Holger Schröfel

A comparison of transcatheter aortic valve implantation and surgical aortic valve replacement in 1,141 patients with severe symptomatic aortic stenosis and less than high risk

To assess outcomes for patients undergoing transcatheter aortic valve implantation (TAVI) versus surgical aortic valve replacement but with less than high risk.

Prospective multicentre evaluation of a novel, low-profile transapical delivery system for self-expandable transcatheter aortic valve implantation: 6-month outcomes†

OBJECTIVES We assessed the safety and efficacy of a novel low-profile, 22-Fr transapical delivery system together with the ACURATE neo™ resheathable transcatheter heart valve. METHODS This prospective, single-arm, multicentre study enrolled 60 patients with severe symptomatic aortic stenosis and high surgical risk ineligible for transfemoral access. Primary end points were 6-month mortality and procedural success. RESULTS The mean age of patients was 79.8 ± 4.7 years, and the patients had severe comorbidities including coronary artery disease (71.7%), diabetes (38.3%), atrial fibrillation (30.0%) and chronic obstructive pulmonary disease (21.7%); logistic EuroSCORE-I, -II and the Society of Thoracic Surgeons (STS) scores were 20.9 ± 8.9%, 6.1 ± 5.0% and 4.3 ± 2.9%, respectively. A non-rib spreading approach using soft tissue retractors only was used in 88.3% of patients (n = 53). Resheathing and repositioning of transcatheter heart valve were performed in 6.7% of cases (n = 4); the device implantation time was 3 ± 2 min. Apical access site complications occurred in 1.7% (n = 1). Procedural success was 98.3% (n = 59), and procedural success in the absence of major adverse cardiac and cerebrovascular events at 30 days was 90.0% (n = 54). At 30 days, cardiovascular and overall mortality were 8.3% (n = 5), stroke rate was 1.7% (n = 1), and 17.2% of patients (n = 10) received a permanent pacemaker implant. No paravalvular leakage ≥2+ was observed, and the mean transvalvular gradient was 5.9 ± 2.7 mmHg. At 6 months, survival was 84.3% with sustained haemodynamic results. CONCLUSIONS This study indicates safety and efficacy of transapical aortic valve implantation using a novel low-profile delivery system. High procedural success, short implantation times and a low rate of apical access site complications underline the favourable safety profile and ease of use. Clinical trial registration ClinicalTrials.gov: NCT02950428.

Orthotopic branched endovascular aortic arch repair in patients who cannot undergo classical surgery

OBJECTIVES Our goal was to assess the results after orthotopic branched endovascular aortic arch repair using a new double-branch endoprosthesis in patients with thoracic aortic disease affecting the aortic arch who cannot undergo classical surgery. METHODS Within a 4-year period, 15 patients with thoracic aortic disease affecting the aortic arch were treated with the Bolton Relay plus double-branch endoprosthesis (Bolton Medical, Sunrise, FL, USA). We assessed clinical outcome, occurrence of endoleaks and the need for secondary interventions. The median logistic EuroSCORE I level was 13.6 (4.2; 22.8). RESULTS The in-hospital mortality rate was 6.7%. A disabling stroke was observed in 1 (6.7%) patient, whereas non-disabling strokes occurred in 2 (13.3%) patients. Type I and III endoleaks occurred in 6.7%. The median follow-up period was 263 (1st quartile 84; 2nd quartile 564) days. Four patients died during the follow-up period. Aortic-related survival was 100%. CONCLUSIONS Orthotopic branched endovascular aortic arch repair using the Bolton Relay Plus double-branch endoprosthesis is a safe and feasible technique enriching the armamentarium to treat patients with thoracic aortic disease who cannot undergo classical surgery. Aortic-related survival is excellent, and the occurrence of disabling stroke and endoleaks warranting treatment is low. Further studies are needed to assess the long-term durability of this new method.

Transatlantic editorial on transcatheter aortic valve replacement

From the Division of Cardiothoracic Surgery, Joseph B. Whitehead Department of Surgery, Emory University, Atlanta, Ga; Division of Cardiac Surgery, Department of Surgery, Columbia University, New York, NY; Department of Cardiology, Mayo Clinic, Rochester, Minn; Division of Cardiothoracic Surgery, Department of Surgery, Washington University; Department of Cardiology, University Hospital Santa Maria, University of Lisbon, Lisbon, Portugal; Department of Cardiac Surgery, Stanford University, Palo Alto, Calif; Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec; Department of Cardiac Surgery, Leipzig Heart Center, Leipzig; Clinic for Cardiac Surgery Karlsruhe; National Institute Health Research Cardiovascular Biomedical Research Unit, Royal Brompton Hospital and Harefield National Health Service Foundation Trust, London, United Kingdom; Department of Cardiovascular Surgery, Heart Centre Freiburg University, Freiburg, Germany; Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo; and Division of Cardiovascular Surgery, Peter Munk Cardiovascular Center, Toronto General Research Institute, Toronto General Hospital and the University of Toronto, Toronto, Ontario, Canada. Dr Beyersdorf is the Editor of the European Journal of Cardiothoracic Surgery. Dr Patterson is the Editor of Annals of Thoracic Surgery. Dr Weisel is Editor of the Journal of Thoracic and Cardiovascular Surgery. This article has been co-published with permission in The Journal of Thoracic and Cardiovascular Surgery, The Annals of Thoracic Surgery, and European Journal of Cardio-Thoracic Surgery. Received for publication Jan 12, 2017; revisions received March 10, 2017; accepted for publication March 11, 2017. Address for reprints: Vinod H. Thourani, MD, Emory Hospital Midtown, 550 Peachtree St, 6th Floor Medical Office Tower, Atlanta, GA 30308 (E-mail: vthoura@emory.edu). J Thorac Cardiovasc Surg 2017;154:7-21 0022-5223/

