or less in 101 of 104 patients at the end of follow-up. CONCLUSIONS Implementation of new equipment and techniques is challenging. However, minimally invasive mitral valve surgery with the endoclamp system is safe even during the learning curve. During our evolution from simple reconstructions/replacements to complex valve surgery with concomitant procedures, we could safely optimize our technique without mortality. A longer aortic cross-clamp time during the learning curve did not result in longer ICU and hospital stay.

Hospital cost savings and other advantages of sutureless vs stented aortic valves for intermediate-risk elderly patients

PurposeTo evaluate and compare the clinical outcomes and hospital costs of using sutureless aortic valves vs conventional stented aortic valves.MethodsBetween 2007 and 2011, 52 elderly patients undergoing aortic valve replacement for aortic stenosis in our center had a sutureless valve inserted. From among 180 patients who had a stented valve inserted during the same period, 52 patients were matched to the sutureless group, based on age, gender, and operation type. We compared clinical outcomes and hospital costs between the two groups.ResultsThe sutureless group had a higher Euroscore (logistic Euroscore I) risk (12.8 vs 9.7; p = 0.02), with significantly shorter aortic cross-clamp (ACC) time (p < 0.01), cardiopulmonary bypass (CPB) time (p < 0.01), intensive care unit stay (p < 0.01), intubation time (p < 0.01), and overall hospital stay (p = 0.05). The sutureless group also revealed a significant hospital cost saving of approximately 8200€ (p = 0.01).ConclusionsThe clinical and hemodynamic outcomes of using the sutureless bioprosthesis were excellent. The reduced ACC and CPB times had a favorable effect on the duration of intubation and intensive care stay, resulting not only in faster recovery and discharge home, but also in a significant hospital cost reduction.