Outcomes of cardiac surgical procedures performed by trainees versus consultants: A systematic review with meta-analysis.

OBJECTIVES: Cardiac surgery is highly demanding and the ideal teaching method to reach competency is widely debated. Some studies have shown that surgical trainees can safely perform full operations with equivocal outcomes compared with their consultant colleagues while under supervision. We aimed to compare outcomes after cardiac surgery with supervised trainee involvement versus consultant-led procedures. METHODS: We systematically reviewed databases (PubMed/MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, Google Scholar) and reference lists of relevant articles for studies that compared outcomes of cardiac surgery performed by trainees versus consultants. Primary end points included: operative mortality, coronary events, neurological/renal complications, reoperation, permanent pacemaker implantation, and sternal complications. Secondary outcomes included cardiopulmonary bypass and aortic cross-clamp times and intensive care/in-hospital length of stay. Random effects meta-analysis was performed. RESULTS: Thirty-three observational studies that reported on a total of 81,616 patients (trainee: 20,154; consultant: 61,462) were included. There was a difference favoring trainees in terms of operative mortality in the main analysis and in an analysis restricted to propensity score-matched samples, whereas other outcomes were not consistently different in both analyses. Overall cardiopulmonary bypass and aortic cross-clamp times were longer in the trainee group but did not translate in longer intensive care unit or hospital stay. CONCLUSIONS: In the right conditions, good outcomes are possible in cardiac surgery with trainee involvement. Carefully designed training programs ensuring graduated hands-on operative exposure as primary operator with appropriate supervision is fundamental to maintain high-quality training in the development of excellent cardiac surgeons.

Respect versus resect approaches for mitral valve repair: A study-level meta-analysis.

Mitral valve repair (MVr) restores leaflets coaptation while preserving the patient's own valve. The two main techniques are: (a) chordal replacement ("respect approach"), whereby artificial neochordae are used to resuspend prolapsed segments of the affected leaflet - and (b) leaflet resection ("resect approach"), whereby diseased leaflet segment is resected, and the remaining segments are sutured together. Both techniques of MVr are associated with better long-term results, fewer valve-related complications and lower mortality when compared with mitral valve replacement (MVR). They also restore quality of life and improve survival to rates equivalent to those of the general population. We performed a meta-analysis to pool data of clinical studies that compared outcomes of MVr stratified by the surgical technique. Seventeen studies accounting for 6,046 patients fulfilled our eligibility criteria. The "respect approach" outperformed the "resect approach" with lower permanent pacemaker implantation rates and lower mean gradients. Despite any possible advantages of one technique over the other, which approach is best for each patient must be decided on a case-by-case basis and more long-term follow-up data are warranted.

Bioprosthetic valve fracture for valve-in-valve transcatheter aortic valve implantation in patients with structural valve degeneration: Systematic review with meta-analysis.

OBJECTIVES: To determine the outcomes of bioprosthetic valve fracture (BVF) in valve-in-valve transcatheter aortic valve implantation (ViV-TAVI) for patients with structural valve degeneration (SVD) of bioprosthetic surgical valves (BSV) implanted during surgical aortic valve replacement (SAVR). METHODS: A systematic review was conducted including studies published by May 2021. The primary endpoints of the study were 30-day mortality, annular rupture, stroke, paravalvular leak, pacemaker implantation, and coronary obstruction. The secondary endpoints were mean valve gradients (mmHg) and aortic valve area (AVA-cm2 ). A meta-analysis was conducted using the software R, version 3.6.3 (R Foundation for Statistical Computing). RESULTS: Four studies including 242 patients met our eligibility criteria. The overall proportions for 30-day mortality, annular rupture, stroke, paravalvular leak, pacemaker implantation and coronary obstruction were 2.1%, <1.0%, <1.5%, <1.0%, <1.0%, and <1.5%, respectively. After ViV-TAVI with BVF, the difference in means for mean valve gradients showed a significant reduction (random-effects model: -26.7; -28.8 to -24.7; p < .001), whereas the difference in means for AVA showed a significant increase (random-effects model: 0.55 cm2 ; 0.13-0.97; p = .029). Despite the improvement in AVA means, these remain too low after the procedure highly likely due to the small size of the bioprosthetic valves implanted during the index SAVR. CONCLUSION: ViV-TAVI with BVF has proven to be a promising option but data are still too scarce to enable us to draw definitive conclusions. Despite the decrease in gradients, postprocedural AVA remains worrisome. Studies with better designs and larger sample sizes are needed to advance this treatment option.

