The Year in Perioperative Echocardiography: Selected Highlights from 2018.

This article is the third of an annual series reviewing the research highlights of the year pertaining to the subspecialty of perioperative echocardiography for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief, Dr. Kaplan, and the editorial board for the opportunity to continue this series. In most cases, these will be research articles targeted at the perioperative echocardiography diagnosis and treatment of patients after cardiothoracic surgery; but in some cases, these articles will target the use of perioperative echocardiography in general.

[Future interventional procedures for valve diseases]. / Zukünftige interventionelle Verfahren bei Herzklappenerkrankungen.

BACKGROUND: Percutaneous valve therapies represent one of the most innovative areas within interventional cardiology in the past 10 years. AIM: The aim of this work is to give an overview of current and upcoming therapeutic options. MATERIALS AND METHODS: In this manuscript, the results of a retro- and prospective literature research are summarized. RESULTS AND DISCUSSION: With the introduction of percutaneous therapies for valvular heart disease, patients who were previously considered too ill for surgery can now be treated. The percutaneous treatment of aortic or mitral valve disease has become standard therapy. Likewise, promising results have been obtained for percutaneous treatment options for pathologies of the tricuspid valve, which are still under intense investigation.

Percutaneous heart valves; past, present and future.

Percutaneous heart valves provide a promising future for patients refused surgery on the grounds of significant technical challenges or high risk for complications. Since the first human intervention more than 10 years ago, over 50 different types of valves have been developed. The CoreValve and Edwards SAPIEN valves have both experienced clinical trials and the latter has gained FDA approval for implantation in patients considered inoperable. Current complications, such as major vascular bleeding and stroke, prevent these valves from being commonly deployed in patients considered operable in conventional surgery. This review focuses on the past and present achievements of these valves and highlights the design considerations required to progress development further. It is envisaged that, with continued improvement in valve design and with increased clinical and engineering experience, percutaneous heart valve replacement may one day be a viable option for lower-risk operable patients.

In patients undergoing valve-sparing aortic root replacement, is reimplantation superior to remodelling?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: in patients undergoing valve-sparing aortic root replacement, is reimplantation superior to remodelling? The purpose of this best evidence topic was to re-review the updated evidence that has become available in the near decade since the previous review published in 2011. Altogether more than 300 papers were found using the reported search, of which 8 papers represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The included studies have significant limitations relating to low-level evidence study design, variable outcome collection and limited significance testing with direct comparison. Long-term outcomes such as survival, recurrence of aortic regurgitation and valve reintervention were largely equal between the two procedures across the studies. This review, updated from the previous best evidence topic, continues to suggest that there are no clear recommendations or even consensus to guide clinical decision-making when choosing between remodelling or reimplantation approaches to valve-sparing aortic root replacement. To date, no study provides strong clinical benefit to favour either procedure in terms of perioperative outcomes, medium-long term survival or reintervention of the aortic valve. As such, procedure selection should be based upon patient factors and valve evaluation, combined with surgeon preference and experience.

The Perceval Sutureless Aortic Valve: Review of Outcomes, Complications, and Future Direction.

Surgical aortic valve replacement with a stented prosthesis has been the standard of care procedure for aortic stenosis. The Perceval (LivaNova, London, United Kingdom) is a sutureless aortic valve bioprosthesis currently implanted in more than 20,000 patients. The purpose of this article was to review the literature available after 9 years of clinical experience of the Perceval aortic valve. PubMED, Embase, and the Cochrane Library databases were searched. A meta-analysis of summary statistics from individual studies was conducted. A total of 333 studies were identified and 84 studies were included. Thirty-day mortality and 5-year survival ranged from 0% to 4.9% and 71.3% to 85.5%, respectively. Compared with stented prosthesis, pooled analysis demonstrated a statistically significant reduction in aortic cross-clamp and cardiopulmonary bypass times (minutes) with Perceval (38.6 vs 63.3 and 61.4 vs 84.9, P < 0.00001, respectively). Compared with transcatheter aortic valve implantation, pooled analysis demonstrated a statistically significant reduction with Perceval in paravalvular leakage (1.26% vs 14.31%) and early mortality (2.3% vs 6.9%). Favorable hemodynamics, acceptable valve durability, and ease of implantation in minimally invasive cases were reported as benefits. A trend toward increased rates of permanent pacemaker implantation and low postoperative platelet count were identified. Special use and off-label procedures described included bicuspid aortic valves, valve-in-valve for homograft and stentless prosthesis failure, concomitant valvular procedures, porcelain aorta, and endocarditis. The Perceval valve has shown safe clinical and hemodynamic outcomes. Outcomes support its continued usage and potential expansion.

