Sharaf-Eldin Shehada

Propensity score analysis of outcomes following minimal access versus conventional aortic valve replacement

OBJECTIVESnMinimal access aortic valve replacement has become routine in many institutions. Aim of this study was to compare the clinical outcomes between conventional and minimal access aortic valve replacement.nnnMETHODSnWe retrospectively analysed the data of 2103 patients who underwent primary, isolated aortic valve replacement (AVR) in our institution between January 2001 and May 2012 with a minimal access AVR (MAAVR) via the upper partial ministernotomy approach (n = 936) or conventional AVR (CAVR) via the full sternotomy approach (n = 1167). After propensity score matching considering potential confounders [age, sex (female), weight, height, preoperative serum creatinine level, previous myocardial infarction, LV-EF and aortic valve pathology (isolated AS)], 585 matched patients were included in each group.nnnRESULTSnMean age (65 ± 10.5 vs 65.7 ± 11.5 years, P = 0.23), gender (females 37.2%, P = 0.9), aortic cross-clamp time (65.6 ± 18.4 vs 64.3 ± 19.8 min, P = 0.25) and postoperative blood loss [median (IQR) 400 (224-683) vs 400 (250-610) ml, P = 0.83) were similar in MAAVR and CAVR group. Thirty-day mortality was also not significantly different (1.5 vs 1.7%, P = 0.74, respectively). In contrast, CPB times were significantly longer in MAAVR (93.5 ± 25 vs 88 ± 28 min, P < 0.001). Intraoperative and postoperative autologous blood transfusions were significantly lower in MAAVR (927.2 ± 425.6 vs 1036.4 ± 599.6 ml, P < 0.001 and 170.2 ± 47.6 vs 243.5 ± 89.3 ml, P < 0.001, respectively). Intubation time was significantly shorter in MAAVR [median (IQR) 7 (5-11) vs 8 (6-14) h, P = 0.01). The incidence of renal insufficiency (creatinine ≥1.5 mg/dl) and respiratory insufficiency (need for non-invasive ventilation, reintubation or tracheotomy) was significantly lower in MAAVR (9 vs 16%, P < 0.001 and 8.5 vs 11.8%, P = 0.03, respectively).nnnCONCLUSIONSnIn comparison with CAVR, our study shows that MAAVR is a safe and effective procedure associated with low mortality rate and good long-term survival rates. In addition to that, MAAVR was associated with shorter ventilation times, lower rate of autologous blood transfusion, as well as a lower rate of postoperative respiratory and renal insufficiency. Because of the superior cosmetic results, we therefore advocate MAAVR as the procedure of choice for primary isolated AVR.

Minimal access versus conventional aortic valve replacement: a meta-analysis of propensity-matched studies

Conventional aortic valve replacement (CAVR) via a full sternotomy is the standard surgical approach for aortic valve replacement. Minimal access aortic valve replacement (MAAVR) is commonly performed via a partial sternotomy and a right minithoracotomy. Such procedures aim not only to reduce the invasiveness but to offer the same quality, safety and results of the conventional approach. Our goal was to compare both procedures by performing a meta-analysis of reports with risk adjustment that performed a propensity-matched analysis. Relevant articles were searched for in Medline, the Cochrane Database of Systematic Reviews and the Scopus database based on predefined criteria and end-points. The early and late outcomes and complications were compared in the selected studies. A total of 4558 patients from 9 studies were enrolled; 2279 (50%) underwent CAVR and 2279 (50%) underwent MAAVR. There was a significantly lower rate of postoperative low output syndrome (1.4% vs 2.3%, Pu2009=u20090.05) and atrial fibrillation (11.7% vs 15.9%, Pu2009=u20090.01) in the MAAVR than in the CAVR group, respectively. In contrast, aortic cross-clamp and cardiopulmonary bypass times were significantly longer in the MAAVR group (Pu2009<u20090.05). Finally, the incidence of early deaths (1.5% vs 2.2%, Pu2009=u20090.14), stroke (1.4% vs 2%, Pu2009=u20090.20), myocardial infarction (0.4% vs 0.5%, Pu2009=u20090.65), renal injury (4.5% vs 6%, Pu2009=u20090.71), respiratory complications (9% vs 10.1%, Pu2009=u20090.45), re-exploration for bleeding (4.9% vs 4.1%, Pu2009=u20090.27) and pacemaker implantation (3.3% vs 4.1%, Pu2009=u20090.31) was similar in both groups, respectively. In summary, even though MAAVR procedure, either through partial sternotomy or right minithoracotomy, provides patient satisfaction due to the smaller incision and better cosmetics, MAAVR is as safe as the CAVR procedure. Although MAAVR takes slightly longer, it was not associated with greater cardiopulmonary bypass-related adverse effects. Interestingly, MAAVR shows a lower incidence of low cardiac output syndrome and atrial fibrillation.