Percutaneous closure of left ventricular pseudoaneurysm in a patient with concomitant true left ventricular aneurysm.

BACKGROUND: Left ventricular aneurysms (LVA) are serious complications of myocardial infarction, being divided into true and false type. The false one-pseudoaneurysm (PA), is a life-threatening condition that requires urgent treatment due to the high risk of rupture. CASE PRESENTATION: An 84-year-old female presented with progressive heart failure symptoms. Investigation showed a small true LVA and a large PA. Open surgical repair was ruled out as Euroscore and Society of Thoracic Surgeons (STS) score were 42.80% and 39.97%, respectively. After discussion at our Heart Team meeting, percutaneous approach was found to be the best option. Guided by transesophageal echocardiography, we used an interventricular septal defect occluder to close the gap between the LV and the PA. Control ventriculography showed full closure of the gap, with no residual flow to the PA cavity. The patient was discharged from the hospital on the fifth postoperative day and has remained asymptomatic since then. CONCLUSION: Percutaneous approach proved to be a safe and effective modality to treat LV PA. The device implanted achieved the goal of blocking blood flow through the communication between LV and the PA.

Balloon versus self-expandable transcatheter aortic valve implantation for bicuspid aortic valve stenosis: A meta-analysis of observational studies.

BACKGROUND: There is a rising trend for transcatheter aortic valve implantation (TAVI) in bicuspid aortic stenosis patients. Data on the use of self-expandable (SEV) vs. balloon-expandable (BEV) valves in these patients are scarce. Therefore, we systematically compared clinical outcomes in bicuspid aortic stenosis patients treated with SEV and BEV. METHODS: Data were extracted from PubMed/MEDLINE, EMBASE, CENTRAL/CCTR, ClinicalTrials.gov, SciELO, LILACS, Google Scholar and reference lists of relevant articles. Eight studies published from 2013 to 2020 including a total of 1,080 patients (BEV: n = 620; SEV: n = 460) were selected. Primary endpoints were procedural, 30-day and 1-year mortality. Secondary endpoints were new pacemaker implantation, annular rupture, coronary obstruction, moderate-to-severe paravalvular leak, need of second valve, stroke and acute kidney injury. RESULTS: We found no statistically significant difference in mortality between patients treated with BEV vs. SEV during index procedure, at 30 days and at 1 year. BEVs showed a statistically significant higher risk of annulus rupture (2.5%) in comparison with SEV (0%) (OR 5.81 [95% CI, 3.78-8.92], p < .001). New generation BEVs were also associated with significantly less paravalvular leak when compared to new generation SEVs (OR 0.08 [95% CI, 0.02-0.35], p = .001). CONCLUSIONS: This meta-analysis of observational studies of TAVI for bicuspid valves, showed no difference in short- and mid-term TAVI mortality with BEVs and SEVs. BEVs presented a higher risk of annular rupture in comparison with SEV.

Total Arterial Coronary Bypass Graft Surgery is Associated with Better Long-Term Survival in Patients with Multivessel Coronary Artery Disease: a Systematic Review with Meta-Analysis.

