Late clinical and echocardiographic results with the Magna Ease© pericardial aortic bioprosthesis.

OBJECTIVES: The population of candidates to surgical aortic valve replacement (SAVR) is evolving. The Perimount Magna Ease© bioprosthesis has been introduced relatively recently in the practice. We aimed at evaluating its long-term results. METHODS: This article describes a single-centre cohort of 1016 consecutive SAVRs with the Magna Ease© valve (2008-2014), consisting of an all-comers population. We performed a prospective collection of in-hospital data, systematic clinical and echocardiographic follow-up. Valve-related events were as follows: structural valve deterioration (SVD; according to modified definition criteria), nonstructural valve dysfunction, patient-prosthesis mismatch (PPM). RESULTS: Age at SAVR was 73.4 ± 9.5 years; calcified aortic stenosis was the indication to surgery in 59.6%. A total of 974 patients entered the follow-up; 564 were alive at the last follow-up (median duration: 9.8 years) (up to 13.4 years). New York Heart Association class was I or II in 92.1%. Overall survival at 10 years was 56.8 ± 1.8%. Freedom from SVD at 10 was 96.5 ± 0.8% (Kaplan-Meier) and 97.4 ± 0.6% (competing risks) (28 SVD events after 6.9 ± 3.3 years). There were 15 reinterventions for SVD (redo-SAVR and Transcatheter Aortic Valve Implantation (TAVI)); 10-year freedom from reintervention was 97.8 ± 0.6%. Moderate and severe PPM occurred in 26.8% and 5.4%, respectively, without association with late mortality (P = 0.12 for moderate and P = 0.70 for severe PPM). Freedom from valve-related mortality was 97.8 ± 0.5% at 10 years. CONCLUSIONS: In this follow-up of the Magna Ease bioprosthesis for SAVR, data indicate good late outcomes (30-day outcomes are excluded). Continued follow-up is required to further support its use in patients with life expectancy >10-12 years.

Transcatheter edge-to-edge repair following surgical valve repair with ring implantation: Results from the multicentre "Clip-in-Ring" registry.

BACKGROUND: Management of mitral regurgitation recurrence after failed surgical valve repair with ring implantation is controversial. AIM: To describe the French experience regarding midterm safety and efficacy of transcatheter edge-to-edge mitral valve repair (TEER) in patients with failed surgical valve repair with ring implantation. METHODS: The "Clip-in-Ring" registry is a multicentre registry conducted in 11 centres in France, approved by local institutional review boards, of consecutive TEER following surgical valve repair with ring implantation. Outcomes were Mitral Valve Academic Research Consortium (MVARC) technical success, modified 30-day device and procedural success (where 10mmHg is considered as a cut-off for significant mitral stenosis) and MVARC complications. RESULTS: Twenty-three patients were studied: mean age, 69±10years; male sex, 74%; EuroSCORE II, 16±17; left ventricular ejection fraction, 53±12%; mitral regurgitation grade 3+/4+, 17%/78%; New York Heart Association class III/IV, 47%/22%; median surgery to TEER delay, 23 (6-94) months. Technical success was 100%. At discharge, residual mitral regurgitation grade was≤2+ in 87% and median transmitral gradient was 4 (3-5) mmHg. Thirty-day modified MVARC device and procedural success was 82%: four patients (17%) had residual mitral regurgitation grade>2+, including two patients who needed complementary surgery. No patient had a 30-day transmitral gradient>7mmHg. No patient died or had a stroke or any life-threatening complications. One patient presented a vascular access complication requiring transfusion. No other MVARC-2 adverse event was reported. CONCLUSIONS: TEER in patients with failed mitral ring is feasible and safe. Further studies should delineate its exact role in the therapeutic armamentarium for this medical issue.

Delayed hospitalisation for heart failure after transcatheter repair or medical treatment for secondary mitral regurgitation: a landmark analysis of the MITRA-FR trial.