David Procedure—Reconstruction of the Native Insufficient Valve

Abstract Aortic valve (AV)–sparing procedures were devolved and rapidly improved the morbidity of patients suffering from aortic aneurysm of either the aortic root or the ascending aorta and in cases of AV regurgitation. Reimplantation of the AV and remodeling of the aortic root are the known types of AV-sparing procedures. The aim of this chapter is to describe the reimplantation of AV during valve-sparing procedure. The key point of a successful procedure with a long-term stability of the valve is usually attributed to choosing the appropriate prosthesis size and the accuracy of the reimplantation technique. The new technique modification describes the reimplantation of a normal tricuspid valve, AV with prolapsed cusp(s), and cases of bicuspid valve with pitfalls of reimplantation.

Infections after transcatheter versus surgical aortic valve replacement: mid-term results of 200 consecutive patients

BackgroundnTranscatheter aortic valve implantation (TAVI) is the standard therapy for high-risk patients with aortic stenosis (AS). TAVI-outcomes are widely investigated in comparison to surgical aortic valve replacement (SAVR), but less is known about infectious complications after TAVI. We aimed to compare early and mid-term infectious outcomes of patients undergoing TAVI or SAVR.nnnMethodsnThe present study is a prospective single-centre study including 200 consecutive patients between 06/2014-03/2015 undergoing TAVI (either transfemoral or transapical and transaortic, n=47+53=100) or SAVR (either isolated or concomitant with CABG, n=52+48=100). The mean age and log. EuroSCORE were significantly different between both groups (81±6 versus 69±11 years, P<0.001 and 23.1%±13.8% versus 8.7%±9.5%, P<0.001). Primary endpoints included wound healing disorders, respiratory and urinary tract infections and incidence of endocarditis or sepsis within hospital stay. Secondary endpoints included infectious parameters, infectious related rehospitalisation and 2-year mortality.nnnResultsnPrimary endpoints showed no difference in overall TAVI- versus SAVR-groups regarding respiratory- (14% versus 19%, P=0.45), urinary-tract (7% versus 4%, P=0.54) infections, sepsis (5% versus 6%, P=1.0), endocarditis (0% versus 1%, P=1.0) or 30-day mortality (10% versus 4%, P=0.09), except for wound disorders, which were significantly lower in the TAVI-group (1% versus 8%, P=0.035), respectively. Secondary endpoints reported no difference regarding infectious related rehospitalisation (4% versus 4%, P=1.0), but significantly higher 2-year mortality (28% versus 16%, P=0.048) in the TAVI-group.nnnConclusionsnSo far, little has been studied about infectious complications after TAVI. This study reports no difference between the overall TAVI and SAVR groups regarding infectious complications. However, SAVR group show more wound healing disorders but less mortality than TAVI group.

Endoscopy in aortic valve repair: does it worth it?

BackgroundnAortic valve repair (AVR) is a technically challenging procedure. Usually, the repaired valve is checked after weaning from cardiopulmonary bypass (CPB). We aimed to evaluate intraoperative and clinical outcomes of AVR patients in whom intraoperative aortic root endoscopy was applied.nnnMethodsnThe present study was a retrospective single-center study. An autoclavable video-scope was used to evaluate aortic valve. During endoscopy, crystalloid cardioplegia was administered to pressurize the aortic root. Primary endpoints were: need for Re-CPB after weaning from bypass and early postoperative aortic valve regurgitation. Secondary endpoints included: 30-day mortality and freedom from aortic regurgitation/reoperation during follow-up.nnnResultsnA total of 66 consecutive patients who underwent AVR (05/2014-03/2017) were evaluated. Patients mean age was 53.5±14.5 years and 74.2% were male. Seventy-three percent of the patients were in New York Heart Association (NYHA) functional class III/IV. The main underlying aortic valve pathology was aortic valve regurgitation in 83.3%, 9.1% aortic stenosis and combination of both in 7.6%. A tricuspid or bicuspid aortic valve was observed in 48.5% and 43.9%, respectively, whereas 7.6% showed a functional unicuspid aortic valve. Intraoperative results revealed endoscopy as a helpful tool, where second time cross-clamp was avoided in most (58, 87.9%) of patients. Thirty-day mortality was 3.0%. During follow-up (28±10 months), 2 patients required re-operation due to recurrent aortic valve regurgitation.nnnConclusionsnThe present analysis showed, that intraoperative aortic valve endoscopy is a helpful tool to evaluate AVR before weaning from bypass. This easy-to-use tool gives real-time information about the intraoperative result and might provide additional guidance to achieve optimal results after AVR.