INTRODUCTION: The benefit of total arterial revascularization (TAR) in coronary artery bypass grafting (CABG) remains a controversial issue. This study sought to evaluate whether there is any difference on the long-term results of TAR and non-TAR CABG patients. METHODS: The Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica dataBASE (EMBASE), Cochrane Central Register of Controlled Trials (CENTRAL/CCTR), Clinical Trials.gov, Scientific Electronic Library Online (SciELO), Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), and Google Scholar databases were searched for studies published by October 2020. Randomized clinical trials and observational studies with propensity score matching comparing TAR versus non-TAR CABG were included. Random-effects meta-analysis was performed. The current barriers to implementation of TAR in clinical practice and measures that can be used to optimize outcomes were reviewed. RESULTS: Fourteen publications (from 2012 to 2020) involving a total of 22,746 patients (TAR: 8,941 patients; non-TAR: 13,805 patients) were included. The pooled hazard ratio (HR) for long-term mortality (over 10 years) was lower in the TAR group than in the non-TAR group (random effect model: HR 0.676, 95% confidence interval 0.586-0.779, P<0.001). There was evidence of low heterogeneity of treatment effect among the studies for mortality, and none of the studies had a particular impact on the summary result. The result was not influenced by age, sex, or comorbidities. We identified low risk of publication bias related to this outcome. CONCLUSION: This review found that TAR presents the best long-term results in patients who undergo CABG. Given that many patients are likely to benefit from TAR, its use should be encouraged.

Total arterial coronary bypass graft surgery is associated with better long-term survival in patients with multivessel coronary artery disease: a systematic review with meta-analysis

Abstract Introduction: The benefit of total arterial revascularization (TAR) in coronary artery bypass grafting (CABG) remains a controversial issue. This study sought to evaluate whether there is any difference on the long-term results of TAR and non-TAR CABG patients. Methods: The Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica dataBASE (EMBASE), Cochrane Central Register of Controlled Trials (CENTRAL/CCTR), Clinical Trials.gov, Scientific Electronic Library Online (SciELO), Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), and Google Scholar databases were searched for studies published by October 2020. Randomized clinical trials and observational studies with propensity score matching comparing TAR versus non-TAR CABG were included. Random-effects meta-analysis was performed. The current barriers to implementation of TAR in clinical practice and measures that can be used to optimize outcomes were reviewed. Results: Fourteen publications (from 2012 to 2020) involving a total of 22,746 patients (TAR: 8,941 patients; non-TAR: 13,805 patients) were included. The pooled hazard ratio (HR) for long-term mortality (over 10 years) was lower in the TAR group than in the non-TAR group (random effect model: HR 0.676, 95% confidence interval 0.586-0.779, P<0.001). There was evidence of low heterogeneity of treatment effect among the studies for mortality, and none of the studies had a particular impact on the summary result. The result was not influenced by age, sex, or comorbidities. We identified low risk of publication bias related to this outcome. Conclusion: This review found that TAR presents the best long-term results in patients who undergo CABG. Given that many patients are likely to benefit from TAR, its use should be encouraged.

Valve-in-Valve Transcatheter Aortic Valve Replacement Versus Redo Surgical Aortic Valve Replacement: An Updated Meta-Analysis.

OBJECTIVES: The aim of this study was to evaluate early results of valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR) versus redo surgical aortic valve replacement (SAVR) for structural valve degeneration (SVD). BACKGROUND: ViV TAVR has been increasingly used for SVD, but it remains unknown whether it produces better or at least comparable results as redo SAVR. METHODS: Observational studies comparing ViV TAVR and redo SAVR were identified in a systematic search of published research. Random-effects meta-analysis was performed, comparing clinical outcomes between the 2 groups. RESULTS: Twelve publications including a total of 16,207 patients (ViV TAVR, n = 8,048; redo SAVR, n = 8,159) were included from studies published from 2015 to 2020. In the pooled analysis, ViV TAVR was associated with lower rates of 30-day mortality overall (odds ratio [OR]: 0.53; 95% confidence interval [CI]: 0.32 to 0.87; p = 0.017) and for matched populations (OR: 0.419; 95% CI: 0.278 to 0.632; p = 0.003), stroke (OR: 0.65; 95% CI: 0.55 to 0.76; p < 0.001), permanent pacemaker implantation (OR: 0.73; 95% CI: 0.22 to 2.43; p = 0.536), and major bleeding (OR: 0.49; 95% CI: 0.26 to 0.93; p = 0.034), as well as with shorter hospital stay (OR: -3.30; 95% CI: -4.52 to -2.08; p < 0.001). In contrast, ViV TAVR was associated with higher rates of myocardial infarction (OR: 1.50; 95% CI: 1.01 to 2.23; p = 0.045) and severe patient-prosthesis mismatch (OR: 4.63; 95% CI: 3.05 to 7.03; p < 0.001). The search revealed an important lack of comparative studies with long-term results. CONCLUSIONS: ViV TAVR is a valuable option in the treatment of patients with SVD because of its lower incidence of post-operative complications and better early survival compared with redo SAVR. However, ViV TAVR is associated with higher rates of myocardial infarction and severe patient-prosthesis mismatch.