Use of valve surgery in Canada.

BACKGROUND: To date, although clinical databases have been used to report on single centre or regional valve surgery outcomes, neither clinical nor administrative data have been used to examine rates of valve surgery use across large geographical regions. The objective of the present study was to use administrative data to evaluate use of valve surgery over time and across Canada. METHODS: All cases of aortic valve replacement (AVR), mitral valve replacement (MVR), mitral valve repair (MV repair), combined AVR and coronary artery bypass grafting (CABG), and combined MVR/MV repair and CABG between fiscal years 1994/95 and 1999/2000 were identified using hospital discharge abstract data obtained from the Canadian Institute of Health Information. Age- and sex-adjusted rates of valve surgery were then calculated by province and by procedure type. RESULTS: Rates of valve surgery for all procedure types increased between fiscal years 1994/95 and 1999/2000 with the exception of MVR, which remained relatively constant. Significant variation in rates of valve surgery was found between male and female residents. Similar variation was also demonstrated across provinces by year and by procedure type. CONCLUSION: There was a trend toward increased use of valve surgery over time for most procedures. Variation in rates of valve surgery exists across provinces. These results provide a starting point from which to track future trends in use and outcomes for these major procedures.

Advances in percutaneous treatment of mitral regurgitation.

Percutaneous techniques for the treatment of mitral regurgitation have aroused much interest in recent years. Percutaneous mitral annuloplasty can be performed indirectly by using devices implanted in the coronary sinus or directly by using a retrograde approach. However, as yet, the results of these techniques are scarce and some devices have a high complications rate. The most frequent percutaneous mitral valve repair technique consists of mitral leaflet plication by implanting 1 or more percutaneous clips (MitraClip) in an imitation of the Alfieri surgical technique. Clinical experience with this device is broader than that with any other. The MitraClip device is associated with improved mitral regurgitation in a high percentage of carefully-selected patients. However, the single randomized study performed to date (EVEREST) showed its efficacy to be less than that of surgical repair and we await the results of new randomized studies that should clarify which patient-type can benefit most from this technique. Other left ventricular remodeling devices, tendinous cord implantation, and leaflet ablation are currently undergoing preclinical development or first-in-human experimentation. Finally, the development of biological prostheses for percutaneous mitral valve replacement is at an early stage. Many promising experiments at the preclinical phase and initial experiments in humans will very probably multiply in the near future. However, the true role of this technique in treating mitral valve disease will have to be evaluated in appropriately designed randomized controlled studies.

Contemporary management of aortic stenosis: surgical aortic valve replacement remains the gold standard.

Aortic valve disease is the most frequent acquired heart valve lesion in humans. In western communities, approximately 90% of patients present with aortic stenosis (AS), predominantly of a calcific degenerative aetiology. The remaining approximately 10% of patients predominantly present with aortic valve incompetence.

On the horizon: minimally invasive cardiac surgery.

The landscape of cardiac surgery is changing. Advances in endoscopic and other instrumentation procedures such as port access, video instrumentation, and computer-assisted technology are opening new vistas for cardiac surgery. On the immediate horizon is minimally invasive cardiac surgery, also known as keyhole surgery. Imagine a patient not needing a median sternotomy incision or cardiopulmonary bypass. This new type of cardiac surgery is currently being explored at some cardiac surgical centers internationally. This article explores the current state-of-the-art related to minimally invasive direct coronary artery bypass surgery. The operative procedure, implications for perioperative nursing care, likely future technologies, and the research literature on outcomes are also discussed.