BACKGROUND: In the MITRA-FR trial, transcatheter mitral valve repair (TMVR) was not associated with a 2-year clinical benefit in patients with secondary mitral regurgitation (SMR). AIMS: This landmark analysis aimed at investigating a potential reduction of the hospitalisation rate for heart failure (HF) between 12 and 24 months after inclusion in the MITRA-FR trial in patients randomised to the intervention group (TMVR with the MitraClip device), as compared with patients randomised to the control group (guideline-directed medical therapy [GDMT]). METHODS: The MITRA-FR trial randomised 307 patients with SMR for TMVR on top of GDMT (TMVR group; n=152) or for GDMT alone (control group; n=155). We conducted a 12-month landmark analysis in surviving patients who were not hospitalised for HF within the first 12 months of follow-up. The primary endpoint was the 1-year cumulative number of HF hospitalisations. RESULTS: A total of 140 patients (TMVR group: 67; GDMT group: 73) were selected for this landmark analysis with similar characteristics at inclusion in the trial. The primary endpoint was 28 events per 100 patient-years in the TMVR group, as compared with 60 events per 100 patient-years in the GDMT group (hazard ratio [HR] 0.46, 95% confidence interval [CI]: 0.20-1.02; p=0.057). CONCLUSIONS: In this landmark analysis of the MITRA-FR trial, the cumulative rate of HF hospitalisation between 12 and 24 months among patients treated with TMVR on top of GDMT was approximately half as many as those of patients treated with GDMT alone, a difference which did not reach statistical significance in the setting of a low number of events.

Durability of Mitral Valve Replacement With a Third-generation Bioprosthesis.

BACKGROUND: Our aim was to evaluate the durability of a third-generation porcine bioprosthesis (Epic porcine xenograft; Abbott Cardiovascular Inc, St Paul, MN) in the mitral position, according to patients' age at surgery. METHODS: Four hundred eighty-two mitral valve replacements using the Epic valve at a single center were included (2009-2018). Perioperative and early postoperative data were prospectively collected. A systematic follow-up was performed (99% complete, 1609.5 patient-years; average, 3.8 ± 2.5). Standardized definitions of valve-related events were adopted. Mean patient age at mitral valve replacement was 68.1 ± 10.4 years. RESULTS: Operative mortality was 9.3%. There were 5 early valve-related reoperations, mainly due to recurrent infectious endocarditis. Global survival at 8.8 years was 69.5% ± 5%. Nine structural valve deterioration (SVD) events occurred during follow-up (3 receiving reoperations, 4 transcatheter mitral valve replacement valve-in-valve, and 2 medical treatment only). The freedom from SVD at 5 and 10 years was 97.4% ± 1.2% and 89.6% ± 4.4% (actuarial) and 97.8% ± 1% and 91.9% ± 3.3%, respectively (competing risks). After stratification into subgroups by age at surgery (≤59 years, 50.8%; 60-69, 32.8%; ≥70, 16.4%) there was no significant intergroup difference in freedom from SVD (log-rank P = .24). The overall freedom from any reintervention for SVD at 10 years was 90.5% ± 4.4% (actuarial) and 92.7% ± 3.3% (competing risks), with no intergroup difference (log-rank P = .14). The freedom from any valve-related complication at 8.4 years was 83.2% ± 4.5% (actuarial). CONCLUSIONS: The Epic bioprosthesis shows good durability at 5 to 10 years in the mitral position.

Early and long-term results of hypothermic circulatory arrest in aortic surgery: a 20-year single-centre experience.