Aortic valve construction using pericardial tissue: short-term single-centre outcomes†

OBJECTIVESnAortic valve construction using pericardial tissue has been known since the late 1960s. The procedure was re-introduced by Ozaki in 2010 and is currently used to treat specific aortic valve diseases. The exact sizing of the neo-cusps and the insertion of the commissures remain the keys to success when performing this procedure. We evaluated our experience using modified custom-made templates.nnnMETHODSnIn this prospective single-centre study, we evaluated 52 consecutive patients who underwent aortic valve construction between September 2015 and March 2017 using either autologous (16 patients, 30.8%) or tissue-engineered pericardium (36 patients, 69.2%). Most patients (34, 65.4%) presented with aortic stenosis or endocarditis (5, 9.6%). Twenty patients had bicuspid and 5 had unicuspid valves. A modified sizing technique with specially designed templates was used. The primary end point was early death; the secondary end points were major adverse cardiac and cerebrovascular events, freedom from reoperation and overall mortality rate. Echocardiographic follow-up was performed intraoperatively and at 12-month intervals.nnnRESULTSnThe mean age was 60u2009±u200914u2009years; 63.5% were men; and 34 (65.4%) patients had combined procedures. The mean cross-clamp time was 99u2009±u200917u2009min. Early outcomes included 1 stroke, 2 patients needing short-term dialysis and 1 death. During follow-up (mean 11.2u2009±u20094.8u2009months), trace aortic regurgitation was observed in 4 patients; the mean pressure gradient was 6.8u2009±u20092.9u2009mmHg. Three patients died later (of non-cardiac reasons), and 5 patients needed reoperation due to endocarditis.nnnCONCLUSIONSnAortic valve construction using pericardial tissue could be an alternative in middle-age patients presenting with aortic valve disease in whom valve repair was not possible. The newly designed templates allow exact sizing of the neo-cusps and optimal commissure implantation; however, long-term follow-up in a larger cohort is warranted to assess the durability of the neo-valves.

Emergent surgical removal of a migrated left atrial appendage occluder

Occlusion of the left atrial appendage (LAA) in patients with atrial fibrillation has become a standard therapy to prevent thromboembolic complications. We aim to present 3 cases of LAA occluder embolization after percutaneous WATCHMAN™ device implantation, which required emergent surgical retrieval. The device was dislocated in the left atrium, introducing LAA perforation and resulting in pericardial effusion and later tamponade in 1 patient who developed multiorgan failure and died 8u2009days postoperatively. Other patients were successfully operated and discharged. Hence, LAA occluder embolization may occur asymptomatically with immediate/late serious complications, which indicates emergent surgery.

Feasibility and safety of combined percutaneous coronary intervention among high-risk patients with severe aortic stenosis undergoing transcatheter aortic valve implantation: a systematic review and meta-analysis