Anatomic feasibility of an endovascular valve–carrying conduit for the treatment of type A aortic dissection

36.00 Copyright 2017 Jointly between The American Association for Thoracic Surgery, the European Association for Cardio-Thoracic Surgery, and the Society for Thoracic Surgeons. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jtcvs.2017.03.047 The treatment of aortic stenosis is changing rapidly, and sharing ideas from across the Atlantic will help us provide the most optimal care for our patients.

Surgical Treatment of Native and Prosthetic Aortic Infection With Xenopericardial Tube Grafts

Objective: The study objective was to screen patients with acute type A aortic dissection for anatomic feasibility of ascending aortic endovascular treatment with a valve‐carrying conduit. Methods: High‐quality computed tomography scans of 167 patients were available for screening. Aortic dimensions were measured using multiplanar reconstruction in the plane perpendicular to the manually corrected aortic center line. The simulated stent‐graft 10‐mm–long landing zones were measured starting at the sinotubular junction (proximal landing zone) and ending at the brachiocephalic trunk (distal landing zone). Exclusion criterion was an entry within the aortic root or the landing zone. Results: In 113 patients (68%), the entry was in a coverable zone in the ascending aorta with sufficient proximal and distal landing zone or in more distal aortic segments. In these patients, the median distance between the proximal and distal landing zone was 89.1 (first quartile: 80.0 mm; third quartile: 101.2 mm) and the median diameter difference was 5.0 mm (2.0; 10.1) (12.3 [4.9; 23.0] %). The diameter difference was less than 2 mm in 32 patients (28%), between 6 mm and 10 mm in 20 patients (18%), between 10 mm and 14 mm in 11 patients (10%), and 14 mm or greater in 10 patients (9%). Conclusions: Two thirds of all patients who present with type A dissections are potential candidates for treatment with endovascular valve–carrying conduits, but most patients would require tapered stent‐grafts. Graphical abstract Figure. No caption available.

Balloon-expandable transapical transcatheter aortic valve implantation with or without predilation of the aortic valve: results of a multicentre registry

BACKGROUND The study sought to report our results of surgical treatment of native and prosthetic aortic infection with xenopericardial tube grafts from the ascending aorta to beyond the bifurcation. METHODS Within a 28-month period, 20 patients were treated with a bovine self-made pericardial tube graft to replace infected vascular grafts (after conventional surgical aortic replacement or endovascular stent graft implantation) or to treat a contaminated surgical site. An integrated standardized therapeutic concept was applied in all patients, consisting of complete removal of the infected prosthetic material, extensive debridement, and orthotopic vascular reconstruction with self-made tube grafts constructed from a bovine pericardial patch. RESULTS Four patients died perioperatively (20%) due to sepsis, pulmonary failure, or sudden circulatory arrest. The mean follow-up was 18 months (first quartile 2, third quartile 17 months). Interval computed tomography scans revealed 100% freedom from proven aortic reinfection, but reinfection cannot be ruled out in 4 patients who died of unknown causes during follow-up or because of ongoing sepsis. Three patients required aortic reintervention for a suture-line aneurysm, for graft occlusion, and for the development of a neoaortointestinal fistulation, respectively. CONCLUSIONS Patients with infectious aortic disease present in a frail state and the initial and the late mortality is substantial. Yet, surgical treatment of native and prosthetic aortic infection with xenopericardial tube grafts shows promising short-term results with regard to durability and freedom from reinfection in any aortic segment. Further studies are needed to learn of the long-term behavior of these grafts.