AIMS: The aim of this study was to document the postoperative outcomes of patients who underwent hypothermic circulatory arrest (HCA), the evolution of HCA management over time and to identify the risks factor for early mortality and postoperative stroke. METHODS: Four hundred and twenty-four patients who underwent aortic surgery with HCA at our institution between January 1995 and June 2016 were consecutively included. RESULTS: The main indications were degenerative aneurysm (254; 59.9%) and acute type A aortic dissection (146; 34.4%). Interventions were performed under deep (18.4 ±â€Š0.9°C; n = 350; 82.5%) or moderate (23.9 ±â€Š1.9°C; n = 74; 17.5%) hypothermia. Antegrade cerebral perfusion (ACP) was employed in 86 (20.3%) cases. The use of moderate hypothermia significantly increased from 2011, to become the preferred strategy in 2016. The in-hospital mortality was 12.5% and the postoperative stroke rate was 7.1%. Kaplan--Meier 5-year survival was 65.7%. Nonelective timing [odds ratio (OR) 4.05; P < 0.001], stroke (OR 3.77' P = 0.032), renal failure (OR 2.49; P = 0.023), redo surgery (2.42; P = 0.049) and CPB time (OR 1.05; P = 0.03) were independent risk factors for in-hospital mortality in multivariate analysis. Femoral cannulation was the only independent risk factor for stroke (OR 3.97; P = 0.002). The level of hypothermia and the use of ACP were not associated with either in-hospital mortality or postoperative stroke. CONCLUSION: HCA might be widely considered to achieve a radical treatment of the aortic disease, provided that hypothermia is maintained below the 24°C safety threshold and ACP is used for HCA exceeding 30 min, to ensure optimal brain, spinal cord and visceral organs protection.

Adult cardiac surgery during COVID-19 lockdown: Impact on activity and outcomes in a high-volume centre.

BACKGROUND: The coronavirus disease 2019 (COVID-19) outbreak had a direct impact on adult cardiac surgery activity, which systematically necessitates a postoperative stay in intensive care. AIM: To study the effect of the COVID-19 lockdown on cardiac surgery activity and outcomes, by making a comparison with the corresponding period in 2019. METHODS: This prospective observational cohort study compared adult cardiac surgery activity in our high-volume referral university hospital from 9 March to 10 May 2020 versus 9 March to 10 May 2019. Data were collected in our local certified database and a national database sponsored by the French society of thoracic and cardiovascular surgery. The primary study endpoints were operative mortality and postoperative complications. RESULTS: With 105 interventions in 2020, our activity dropped by 57% compared with the same period in 2019. Patients were at higher risk, with a significantly higher EuroSCORE II score (3.8±4.5% vs. 2.0±1.8%; P<0.001) and higher rates of active endocarditis (7.6% vs. 2.9%; P=0.047) and recent myocardial infarction (9.5% vs. 0%; P<0.001). The weight and priority of the interventions were significantly different in 2020 (P=0.019 and P<0.001, respectively). The rate of acute aortic syndromes was also significantly higher in 2020 (P<0.001). Operative mortality was higher during the lockdown period (5.7% vs. 1.7%; P=0.038). The postoperative course was more complicated in 2020, with more postoperative bleeding (P=0.003), mechanical circulatory support (P=0.032) and prolonged mechanical ventilation (P=0.005). Only two patients (1.8%) developed a positive status for severe acute respiratory syndrome coronavirus 2 after discharge. CONCLUSIONS: Adult cardiac surgery was heavily affected by the COVID-19 lockdown. A further modulation plan is necessary to improve outcomes and reduce postponed operations to decrease operative mortality and morbidity.

Thoracic splenosis: Case report of a symptomatic case.

Thoracic splenosis is the autotransplantation of splenic tissue in the left thoracic cavity as a result of a splenic injury. This rare pathology is usually asymptomatic and may be discovered on incidental imaging, but the diagnosis often requires invasive procedures such as surgery in order to eliminate a neoplasic origin. We report a rare symptomatic case of a 39-year-old man presenting with chest pain and multiple nodules revealed on a computed tomography scan. The patient underwent a surgical exploration and the pathological studies concluded to a thoracic splenosis. Indeed, the previous medical history of the patient revealed a left thoraco-abdominal traumatism during childhood. The aim of this paper is to emphasize that the diagnosis can now be performed using only imaging techniques such as technetium-99 sulfur colloid or labelled heat-denatured red blood cell scintigraphy to avoid unnecessary invasive procedures including thoracotomy.

