Vadim Moustafine

A Randomized Multicenter Trial of Minimally Invasive Rapid Deployment Versus Conventional Full Sternotomy Aortic Valve Replacement

BACKGROUND Minimally invasive surgical procedures (MIS) may offer several advantages over conventional full sternotomy (FS) aortic valve replacement (AVR). A novel class of aortic valve prostheses has been developed for rapid-deployment AVR (RDAVR). We report a randomized, multicenter trial comparing the outcomes for MIS-RDAVR with those of conventional FS-AVR. METHODS A total of 100 patients with aortic stenosis were enrolled in a prospective, multicenter, randomized comparison trial (CADENCE-MIS). Exclusion criteria included ejection fraction below 25%, AVR requiring concomitant procedures, and recent myocardial infarction or stroke. Patients were randomized to undergo MIS-RDAVR through an upper hemisternotomy (n = 51) or AVR by FS with a conventional stented bioprosthesis (n = 49). Three patients were excluded before the procedure, and 3 more patients who were randomized to undergo RDAVR were excluded because of their anatomy. Procedural, early clinical outcomes, and functional outcomes were assessed for the remaining 94 patients. Hemodynamic performance was assessed by an echocardiography core laboratory. RESULTS Implanted valve sizes were similar between groups (22.9 ± 2.1 vs 23.0 ± 2.1 mm, p = 0.9). MIS-RDAVR was associated with significantly reduced aortic cross-clamp times compared with FS-AVR (41.3 ± 20.3 vs 54.0 ± 20.3 minutes, p < 0.001), although cardiopulmonary bypass times were similar (68.8 ± 29.0 vs 74.4 ± 28.4 minutes, p = 0.21). Early clinical outcomes were similar between the two groups, including quality of life measures. The RDAVR patients had a significantly lower mean transvalvular gradient (8.5 vs 10.3 mm Hg, p = 0.044) and a lower prevalence of patient-prosthesis mismatch (0% vs 15.0%, p = 0.013) 3 months postoperatively compared with the FS-AVR patients. CONCLUSIONS RDAVR by the MIS approach is associated with significantly reduced myocardial ischemic time and better valvular hemodynamic function than FS-AVR with a conventional stented bioprosthesis. Rapid deployment valves may facilitate the performance of MIS-AVR.

State of the art in neuroprotection during acute type A aortic dissection repair

Temporary (TND) or permanent neurologic dysfunctions (PND) represent the main neurological complications following acute aortic dissection repair. The aim of our experimental and clinical research was the improvement and update of the most common neuroprotective strategies which are in present use. Hypothermic circulatory arrest (HCA): Cerebral metabolic suppression at the clinically most used temperatures (18-22°C) is less complete than had been assumed previously. If used as a ‘stand-alone’ neuroprotective strategy, cooling to 15-20°C with a jugular SO2 ≥ 95% is needed to provide sufficient metabolic suppression. Regardless of the depth of cooling, the HCA interval should not exceed 25 min. After 40 min of HCA, the incidence of TND and PND increases, after 60 min, the mortality rate increases. Antegrade selective cerebral perfusion (ASCP): At moderate hypothermia (25-28°C), ASCP should be performed at a pump flow rate of 10ml/kg/min, targeting a cerebral perfusion pressure of 50-60mmHg. Experimental data revealed that these conditions offer an optimal regional blood flow in the cortex (80±27ml/min/100g), the cerebellum (77±32ml/min/100g), the pons (89±5ml/min/100g) and the hippocampus (55±16ml/min/100g) for 25 minutes. If prolonged, does ASCP at 32°C provide the same neuroprotective effect? Cannulation strategy: Direct axillary artery cannulation ensures the advantage of performing both systemic cooling and ASCP through the same cannula, preventing additional manipulation with the attendant embolic risk. An additional cannulation of the left carotid artery ensures a bi-hemispheric perfusion, with a neurologic outcome of only 6% TND and 1% PND. Neuromonitoring: Near-infrared spectroscopy and evoked potentials may prove the effectiveness of the neuroprotective strategy used, especially if the trend goes to less radical cooling. Conclusion: A short interval of HCA (5 min) followed by a more extended period of ASCP (25 min) at moderate hypothermia (28°C), with a pump flow rate of 10ml/kg/min and a cerebral perfusion pressure of 50 mmHg, represents safe conditions for open arch surgery.