Impact of the type of transcatheter heart valve on the incidence of early subclinical leaflet thrombosis

OBJECTIVES To assess safety and efficacy of transapical transcatheter aortic valve implantation (TA-TAVI) in the absence of predilation using balloon aortic valvuloplasty (BAV). Predilation of the stenosed valve using BAV is a routine step in TA-TAVI; however, evidence supporting its clinical value is lacking, and several studies have linked it with higher complication rates. METHODS A prospective, two-armed, multicentre registry (EASE-IT TA) to gather data on patients undergoing TA-TAVI with or without BAV, using the Edwards SAPIEN 3 valve was designed. The primary evaluation criterion was a composite of all-cause mortality, non-fatal stroke, non-fatal myocardial infarction, acute kidney injury and pacemaker implantation [per Valve Academic Research Consortium-2 (VARC-2)] within 30 days after TAVI. RESULTS A total of 198 subjects underwent TA-TAVI, 61 with and 137 without BAV. Patient characteristics were comparable at baseline (mean ± SD: age 80.3 ± 5.7 years; logistic EuroSCORE 20.2 ± 12.6). Similar reductions in peak and mean transvalvular gradients were observed post-procedurally. There was a significant reduction of fluoroscopy time without BAV (4.7 vs 7.9 min; P = 0.039) and significantly decreased odds of catecholamine administration (17.5% vs 32.8%; P = 0.017). A decreased odds of the primary evaluation criterion in patients without BAV after 30 days (adjusted odds ratio 0.71; 95% confidence interval 0.34-1.82) and the same composite end-point after 6 months (adjusted odds ratio 0.74; 95% confidence interval 0.37-1.47) were not significant even after multivariable adjustment. CONCLUSIONS TA-TAVI without BAV appears to be at least equal to its conventional counterpart in terms of efficacy and may offer advantages in terms of safety. Thus, there appears to be little justification for maintaining the BAV step in TA-TAVI for many patients.

Transatlantic Editorial on Transcatheter Aortic Valve Replacement

OBJECTIVES The aim of this study was to investigate whether balloon-expandable and self-expandable transcatheter heart valves (THVs) differ in terms of the incidence of early subclinical leaflet thrombosis (LT). METHODS Electrocardiographic-gated cardiac dual-source computed tomography angiography was performed at a median of 5 days after transcatheter aortic valve implantation and assessed for evidence of LT. RESULTS Of the 629 consecutive patients, 538 (86%) received a balloon-expandable THV and 91 (14%) a self-expandable THV. LT was documented in 77 (14%) patients with a balloon-expandable valve and in 16 (18%) with a self-expandable valve (P = 0.42). Similarly, LT was not significantly related to THV size (P = 0.62). Corresponding to a lower rate of atrial fibrillation in the group with LT [25 (27%) vs 222 (41%), P = 0.01], anticoagulation at the time of computed tomography angiography was less frequent in this group [21 (23%) vs 183 (34%), P = 0.03]. Among the other potentially relevant covariables, there was no significant difference in the clinical baseline and the procedural characteristics between patients with and without LT (age 82 ± 6 years vs 82 ± 6 years, P = 0.51; ejection fraction 49 ± 10% vs 50 ± 10%, P = 0.47). In multivariate logistic regression analysis, including potentially relevant covariables, valve type was not significantly associated with LT (P = 0.36). In the univariate and multivariate analyses, only the lack of anticoagulation at the time of computed tomography angiography was predictive of thrombus formation [0.563 (0.335-0.944), P = 0.03; 0.576 (0.343-0.970), P = 0.04]. CONCLUSIONS In this large retrospective study of 629 patients, the type and the size of THV was not predictive of early LT.

Endovascular treatment of acute Type A aortic dissection—the Endo Bentall approach

From the Division of Cardiothoracic Surgery, Joseph B. Whitehead Department of Surgery, Emory University, Atlanta, Ga; Division of Cardiac Surgery, Department of Surgery, Columbia University, New York, NY; Department of Cardiology, Mayo Clinic, Rochester, Minn; Division of Cardiothoracic Surgery, Department of Surgery, Washington University; Department of Cardiology, University Hospital Santa Maria, University of Lisbon, Lisbon, Portugal; Department of Cardiac Surgery, Stanford University, Palo Alto, Calif; Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec; Department of Cardiac Surgery, Leipzig Heart Center, Leipzig; Clinic for Cardiac Surgery Karlsruhe; National Institute Health Research Cardiovascular Biomedical Research Unit, Royal Brompton Hospital and Harefield National Health Service Foundation Trust, London, United Kingdom; Department of Cardiovascular Surgery, Heart Centre Freiburg University, Freiburg, Germany; Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo; and Division of Cardiovascular Surgery, Peter Munk Cardiovascular Center, Toronto General Research Institute, Toronto General Hospital and the University of Toronto, Toronto, Ontario, Canada. Dr Beyersdorf is the Editor of the European Journal of Cardiothoracic Surgery. Dr Patterson is the Editor of Annals of Thoracic Surgery. Dr Weisel is Editor of the Journal of Thoracic and Cardiovascular Surgery. This article has been co-published with permission in The Journal of Thoracic and Cardiovascular Surgery, The Annals of Thoracic Surgery, and European Journal of Cardio-Thoracic Surgery. Received for publication Jan 12, 2017; revisions received March 10, 2017; accepted for publication March 11, 2017. Address for reprints: Vinod H. Thourani, MD, Emory Hospital Midtown, 550 Peachtree St, 6th Floor Medical Office Tower, Atlanta, GA 30308 (E-mail: vthoura@emory.edu). J Thorac Cardiovasc Surg 2017;154:7-21 0022-5223/