Left ventricular function after correction of mitral regurgitation: Impact of the clipping approach.

AIMS: Functional mitral regurgitation (FMR) is associated with poor outcome in systolic heart failure (HF) patients. Percutaneous edge-to-edge mitral valve repair (PMVR) in Mitra-Fr study failed to prove any beneficial effect over optimal medical treatment (OMT) but win in COAPT study. Nevertheless, little is known about the effect of PMVR on LV performance and mechanics in HF patients with severe secondary MR. METHOD AND RESULTS: Thirty-seven patients with severe FMR undergoing PMVR were included and compared (according to indices of LV myocardial function and the relationship between LV-size and the degree of regurgitation) to nineteen patients with FMR treated by OMT. Both groups were clinically comparable. At 6-month follow-up, cardiac index such as LV global constructive work (GCW) improved significantly in both groups (1.86 vs 2.13 L/min/m2 , P = .02, 1.73 vs 2.28 L/min/m2 P = .002 and 977 vs 1101 mm Hg.%, P = .003, 967 vs 1110 mm Hg.%, P = .002 for PMVR and OMT groups, respectively) whereas left ventricular (LV) end-systolic volume index, LV ejection fraction, and global longitudinal strain were not different. Receiver operating characteristics in PMVR with LVEF ≤ 35% subgroup analysis demonstrated that global work index (GWI) had the best ability to identify patients with worse evolution (AUC = 0.882; P = .009), confirmed by univariable logistic regression, particularly for patients with GWI < 482 mm Hg.%. CONCLUSION: Echocardiographic characteristics at 6-month follow-up are not different when compare PMVR and OMT for HF patients with severe FMR. A low global work index might be a tool for discouraging the implantation of clips for this indication.

Predictors of post-operative cardiovascular events, focused on atrial fibrillation, after valve surgery for primary mitral regurgitation.

Aims: Primary mitral regurgitation (PMR) can be considered as a heterogeneous clinical disease. The optimal timing of valve surgery for severe PMR remains unknown. To determine whether unbiased clustering analysis using dense phenotypic data (phenomapping) could identify phenotypically distinct PMR categories of patients. Methods and results: One hundred and twenty-two patients who underwent surgery were analysed, excluding patients with pre-operative permanent atrial fibrillation (AF), were prospectively included before surgery. They were given an extensive echocardiographic evaluation before surgery, and clinical data were collected. These phenotypic variables were grouped in clusters using hierarchical clustering analysis. Then, different groups were created using a dedicated phenomapping algorithm. Post-operative outcomes were compared between the groups. The primary endpoint was post-operative cardiovascular events (PCE), defined as a composite of: deaths, AF, stroke, and rehospitalization. The secondary endpoint was post-operative AF. Data from three phenogroups with different characteristics and prognoses were identified. Phenogroup-1 (67 patients) was the reference group. Phenogroup-2 (33 patients) included intermediate-risk male and smoker patients with heart remodelling. Phenogroup-3 (22 patients) included older female patients with comorbidities (chronic renal failure, paroxysmal AF) and diastolic dysfunction. They had a higher risk of developing both PCE [(hazard ratio) HR = 3.57(1.72-7.44), P < 0.001] and post-operative AF [HR = 4.75(2.03-11.10), P < 0.001]. Pre-operative paroxysmal AF was identified as an independent risk factor for PCE. Conclusion: Classification of PMR can be improved using statistical learning algorithms to define therapeutically homogeneous patient subclasses. High-risk patients can be identified, and these patients should be carefully monitored and may even be treated earlier.

Hemodynamic Results and Mid-term Follow-up of 850 19 to 23 mm Perimount Magna Ease Valves.