Impact of Aortic Annulus Enlargement on the Outcomes of Aortic Valve Replacement: A Meta-analysis.

We sought to evaluate the impact of surgical aortic annulus enlargement (ARE) on the perioperative outcomes of surgical aortic valve replacement. Databases were searched for articles published by October 2019 in order to carry out a systematic review followed by meta-analysis. Thirteen studies with 40,447 patients (aortic valve replacement [AVR] with aortic annulus enlargement [AAE]: 4686 patients; AVR without AAE: 35,761 patients) were included. The total rate of AAE was 11.6%, ranging from 4.1%-28.1%. The overall unadjusted odds ratio (OR) (95% confidence interval [CI]) for operative mortality showed a statistically significant difference between the groups, with higher risk in the "AVR with AAE" group (OR 1.388; 95% CI 1.049-1.836, P < 0.001), but not for isolated AVR+AAE (OR 1.341; 95% CI 0.920-1.956, P = 0.127) and also not in matched populations (OR 1.003; 95% CI 0.773-1.300, P = 0.984). The "AVR with AAE" group showed an overall lower risk of significant patient-prosthesis mismatch (PPM) (OR 0.567; 95% CI 0.376-0.854, P = 0.007) and a higher overall difference in means of indexed effective orifice area (iEOA) (random effect model: 0.058 cm2/m2; 95% CI 0.024-0.092, P < 0.001). The overall ORs for myocardial infarction, stroke, complete heart block/permanent pacemaker implantation and reoperation for bleeding showed no statistically significant difference between the groups. AAE is a useful adjunct to AVR, but the benefit of reduced PPM must be balanced against a possibly higher risk of perioperative mortality.

Asymptomatic severe aortic stenosis, bicuspid aortic valves and moderate aortic stenosis in heart failure: New indications for transcatheter aortic valve implantation.

Aortic stenosis (AS) remains one of the most common valvular heart diseases, with enormous impact on patient survival. Over the past years, transcatheter aortic valve implantation (TAVI) has become a reality worldwide, offering a less invasive method to treat AS. Apart from the classical indications for aortic valve disease, recent studies tried to address unanswered questions for TAVI - asymptomatic severe AS, bicuspid aortic valves and moderate AS in patients with heart failure. This review discusses the rationale of those possible indications, pitfalls and current evidence in the medical literature.

Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) in adults: Collateral circulation does not preclude direct reimplantation.

BACKGROUND: The adult type of anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is characterized by late presentation due to collateral coronary flow. Patients often present with long time recurrent angina or dyspnea. Surgical correction can be a challenge due to the vast collateral coronary circulation. CASE PRESENTATION: A previously healthy 41-year-old male presented in the emergency room referring typical angina and dyspnea. Coronary angiography revealed ALCAPA. Surgical correction was indicated. Under cardiopulmonary bypass, the left main coronary artery ostium was isolated and directly reimplanted in the aorta. The patient was discharged from the hospital without complications and asymptomatic. Control coronary angiography showed enlarged left main coronary artery and regression of the collateral circulation. CONCLUSION: Even with a well-developed collateral circulation, detachment of the left coronary artery and direct implantation in the aorta is feasible, achieving good long-term results.

Mitral valve repair with minimally invasive approaches vs sternotomy: A meta-analysis of early and late results in randomized and matched observational studies.