Simultaneous Double Valve-in-Valve TAVI Procedure for Failed Bioprostheses

A 78-year-old female patient who had undergone double valve replacement in 2010 presented in 2014 with severe New York Heart Association grade IV dyspnea. The decision was made to perform a transapical valve-in-valve transcatheter aortic valve implantation (TAVI) procedure in the mitral and aortic positions simultaneously. The postoperative course was uneventful, and the patient was extubated 6 hours after the TAVI procedure.

Minimally Invasive Aortic Root Surgery: Mid-term Results in a 2-year Follow-up

Objectives: Minimally Invasive Surgery (MIS) through Partial Upper Sternotomy (PUS) for aortic root surgery represents an alternative to the Full Median Sternotomy (FMS). PUS offers less operative trauma which improves the postoperative outcome. Nevertheless, the PUS requires a demanding surgical technique, with longer operation times, offering a reduced surgical field. We analyzed the mid-term outcome of our patients who underwent either root replacement (Bentall) or aortic root sparing valve reconstruction (David) via PUS to evaluate the safety of this access. Methods: Between 11/2011-04/2017, a total of 47 consecutive patients underwent aortic root surgery with aortic aneurysm and/or localized aortic dissection through Bentall or David operation through a J-shaped PUS (33 males, 14 females, and mean Age 57.9 ± 10.5 years). Bentall operation was performed in 36 patients (77%), whereas 11 patients (23%) received a David procedure. Endpoints were procedure related complications, the 30-day and 2-year mortality, the need for re-do surgery and occurrence of MACCE in a 2-year follow-up. Postoperative patient’s contentment analysis was performed using a questionnaire regarding the post-operative life quality, the satisfaction with the cosmetic result and the approach preference (PUS vs. FUS) for a potential following aortic surgery. Results: In all patients a J-shaped sternotomy was applied. Respectively, mean operation time was 287.3 ± 72.6 minutes, mean cardiopulmonary bypass (CPB) time 174 ± 54.8 min, mean cross-clamp time 133 ± 33.1 min. Re-thoracotomy due to postoperative bleeding was needed in six patients (13%). Superficial wound healing disturbance was observed in one patient (8%) and no deep sternal infection or sternum instability occurred. Hospitalization time was 11.8 ± 4.4 days, mean ICU-stay 1.9 ± 1.3 days with a ventilation-time of 11.3 ± 5.8 h. During the first 30 postoperative days no MACCE occurred and the mortality rate was 0%. After 2 years the total rate of Mortality, occurrence of MACCE, and need for re-do surgery was as follow (6.3%, 4.2%, and 4.2%). 6 month after surgery 67% of the patients declared to have a better life quality and performance, 93% to be satisfied with the cosmetic result and 92% stated that they would prefer the PUS for a potential future aortic surgery. Conclusion: Minimally invasive surgery of aortic root through partial upper sternotomy is a safe alternative to the full median sternotomy. Although it requires longer operative times, it offers-due to the diminished trauma-a reduced postoperative morbidity with a fast postoperative recovery and good postoperative outcome.

Open transcatheter aortic valve implantation on a degenerated bioprosthetic valve conduit

Abstract The degeneration of bioprosthetic aortic Conduit with hemodynamic dysfunction mostly requires a re-do surgery, which is associated with an increased perioperative risk. Considering this, an open implantation of a transcatheter aortic bioprothesis (TAVI) after resection of the degenerated valve leaflets could be of great benefit, reducing cross-clamp and cardiopulmonary bypass duration, especially in combined surgery in high-risk patients. This is a case of a high-risk female (78 years, EuroScore 59%) treated with an open TAVI as an alternative to conventional valve or aortic conduit replacement for degenerative aortic valve due to endocarditis lente, 2 years following a bio-Bentall procedure.