BACKGROUND: Aortic valve replacement (AVR) in small aortic roots remains a surgical dilemma with a higher risk of patient-prosthesis mismatch (PPM). The Perimount Magna Ease aortic valve (PMEAV) represents an attractive device in such cases. We examined the early hemodynamic performance, the mid-term outcomes of the PMEAV, and the impact of PPM on outcome and functional class. METHODS: We performed a retrospective analysis of prospectively collected in-hospital data, and a prospective single-center follow-up of 849 patients who received a 19 to 23 mm PMEAV (2008-2014). Concomitant mitral or tricuspid replacement was the exclusion criterion. Early hemodynamic features were prospectively collected; mid-term follow-up was conducted according to current guidelines. RESULTS: Size of implanted prosthesis was 19 mm in 11.5% of patients, 21 mm in 36.9%, and 23 mm in 51.5%. Operative mortality was 4.5% (3.1% for isolated AVR). The rate of severe and moderate PPMs was significantly higher in the 19 mm group. Follow-up was 99.9% complete (3.7 ± 2 years). Actuarial freedom from structural valve deterioration (SVD) at 5 years was 99.1%. At stratified Kaplan-Meier's analysis, PPM and age <70 years were associated with SVD. PPM was not associated with worse functional status (New York Heart Association class) or mortality at follow-up. CONCLUSION: This series shows satisfactory clinical outcomes of the PMEAV implanted in small aortic annuli at mid-term follow-up. Although PPM may occur in smaller sizes, it has limited clinical impact, and it is not associated with mid-term mortality or worse functional class. Few SVD events are evidenced; nonetheless, limited follow-up duration and its methodology need to be considered.

Prognostic impact of blood product transfusion in VA and VV ECMO.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is an accepted and reliable technique to provide temporary circulatory and/or respiratory support. Our objective was to describe the transfusion requirements in ECMO recipients. Secondarily, we addressed the effect of indications for ECMO on transfusion requirements and the baseline factors associated with worse survival. METHODS: We reviewed the prospectively collected data of 509 patients receiving venoarterial (VA) or venovenous (VV) ECMO therapy (2005-2016). Follow-up was prospectively conducted. Data were prospectively entered in the Rennes ECMO database. RESULTS: VA ECMO was employed in 81% of cases; indications were post-cardiotomy myocardial failure in 28% of cases, post-heart transplantation (early graft failure) in 13.2% and cardiogenic shock in 149 (36.4%). VV ECMO was employed in the remaining patients. Average follow-up was 80.25 ± 85.13 days and was 100% complete. In the VA and VV groups, survival at the 30th post-implantation day was 58.3% and 71.1%, respectively, and survival at 6 months was 40.5% and 50.5%, respectively. Platelets and prothrombin time (PT) levels were significantly lower in the VA ECMO group at implantation (p<0.001). VA ECMO patients had a higher rate of thrombotic/haemorrhagic complications (p<0.001) and received both fresh frozen plasma (FFP) (60.5% vs. 31.8% p<0.001) and platelet units (Plt) (61.7% vs. 34.1% p<0.001) more frequently than VV ECMO patients. Post-cardiotomy and post-transplantation patients had significantly higher rates of transfusion of packed red blood cells (pRBC), FFP and Plt than other VA ECMO cases (p<0.001, all). Mortality was equal or greater than 80% among patient subgroups who received more than 19 pRBC, 5 Plt and/or 12 FFP. CONCLUSIONS: An ECMO program is associated with important consumption of blood products. VA ECMO patients have a greater transfusion burden than VV ECMO patients. Mortality is greater in the case of extreme transfusion requirements.

Conventional aortic valve replacement in 2005 elderly patients: a 32-year experience.

