Pierre-Yves Etienne

Transaortic transcatheter aortic valve implantation with the Edwards Sapien valve: Feasibility, technical considerations, and clinical advantages

The randomized Partner study [1] has recently shown superiority of transfemoral transcatheter aortic valve implantation, in patients who are not candidates for surgical aortic valve replacement, when compared with conventional nonsurgical therapies. In patients who are not candidates for the transfemoral approach because of peripheral vascular disease or other contraindications, deployment of the SAPIEN valve (Edwards Lifesciences, Irvine, CA) in an antegrade fashion can be achieved through the apex of the left ventricle. However this valuable technique carries specific risks inherent to the access route. Transaortic implantation, through an upper ministernotomy, offers a new alternative that could avoid complications related to the transapical approach.

Free internal mammary artery graft in myocardial revascularization.

Between August 1986 and March 1993, 124 patients (102 men; mean age of 59 years) underwent myocardial revascularization with the use of at least one free internal mammary artery (FIMA). This group represents 4.5% of the 2725 coronary bypasses performed during the same period. Seventy-six patients (61%) had suffered from at least one previous myocardial infarction. Forty-five patients (36%) had unstable angina; three-vessel disease was found in 100 cases (80.5%) and a left ventricular ejection fraction lower than 0.4 in 22 (17.7%). There were 18 (14.5%) redo procedures and 90 (72.5%) bilateral internal mammary artery (IMA) grafts. The reasons for using a FIMA were: too short an internal mammary artery pedicle in 83 patients, IMA injury at harvesting in 30 patients and post-bypass ischaemia in areas grafted with pedicled IMA (PIMA) in 11 patients. Cardiopulmonary bypass, moderate hypothermia (30 degrees C) and crystalloid anterograde and retrograde cardioplegia were used in all cases. Sixty-seven FIMA grafts were anastomosed directly to the ascending aorta; 57 were sutured via a saphenous hood using a running suture of polypropylene 7/0 and three were anastomosed end-to-end to a PIMA graft. FIMA grafts were directed to the left anterior descending (34%), the circumflex (37%) and the right coronary artery (29%). In total, 179 anastomoses were constructed using 127 FIMA, 136 using PIMA and 158 using saphenous veins (3.8 anastomoses per patient). Hospital mortality and postoperative myocardial infarction rates were 5.6% (seven patients) and 3.2% (four patients), respectively. Cardiac-related mortality was 3.2% (four patients); three of these four patients had been operated on for evolving infarction and one underwent a redo procedure. Four of the 117 survivors died later on; in two, it was cardiac-related and a result of global heart failure at 9 and 12 months. Of the 113 remaining patients, 106 are symptom free after a mean follow-up of 28.2 (range 3-84) months. Fifty-nine patients (50.4%) were restudied by angiography at a mean interval of 15 months. Patency rates of FIMA anastomosed either directly to the aorta or via a saphenous hood were 82.8 or 89.7%, respectively. Patency rates of FIMA directed to the left anterior descending, the circumflex and the right coronary artery were 85.7, 88 and 83.3%, respectively. Global FIMA patency was 86.4%, while global PIMA patency was 100%. The FIMA mid-term patency rates compare unfavourably with those of PIMA: FIMA should therefore be restricted to the cases where PIMA or other pedicled arterial grafts are unavailable.

Preservation of the pulmonary autograft after failure of the Ross procedure

OBJECTIVE Failure of the pulmonary autograft following the Ross Procedure is mainly due to dilatation and/or cusp prolapse causing insufficiency. We analysed the result of pulmonary autograft valve sparing and repair, using techniques developed for native aortic root and valve. METHODS Of a total of 275 patients who underwent Ross operation between 1991 and 2009, 31 needed autograft re-operation. Of the 28 patients re-operated in our centre, 26 (93%) had autograft valve preservation and they represent the study cohort. At the initial Ross procedure, root remplacement technique was performed in 20 patients and autograft inclusion technique was performed in 6. Mean redo interval was 9.3 + or - 3.5 years and mean age at redo was 44 + or - 13 years. Indications for re-operations were neo-aorta dilatation (n=12; 46%), autograft insufficiency (n=4; 15%) and dilatation with autograft insufficiency (n=10; 40%). Neo-aorta dilatation was repaired using valve-sparing root replacement (n=12, 46%) or ascending aorta replacement (n=10; 40%). Cusp prolapse was repaired by commissural re-suspension (n=1), free margin plication (n=10) or re-suspension with polytetrafluoroethylene (PTFE; n=6). Cusp repair was performed in isolation (n=4) or in association with sparing (n=5) or ascending aorta replacement (n=4). RESULTS There was no in-hospital mortality. Two patients having undergone isolated cusp repair needed valve replacement for recurrent insufficiency after 5 days and 8 years postoperatively. At follow-up (100% complete, median: 27 months) all patients were alive, in New York Heart Association (NYHA) class I (n=22; 84%) or II (n=4; 16%). No autograft regurgitation was present in nine patients (five sparing and four ascending aorta replacement); grade I insufficiency was present in 11 (six sparing and five ascending aorta replacement), grade 2 in two (one sparing and one isolated cusp repair) and grade 3 in two (one ascending aorta replacement and one isolated cusp repair). At 3 years, overall freedom from autograft insufficiency > or = grade 3 was 80%. CONCLUSION Preservation of the pulmonary autograft valve can be safely performed in selected patients. At midterm, repair of neo-aorta dilatation using valve-sparing root replacement or ascending aorta replacement showed acceptable results. In contrast, results of cusp repair for isolated autograft insufficiency were unsatisfactory.