BACKGROUND AND AIM OF THE STUDY: Minimally invasive cardiac surgery (MICS) for mitral valve repair (MVRp) has been increasingly used. This study aimed to evaluate the early and late results of MICS for MVRp vs conventional sternotomy. MATERIALS AND METHODS: A systematic review of randomized controlled trials or observational studies (with matched populations) comparing MICS and conventional MVRp reporting any of the following outcomes: mortality, MVRp failure, complications, blood transfusion, readmission within 30 days after discharge, long-term reoperation for mitral regurgitation, operative times, mechanical ventilation time, intensive care unit (ICU) stay, or hospital stay. The pooled treatment effects were calculated using a random-effects model. RESULTS: Ten studies involving 6792 patients (MICS: 3396 patients; Conventional: 3296 patients) met the eligibility criteria. In the pooled analysis, MICS significantly reduced the risk for blood transfusion (odds ratio [OR], 0.654; 95% confidence interval [CI] 0.462-0.928; P = .017) and readmission within 30 days after discharge (OR, 0.615; 95% 0.456-0.829; P = .001). MICS was associated with a significantly longer cross-clamp time (mean difference 14 minutes; 95% CI, 7.4-21 minutes; P < .001), CPB time (24 minutes; 95% CI, 14-35 minutes; P < .001), and total operative time (36; 95% CI, 15-56 minutes; P < .001), but a significantly shorter ICU stay (-8.5; 95% CI -15; -1.8; P = .013) and hospital stay (-1.3, 95% CI -2.1; -0.45; P = .003). This meta-analysis found no significant difference regarding the risk of in-hospital and long-term mortality, nor complications. CONCLUSIONS: Despite longer operative times, MICS for MVRp reduces ICU and hospital stay, as well as readmission rates and the need for transfusion.

German Aortic Valve Score in Risk Assessment for Surgical Aortic Valve Replacement in a Brazilian Center.

OBJECTIVE: To test the German Aortic Valve (GAV) score at our university hospital in patients undergoing isolated aortic valve replacement (AVR). METHODS: A total of 224 patients who underwent isolated conventional AVR between January 2015 and December 2018 were included. Patients with concomitant procedures and transcatheter aortic valve implantation were excluded. Patients' data were collected and analyzed retrospectively. Patients' risk scores were calculated according to criteria described by GAV score. Sensitivity, specificity, and accuracy (area under the ROC curve [AUC]) were also calculated. The calibration of the model was tested by the Hosmer-Lemeshow method. RESULTS: The mortality rate was 8.04% (18 patients). The patients' mean age was 58.2±19.3 years and 25% of them were female (56 patients). Mean GAV score was 1.73±5.86 (min: 0.0; max: 3.53). The GAV score showed excellent discriminative capacity (AUC 0.925, 95% confidence interval 0.882-0.956; P<0.001). The cutoff "1.8" turned out to be the best discriminatory point with the best combination of sensitivity (88.9%) and specificity (75.7%) to predict operative death. Hosmer-Lemeshow method revealed a P-value of 0.687, confirming a good calibration of the model. CONCLUSION: The GAV score applies to our population with high predictive accuracy.

Mitral Annular Calcification: Association with Atherosclerosis and Clinical Implications.

PURPOSE OF REVIEW: This review summarizes the pathophysiology of mitral annular calcification (MAC) with recent findings and current strategies for diagnosis and treatment. RECENT FINDINGS: Major factors in MAC development seem to be shear stress of the flow past the mitral valve, local inflammation, and dysregulation in regulators of mineral metabolism. MAC itself poses daunting technical challenges. Implanting a valve on top of the calcium bar might lead to paravalvular leak (PVL) that is less likely to heal. Annular decalcification allows for better valve seating and potentially better healing and less PVL. This, however, comes with the risk for catastrophic atrioventricular groove disruption. MAC can be sharply dissected with the scalpel; the annulus can be reconstructed with the autologous pericardium. Transcatheter mitral valve replacement is a promising approach in the treatment of patients who are deemed high-risk surgical candidates with severe MAC. MAC is a multifactorial disease that has some commonalities with atherosclerosis, mainly regarding lipid accumulation and calcium deposition. It is of great clinical importance, being a risk marker of cardiovascular events (including sudden death) and, with its progression, can have a negative impact on patients' lives.