Rapid deployment aortic valve replacement in a minimal access setting: intermediate clinical and echocardiographic outcomes†

OBJECTIVES Transcatheter procedures have overtaken conventional operations in Germany. Considering that this is a highly competitive field, a rate of 25% for minimal access aortic valve replacement seems to be disappointingly low. One way to promote minimal access techniques is through the systematic use of rapid deployment valves. METHODS A total of 143 patients underwent rapid deployment aortic valve replacement via upper right hemisternotomy between March 2012 and September 2015. All patients were followed up annually. Echocardiographic assessment of the valve was performed after 12 months. The cumulative follow-up time was 275.2 patient-years. The median follow-up time was 1.9 years. RESULTS The mean age was 76.4 ± 6.2 years, and the mean logistic EuroSCORE was 11.0 ± 4.3%. Early all-cause mortality was 2.8% (n = 4). Actuarial survival after 1 year was 91.6 ±  2.4%, and after 3 years, it was 84.4 ± 3.6%. Mean transprosthetic gradient after 12 months was 10.3 ± 3.8 mmHg. New onset of higher grade paravalvular leakage did not occur during the follow-up period. Perioperatively, higher grade paravalvular leakage (aortic insufficiency  >1+) occurred in 2 cases (1.4%) . CONCLUSIONS Rapid deployment aortic valve replacement can be performed safely in a minimal access setting with low complication rates and good haemodynamic results. Therefore, rapid deployment valves are a relevant option in minimal access surgery.

Rapid-Deployment Aortic Valve Replacement after Previous Mechanical Valve Implantation

Recent studies report a reproducible reduction of myocardial ischemic and cardiopulmonary bypass times along with excellent hemodynamics and low rates of paravalvular leakage for rapid-deployment valves. A 68-year-old female patient with aortic stenosis and a mechanical mitral valve which was implanted in 2006 received rapid-deployment aortic valve replacement. The procedure could be performed with a cross-clamp time of 45 minutes and a cardiopulmonary bypass time of 60 minutes. Postoperative course was uncomplicated and the patient was discharged to the referring hospital on postoperative day 8.

Rapid deployment aortic valve replacement in the setting of concomitant mitral valve procedures

The technique of rapid deployment aortic valve implantation in patients with concomitant mitral valve surgery is described and the outcome of our first 25 patients reported.

Chronic Pericardial Hematoma with Suppression of the Right Ventricle: A Rare Complication of a Coronary Artery Aneurysm

We present a case of a 67-year-old patient referred to our department with a pericardial mass lesion measuring 11 × 4 × 7.5 cm as diagnosed in computed tomography scan. The patient showed a history of progredient dyspnea. Video-assisted thoracoscopy as well as an explorative full sternotomy to resect the mass lesion had been performed at the referring hospital subsequently before admission to our department. Intermittent hemodynamic instability caused the procedure to stop and a transfer to the cardiothoracic surgery department, following which a resternotomy was performed. Inspection of the surgical site and subsequent intraoperative rapid section revealed an old organized and dense pericardial hematoma adherent to the right ventricle. The suspicion of covered coronary artery perforation led to an intraoperative coronary angiography, which revealed a large proximal coronary aneurysm of the right coronary artery and a subtotal stenosis of the circumflex branch. The hematoma could be removed with decompression of the right ventricle under cardiopulmonary bypass conditions. The further postoperative course was uncomplicated with retransfer to the referring hospital on the postoperative day 8.

Special report: 26-year durability of a bioprosthesis implanted in a 21-year-old patient.

The choice of prosthetic heart valve type is largely dependent upon patients age at implantation and on what, in his eyes, seems more pertinent: avoidance of complications associated with anticoagulation of mechanical valves or structural valve deterioration of bioprosthetic valves. Long lasting and new promising concepts such as transcatheter aortic valve implantation are promoting the use of bioprosthesis even in younger patients. However, it is up to the individual patient to decide.