OBJECTIVES: Considering the good immediate results reported for transcatheter aortic valve implantation in high-risk patients, the role of conventional aortic valve replacement (AVR) is being questioned, especially in elderly patients. The aim of this study was to evaluate our long-term results of conventional AVR in octogenarians. METHODS: A total of 2005 patients aged ≥80 years underwent AVR for aortic stenosis in our institution between 1978 and 2011. Of these, 1009 (50%) patients had an associated extracardiac comorbidity and 650 (32%) patients had coronary lesions. Valve replacement was the sole procedure in 1515 (76%) patients, and 396 (19%) patients had concomitant coronary artery bypass grafting. Data were collected at the time of surgery in our database, and regularly updated by mailed questionnaires and telephone contact. RESULTS: Early mortality of isolated AVR was 5.5% for the last 10 years of the series. Significant risk factors were chronic obstructive pulmonary disease, chronic renal failure, advanced cardiac disease [left or right ventricular failure, New York Heart Association (NYHA) Class IV and atrial fibrillation] and coronary disease. Long-term follow-up was 99.5% complete (9 patients lost to follow-up), totalling 8849 patient-years. Nine hundred and one patients died at late follow-up with a median survival of 7.1 years, with 7 patients becoming centenarian. Apart from older age, main late causes of death were cardiovascular (20.5%), neurological deficit (10.2%) and cancer (10.2%). Actuarial survival was 83%, 62.5% and 25% at 2, 5 and 10 years, respectively. This survival compares favourably with that of a French-matched population. Above all, 90% of late survivors reported functional improvement. Univariable and multivariable analysis identified risk factors of late death as male gender, associated comorbidity, renal failure, advanced cardiac disease, atrial fibrillation and impaired ventricular function. Coronary lesions, associated cardiac surgery and small diameter prostheses (19 or 21 mm) did not impair long-term survival. CONCLUSIONS: AVR is effective for all age groups to treat aortic stenosis. Elderly people should not be denied surgery only because of their old age as conventional AVR provides an excellent quality of life and restores life expectancy. Percutaneous valve implantation is to be considered, in cases of non-operable or high-risk patients. However, to date, open-heart surgery remains the treatment of choice for aortic stenosis for the majority of patients.

Right ventricular exercise contractile reserve and outcomes after early surgery for primary mitral regurgitation.

OBJECTIVE: To assess if the lack of development of right ventricular (RV) contractile reserve during exercise echocardiography (ex-echo) might be a predictor of postoperative major adverse cardiovascular events (MACEs) in patients with primary mitral regurgitation (pMR) undergoing early surgery. METHODS: Comprehensive resting and ex-echo were performed in 142 asymptomatic patients (58±21 years, 68% men, New York Heart Association functional class ≤2) with isolated severe pMR and preserved left ventricular (LV) function (LV ejection >60%, LV end-systolic diameter <45 mm) undergoing mitral valve replacement (n=20) or repair. Postoperative MACEs were defined as occurrence of atrial fibrillation, stroke, cardiac-related hospitalisation or death. RV function was evaluated at rest in every patient during ex-echo by measuring their tricuspid annular plane systolic excursion (TAPSE) value. RESULTS: After median follow-up of 30 months (IQR 16-60 months), MACEs occurred in 48 (34%) patients. Using Bayesian model averaging, among all the characteristics including the type of surgery, exercise TAPSE (ex-TAPSE) emerged as the most likely predictor of prognosis (HR 0.91, 95% CI 0.86 to 0.96). Other probable predictors were exercise fractional area change (HR 0.02, 95% CI 0.00 to 0.80), male gender (HR 0.40, 95% CI 0.21 to 0.75) and RV basal diameter (HR 1.06, 95% CI 0.98 to 1.14). In the receiver operating characteristic curve analysis, an ex-TAPSE value of <26 mm (sensitivity 73% (95% CI 61 to 84) and specificity of 86% (95% CI 77% to 93%)) defined RV dysfunction. Event-free survival at 5 years was significantly lower in the patient group that exhibited no development of RV contractile reserve during exercise: 43.9% (95% CI 31.3 to 61.4) vs 75.8% (95% CI 64.8 to 88.7). CONCLUSION: Lack of development of exercise-induced RV contractile reserve is a prognostic predictor in patients with severe pMR undergoing early mitral valve surgery.

Long-term follow-up of bioprosthetic aortic valve replacement in patients aged ≤60 years.