Embol-X intraaortic filter and transaortic approach for improved cerebral protection in transcatheter aortic valve implantation.

Techniques for transcatheter aortic valve implantation involve manipulation of the native aortic valve and the aortic arch. As a result, excellent technical outcomes of this technique remain counterbalanced by a level of neurologic complications that remain unacceptably high. We present here a report of a new potential combined approach to reduce periprocedural neurologic events. After a 6-cm J-shaped upper-mini-sternotomy, 26-mm Sapien valve (Edwards Lifesciences, Irvine, CA) was deployed through a transaortic approach. In addition, the Embol-X device (Edwards Lifescience) was directly inserted in the distal ascending aorta was deployed during all the procedure. Postoperative evolution was clinically uneventful. Postoperative magnetic resonance imaging revealed no new ischemic lesions in this first patient.

Bilateral internal mammary artery Y construct with multiple sequential grafting improves survival compared to bilateral internal mammary artery with additional vein grafts: 10-year experience at 2 different institutions

OBJECTIVES Utilization of bilateral internal mammary arteries (BIMAs) has been shown to improve long-term outcomes in patients undergoing coronary artery bypass grafting. To achieve complete revascularization, BIMAs may be used as either sole conduits for revascularization through a Y-graft configuration (BIMA-Y) or deployed with additional grafts used in conjunction with BIMAs. The purpose of this study was to compare the long-term outcomes of two institutions that predominantly used either the BIMA-Y configuration or BIMA plus additional grafts to achieve optimal revascularization. METHODS From 1 January 2000 to 31 December 2010, 436 patients were revascularized using a non-sequential BIMA grafting at one institution (Group A), with veins being used for additional targets. At the second institution (Group B), 771 patients were revascularized using a BIMA-Y graft for all distal targets. Kaplan–Meier analysis was used to compare unadjusted survival between the groups. Cox proportional hazards regression modelling was used to provide an adjusted comparison of survival between the groups. RESULTS There was no statistically significant difference between the average number of anastomotic sites used in Group A and Group B (A = 4.0 ± 0.7 vs B = 4.0 ± 0.7; P = 0.24). Group A did not have a significantly greater in-hospital mortality (0.7% vs 1.0% P = 0.39), stroke (0.5% vs 0.8% P = 0.40), deep sternal wound infection (0.0% vs 0.6% P = 0.11) or reoperation for bleeding (1.6% vs 0.6% P = 0.10) than Group B. Cox proportional hazards analyses demonstrated that at 14 years, Group B had a significantly improved survival compared to Group A (Group B = 88% vs Group A = 81%) with an overall reduction in mortality (adjusted hazard ratio 0.780, 95% confidence interval 0.448–0.849; P = 0.043). CONCLUSION Utilization of the BIMA-Y configuration was associated with improved survival when compared to BIMA grafting with additional vein grafts. Further studies are necessary to evaluate the efficacy of BIMA-Y grafting against other means of providing complete arterial revascularization.

Transcatheter resection of the native aortic valve prior to endovalve implantation - A rational approach to reduce TAVI-induced complications.

Complications due to compression of diseased native aortic leaflets between the endovalve and the aortic wall after transcatheter aortic valve implantation (TAVI) have been well described. Four factors have encouraged the evaluation of TAVI in lower-risk populations with aortic stenosis: rapid improvements in TAVI technology, increasing experience in recent years, the encouraging results obtained in multi-center registries and, most importantly, the results from the high-risk cohort of the PARTNER trial. Indeed, some preliminary results of TAVI in intermediate-risk patients with severe aortic stenosis have been promising (1). There are already reports of TAVI in low-risk patient series. Lange (2) reported a series of 420 patients who underwent TAVI using the CoreValve (Medtronic, Inc., Minneapolis, Minnesota) or Edwards SAPIEN (Edwards Lifesciences, Irvine, California) valve. Patients undergoing TAVI in the first quartile had significantly higher logistic EuroSCORES than those in the second, third, or fourth quartiles (Q1: 25.4±16% vs. Q2: 18.8±10% vs. Q3: 18.3±11% vs. Q4: 17.8±12%, analysis of variance P<0.001). There were no significant differences in mortality rate observed between Q1 and Q4 after adjustment for baseline characteristics at 30-day and 6-month follow-up (30-day mortality rate adjusted HR: 0.29; 95% CI: 0.08 to 1.08; P=0.07; 6-month adjusted mortality rate HR: 0.67; 95% CI: 0.25 to 1.77; P=0.42). They conclude that the results of the study demonstrate an important paradigm shift toward the selection of lower surgical risk patients for TAVI. Significantly better clinical outcomes can be expected in lower than in higher surgical risk patients undergoing TAVI. As TAVI becomes more routine widely available, operators may be tempted to implant the device in younger patients with fewer comorbidities. In this paper we will demonstrate the necessity of resecting the native aortic valve prior to TAVI especially in young, low-risk patients. In particular, we will focus on known complications of TAVI and how native aortic valve resection may decrease the occurrence of these complications.

Exclusive Percutaneous Approach for Surgical Transaortic Transcatheter Valve Replacement

Direct transaortic implantation (TAo) has been described as a new alternative approach for transcatheter aortic valve implantation in patients with unsuitable transfemoral access. TAo is usually achieved through an upper ministernotomy or, more recently, through a right thoracotomy in the second intercostal space. We describe here our first experience with a fully thoracoscopic approach that allowed successful deployment of a 23-mm Edwards SAPIEN valve.