OBJECTIVESnRecent reports indicated that percutaneous coronary intervention (PCI) may be correlated with increased mortality in patients undergoing transcatheter aortic valve implantation (TAVI). Therefore, we performed a meta-analysis to determine the feasibility and safety of combined PCI in high-risk patients with severe aortic stenosis undergoing TAVI.nnnMETHODSnA comprehensive literature search was performed using PubMed, Embase and the Cochrane Central Register of Controlled trials through June 2016.nnnRESULTSnFive clinical trials including 1634 patients were identified. The pooled analysis revealed no significant differences in 30-day all-cause mortality [odds ratio (OR) 1.25, 95% confidence interval (CI) 0.52-3.05; Pu2009=u20090.62], 30-day cardiovascular mortality rate (OR 1.59, 95% CI 0.52-4.88; Pu2009=u20090.41) and 1-year mortality rate (OR 1.16, 95% CI 0.85-1.59; Pu2009=u20090.34) among the patients assigned to TAVI and those undergoing TAVI+PCI. The incidence of myocardial infarction (OR 2.96, 95% CI 1.03-8.45; Pu2009=u20090.04) was slightly higher in the TAVI+PCI group. Other complications, such as stroke, kidney injury, bleeding and vascular complications, were not significantly increased in the TAVI+PCI group. Patients treated with a staged procedure of TAVI and PCI but not simultaneous TAVI+PCI showed higher 30-day all-cause mortality as compared to those undergoing isolated TAVI.nnnCONCLUSIONSnCombined TAVI+PCI showed similar rates of death from any cause at 30u2009days and 1u2009year as compared to isolated TAVI. Except for myocardial infarction, the rate of operative complications in the TAVI+PCI group was not detrimental as compared to the isolated TAVI group. The simultaneous treatment of significant coronary artery lesions may be preferred in selected patients undergoing TAVI.

Transcatheter versus Surgical Aortic Valve Replacement after Previous Cardiac Surgery: A Systematic Review and Meta-Analysis

Aim Aortic valve replacement (AVR) in patients with prior cardiac surgery might be challenging. Transcatheter aortic valve replacement (TAVR) offers a promising alternative in such patients. We therefore aimed at comparing the outcomes of patients with aortic valve diseases undergoing TAVR versus those undergoing surgical AVR (SAVR) after previous cardiac surgery. Methods and Results MEDLINE, EMBASE, and the Cochrane Central Register were searched. Seven relevant studies were identified, published between 01/2011 and 12/2015, enrolling a total of 1148 patients with prior cardiac surgery (97.6% prior CABG): 49.2% underwent TAVR, whereas 50.8% underwent SAVR. Incidence of stroke (3.8 versus 7.9%, p=0.04) and major bleeding (8.3 versus 15.3%, p=0.04) was significantly lower in the TAVR group. Incidence of mild/severe paravalvular leakage (14.4/10.9 versus 0%, p < 0.0001) and pacemaker implantation (11.3 versus 3.9%, p=0.01) was significantly higher in the TAVR group. There were no significant differences in the incidence of acute kidney injury (9.7 versus 8.7%, p=0.99), major adverse cardiovascular events (8.7 versus 12.3%, p=0.21), 30-day mortality (5.1 versus 5.5%, p=0.7), or 1-year mortality (11.6 versus 11.8%, p=0.97) between the TAVR and SAVR group. Conclusions TAVR as a redo procedure offers a safe alternative for patients presenting with aortic valve diseases after previous cardiac surgery especially those with prior CABG.

The Fluid Dynamical Performance of the Carpentier-Edwards PERIMOUNT Magna Ease Prosthesis

The aim of the present in vitro study was the evaluation of the fluid dynamical performance of the Carpentier-Edwards PERIMOUNT Magna Ease depending on the prosthetic size (21, 23, and 25u2009mm) and the cardiac output (3.6–6.4u2009L/min). A self-constructed flow channel in combination with particle image velocimetry (PIV) enabled precise results with high reproducibility, focus on maximal and local peek velocities, strain, and velocity gradients. These flow parameters allow insights into the generation of forces that act on blood cells and the aortic wall. The results showed that the 21 and 23u2009mm valves have a quite similar performance. Maximal velocities were 3.03 ± 0.1 and 2.87 ± 0.13u2009m/s; maximal strain Exx, 913.81 ± 173.25 and 896.15 ± 88.16u20091/s; maximal velocity gradient Eyx, 1203.14 ± 221.84u20091/s and 1200.81 ± 61.83u20091/s. The 25u2009mm size revealed significantly lower values: maximal velocity, 2.47 ± 0.15u2009m/s; maximal strain Exx, 592.98 ± 155.80u20091/s; maximal velocity gradient Eyx, 823.71 ± 38.64u20091/s. In summary, the 25u2009mm Magna Ease was able to create a wider, more homogenous flow with lower peak velocities especially for higher flow rates. Despite the wider flow, the velocity values close to the aortic walls did not exceed the level of the smaller valves.