OBJECTIVE: To address the long-term durability of bioprostheses used for aortic valve replacement (AVR) in adult patients aged ≤60 years at the time of surgery. METHODS: Through a retrospective review of a prospectively collected database, we identified 416 bioprosthetic AVRs performed between 1977 and 2013. A prospective follow-up of valve-related and non-valve-related events was performed. RESULTS: Follow-up was 98.5% complete (2423.1 patient-years; average, 6 ± 5.5 years). At 15 years, overall survival was 62.1 ± 4.4%; freedom from valve-related death was 97.1 ± 1.6%. There were 68 SVD events (11.9 ± 28.8 years after surgery). Freedom from SVD at 15 years was 48.7 ± 5.5% for Kaplan-Meier analysis and 61.4 ± 4.3% for competing-risks analysis. After stratification into age subgroups (<40 years, ≥40 and <50 years, and ≥50 and ≤60 years), we observed no significant difference in freedom from SVD (P = .50). The average delay to SVD was not statistically different among subgroups (P = .30). There were 57 reoperations for SVD (11.8 ± 5.2 years after implantation). The 15 year freedom from reoperation for SVD was 55.4 ± 5.6% by Kaplan-Meier analysis and 67.1 ± 4.2% by competing-risks analysis. After stratification by age, freedom from reoperation for SVD was comparable (P = .13). Freedom from any valve-related complication or death was 42 ± 5% by Kaplan-Meier analysis and 54.4 ± 4.1% by competing-risks analysis. CONCLUSIONS: The lifetime risk of SVD is considerable in patients aged ≤60 years at the time of bioprosthesis implantation. Nonetheless, durability remains consistent during the first decade; additional data are required for the second decade. Patients' information is pivotal for valve choice (competing-risks method).

Clinical outcomes in patients after extracorporeal membrane oxygenation support for post-cardiotomy cardiogenic shock: a single-centre experience of 92 cases.

OBJECTIVES: Post-cardiotomy cardiogenic shock is a major concern in cardiac surgery. We reviewed our experience of extracorporeal membrane oxygenation (ECMO) as temporary circulatory support in post-cardiotomy cardiogenic shock. METHODS: Between January 2005 and December 2014, adult patients implanted with ECMO after cardiac surgical procedures were included. Indications for ECMO were failure to be withdrawn from cardiopulmonary bypass or refractory cardiogenic shock occurring during postoperative Days 1 and 2. Patients' characteristics and outcomes were prospectively collected in a local ECMO database. RESULTS: Ninety-two patients, median age of 63 years (17-83 years), were supported by ECMO following valvular surgery (66%), acute aortic dissection (10%) and coronary artery bypass grafting (9%). A total of 37% were combined surgical procedures, 24% were redo procedures and 33% were emergent procedures. The median duration of ECMO support was 6 days (1-28 days). The weaning rate from mechanical support was 48%. Overall 1-month and 6-month survival rates were, respectively, 42% and 39%. Survivors were younger (57 vs 63 years old, P = 0.02) and had a higher preoperative left ventricular ejection fraction (52.5 vs 44.1%, P = 0.017). There was a trend for lower serum creatinine levels and total bilirubin rates in the survivors' group 24 h after initiation of ECMO (respectively, 162 vs 212 µmol/l, P = 0.06; 25.3 vs 54.2 mg/dl, P = 0.08). Valvular surgery and peak lactic acid serum level were associated with poor outcomes. The mean health-related quality of life EuroQoL scale was 68 ± 16/100 at 2 years. CONCLUSIONS: Refractory cardiogenic shock requiring ECMO was most frequently observed after redo valvular surgery in the present study. The overall 6-month survival rate was 39% after ECMO support for post-cardiotomy cardiogenic shock with acceptable health-related quality of life. Improved kidney and liver functions after 24 h of support were associated with favourable outcomes.

Mid-term durability of the Trifecta bioprosthesis for aortic valve replacement.