Calcific Aortic Valve Stenosis and Atherosclerotic Calcification.

PURPOSE OF REVIEW: This review summarizes the pathophysiology of calcific aortic valve stenosis (CAVS) and surveys relevant clinical data and basic research that explain how CAVS arises. RECENT FINDINGS: Lipoprotein(a) [Lp(a)], lipoprotein-associated phospholipase A2 (Lp-PLA2), oxidized phospholipids (OxPL), autotaxin, and genetic driving forces such as mutations in LPA gene and NOTCH gene seem to play a major role in the development of CAVS. These factors might well become targets of medical therapy in the coming years. CVAS seems to be a multifactorial disease that has much in common with coronary artery disease, mainly regarding lipidic accumulation and calcium deposition. No clinical trials conducted to date have managed to answer the key question of whether Lp(a) lowering and anti-calcific therapies confer a benefit in terms of reducing incidence or progression of CAVS, although additional outcome trials are ongoing.

Wrapping of ascending aortic aneurysm with supra-aortic debranching and endovascular repair for aortic arch aneurysm and ruptured descending thoracic aortic aneurysm.

We report a case of a hybrid surgical treatment of a 71-year-old fragile female with severe chronic obstructive pulmonary disease with a 5-year history of progressive back pain and diagnosis of descending thoracic aorta aneurysm (DTAA), but refused operation at first. Since the patient presented with an acute expanding painful pulsatile mass due to a ruptured DTAA contained by the subcutaneous tissue and had a high-risk surgical profile, we agreed that the simplest urgent operation should be performed. Cardiopulmonary bypass with or without deep hypothermic circulatory arrest was ruled out as an option. The initial approach would be permanent bypasses to the supra-aortic trunks and endovascular repair of the ruptured DTAA, but we ran into a problem: the absence of suitable diameter in the ascending aorta to land the prosthesis-zone 0. To overcome this obstacle, we opted to perform a diameter reduction of the ascending aorta by wrapping it with a Dacron tube to create a neck where we could land the endovascular prosthesis. Following this step bypasses from the proximal ascending aorta to the brachiocephalic artery, left common carotid artery and left subclavian artery were created. Since we gained ground to act in zone 0, the first endoprosthesis was landed in the wrapped zone and the aortic arch-from zone 0 to zone 3. The second and third endoprostheses covered the ruptured DTAA above the celiac trunk-zones 4 and 5. Good positioning of the endoprostheses was achieved and we attained procedural success.

German aortic valve score in risk assessment for surgical aortic valve replacement in a brazilian center

Abstract Objective: To test the German Aortic Valve (GAV) score at our university hospital in patients undergoing isolated aortic valve replacement (AVR). Methods: A total of 224 patients who underwent isolated conventional AVR between January 2015 and December 2018 were included. Patients with concomitant procedures and transcatheter aortic valve implantation were excluded. Patients' data were collected and analyzed retrospectively. Patients' risk scores were calculated according to criteria described by GAV score. Sensitivity, specificity, and accuracy (area under the ROC curve [AUC]) were also calculated. The calibration of the model was tested by the Hosmer-Lemeshow method. Results: The mortality rate was 8.04% (18 patients). The patients' mean age was 58.2±19.3 years and 25% of them were female (56 patients). Mean GAV score was 1.73±5.86 (min: 0.0; max: 3.53). The GAV score showed excellent discriminative capacity (AUC 0.925, 95% confidence interval 0.882-0.956; P<0.001). The cutoff "1.8" turned out to be the best discriminatory point with the best combination of sensitivity (88.9%) and specificity (75.7%) to predict operative death. Hosmer-Lemeshow method revealed a P-value of 0.687, confirming a good calibration of the model. Conclusion: The GAV score applies to our population with high predictive accuracy.