OBJECTIVE: To clarify the mid-term durability of the Trifecta bioprosthesis for aortic valve replacement (AVR). METHODS: We retrospectively analyzed the prospectively collected data of 824 consecutive implants of the Trifecta valve at a single institution. A 100% complete follow-up was available (average duration, 2.2 ± 1.3 years; range, 0.03-6.9 years; 1747.6 patient-years). Echocardiography data at discharge were recorded prospectively. RESULTS: Operative mortality was 3.8%; 2.7% in patients receiving isolated AVR. There were 5 valve-related early reoperations, including 1 for infective prosthetic endocarditis and 4 for nonstructural valve dysfunction. The global rate of severe patient-prosthesis mismatch was 1.26%. Overall 5-year survival was 74.9%, and freedom from valve-related death was 97.8%. The majority of deaths attributed to the valve were due to unknown causes. We observed 6 SVD events at 3.4 ± 1.6 years after surgery. At 5 years, the actuarial freedom from SVD was 98% ± 0.9% (n = 6), freedom from reintervention for SVD was 98% ± 0.9% (n = 5, including 2 transcatheter valve-in-valve), and freedom from open reoperation for SVD was 98.9% ± 0.6%. The 5-year freedom from prosthetic endocarditis was 97.7% ± 0.7% (n = 12, 6 requiring reoperation). There was 1 case of late NSVD (5-year freedom, 99.8% ± 0.2%). Freedom from hemorrhagic events was 98.6% ± 0.5% (86% occurring in patients on anticoagulants); there were no thromboembolic events at follow-up. CONCLUSIONS: The Trifecta bioprosthesis is a reliable device for AVR. We confirm excellent immediate hemodynamic properties and a very low rate of patient-prosthesis mismatch. The absolute number of SVD cases observed remains limited; nevertheless, their timing, pathological characteristics, and clinical presentation mandate continued follow-up.

Combined Coronary Revascularization: Single-Center 10-Year Experience.

OBJECTIVE: This study aimed to assess the long-term outcome of combined coronary revascularization. METHODS: Between January 2000 and September 2010, 106 consecutive patients underwent combined coronary revascularization, either the same day or staged within 90 days. Percutaneous coronary intervention was always performed before coronary artery bypass grafting. We identified three groups as follows: one-stop combined coronary revascularization (n = 20), percutaneous coronary intervention for acute coronary syndrome before subsequent surgery (n = 39), and percutaneous coronary intervention for stable coronary artery disease before subsequent surgery (n = 47). Off-pump technique was used in all cases. RESULTS: A total of 107 angioplasties were realized (drug-eluting stents, 21; bare metal stents, 114; balloon angioplasty, 4). Percutaneous coronary intervention was mostly performed in the right coronary artery or branches (85%). The mean (SD) number of grafts was 1.9 (0.6), among them 1.8 (0.7) with arterial grafts. A total of 87.7% of the patients underwent exclusive arterial revascularization. There was one reexploration for bleeding and no in-hospital death. Eleven patients died in the follow-up. Repeat percutaneous coronary intervention was necessary for six patients and repeat surgery for one patient. The mean (SD) follow-up was 6.1 (2.7) years. Complete follow-up was obtained in 96.2% of the patients. Freedom from ischemic events (all-cause deaths, angina, acute coronary syndrome, myocardial infarction) was 86.3% (3.7%) at 5 years and 79.7% (5.2%) at 8 years (no difference between groups). Freedom from major adverse cardiac or cerebrovascular events was 88.8% (3.4%) at 5 years and 75.7% (5.2%) at 8 years (no difference between groups). CONCLUSIONS: Combined coronary revascularization increases the use of arterial grafts, with good long-term outcome.

Uncontrolled daily pulmonary oedema due to severe mitral regurgitation emergently and effectively corrected by Mitraclip® implantation.

MitraClip® is usually implanted in stable patients. We report the case of a patient having a severe, refractory and daily pulmonary oedema, related to a severe restrictive mitral regurgitation secondary to a primitive dilated cardiomyopathy. A Mitraclip® was emergently implanted, with a dramatic long-term clinical success. The critical unstable status of a patient should not prevent any Mitraclip® implantation.