Partial versus Complete Sternotomy for Aortic Valve Replacement-Multicenter Study.

BACKGROUND: The benefits of minimally invasive techniques in cardiac surgery remain poorly defined. We evaluated the short- and mid-term outcomes after surgical aortic valve replacement through partial upper versus complete median sternotomy (MS) in a large, German multicenter cohort. METHODS: A total of 2,929 patients underwent isolated surgical aortic valve replacement via partial upper sternotomy (PUS, n = 1,764) or MS (n = 1,165) at nine participating heart centers between 2016 and 2020. After propensity-score matching, 1,990 patients were eligible for analysis. The primary end point was major adverse cardiac and cerebrovascular events (MACCE), a composite of death, myocardial infarction, and stroke at 30 days and in follow-up, up to 5 years. Secondary end points were acute kidney injury, length of hospital stay, transfusions, deep sternal wound infection, Dressler's syndrome, rehospitalization, and conversion to sternotomy. RESULTS: Unadjusted MACCE rates were significantly lower in the PUS group both at 30 days (p = 0.02) and in 5-year follow-up (p = 0.01). However, after propensity-score matching, differences between the groups were no more statistically significant: MACCE rates were 3.9% (PUS) versus 5.4% (MS, p = 0.14) at 30 days, and 9.9 versus 11.3% in 5-year follow-up (p = 0.36). In the minimally invasive group, length of intensive care unit (ICU) stay was shorter (p = 0.03), Dressler's syndrome occurred less frequently (p = 0.006), and the rate of rehospitalization was reduced significantly (p < 0.001). There were 3.8% conversions to full sternotomy. CONCLUSION: In a large, German multicenter cohort, MACCE rates were comparable in surgical aortic valve replacement through partial upper and complete sternotomies. Shorter ICU stay and lower rates of Dressler's syndrome and rehospitalization were in favor of the partial sternotomy group.

The Clinical Impact of Psoas Muscle Cross-Sectional Area on Medium-Term Mortality After Transcatheter Aortic Valve Implantation.

AIM: Psoas muscle cross-sectional area (CSA) is a proposed marker of frailty associated with mortality after transcatheter aortic valve implantation (TAVI). We assessed the impact of psoas CSA on medium-term mortality over 5 years in a large cohort, adjusted for pre-procedural variables. METHOD: This single-centre registry-derived analysis assessed 1,731 consecutive TAVI patients between 2007 and 31 April 2015 with available abdominal computed tomography scans. Sex-stratified, height-adjusted psoas CSA was measured mid-body of the fourth lumbar vertebra. Kaplan-Meier survival distributions across psoas CSA quartiles were compared. Cox and logistic regression models were used to assess baseline variables associated with the primary outcome, which was mortality within 5 years. RESULTS: Median age was 81 years (interquartile range, 77 - 85); 52.5% were women. The primary endpoint occurred in 555 patients over a mean follow-up of 775 days. Lower psoas CSA quartile patients were older, had a lower body mass index, lower creatinine clearance, and lower rates of previous cardiac surgery, with higher rates of diabetes, coronary artery disease, pacemaker, anaemia, hypoalbuminaemia, and higher European System for Cardiac Operative Risk Evaluation (EuroSCORE). Unadjusted survival by psoas CSA quartile was significantly different in men (log rank p=0.041) but not women (p=0.099). In Bonferroni-adjusted multivariate analysis, psoas CSA quartiles were not significantly associated with mortality. Hypoalbuminaemia (hazard ratio [HR], 2.10; 95% confidence interval [CI], 1.53 - 2.87 [p<0.001]) and increasing age (HR, 1.03 per year; 95% CI, 1.01 - 1.05 [p=0.002]) were associated with increased risk; female sex (HR, 0.63; 95% CI 0.51 - 0.78 [p<0.001]), and hypercholesterolaemia (HR, 0.67; 95%, CI 0.54 0.83 [p<0.001]) with reduced risk. CONCLUSIONS: Psoas CSA was not significantly associated with mortality after adjusting for pre-procedural variables. Hypoalbuminaemia, sex, hypercholesterolaemia, and age were significantly associated with mortality after TAVI.

Transapical Transcatheter Aortic Valve Implantation Using a New TAVI System for High-Risk Patients With Severe Aortic Stenosis.

BACKGROUND: To evaluate the safety and efficacy of transcatheter aortic valve implantation (TAVI) for high-risk patients with aortic stenosis using the J-Valve system. METHODS: 30 high-risk patients with severe AS underwent TAVI procedure were enrolled with mean age 74.5±4.5 years and mean logistic Euro-SCORE-I of 28.4±9.6%. All patients were followed up for 6 months. Outcomes were analysed in accordance with the updated standardised endpoints defined by the Valve Academic Research Consortium -2 (VRAC-2) criteria. RESULTS: VARC-2 defined device success was obtained in 93% (28 of 30 patients). No operative mortality was noted. No major complications such as third-degree AV-block, myocardium infraction or cerebrovascular events were noted during procedure and follow-up. Transvalvular PG was decreased at 6 months compared with preoperative state (PG mean: 55.4±14.9 vs 14.6±6.9mmHg p<0.01). No moderate or above degree paravalvular leakage (PVL) was noted. All patients with successful valve implantation were alive with improved exercise tolerance. CONCLUSIONS: Our initial result has demonstrated that the J-Valve system has the potential to become a feasible treatment option for high-risk patients with severe AS.

Clinical presentation and outcomes after transcatheter aortic valve implantation in patients with low flow/low gradient severe aortic stenosis.

OBJECTIVES: To identify predictors of mortality, functional status, and hemodynamical changes of patients undergoing transcatheter aortic valve implantation (TAVI) for low flow/low gradient aortic stenosis (LF/LG AS). BACKGROUND: There is little published data regarding the outcomes of patients with LF/LG AS following TAVI. METHODS: Sixty-eight patients with severe AS, left ventricular dysfunction (ejection fraction [EF] <35%) and low flow (LF) AS underwent TAVI. Patients were stratified according to the aortic mean pressure gradient (low gradient [LG]; with Pmean ≤40 mm Hg and high gradient [HG]: Pmean >40 mm Hg). The baseline parameters and clinical outcomes were subsequently compared among the two groups. Cox proportional hazards were used to identify predictors of 6-month mortality. RESULTS: There were 38 patients in the LG group and 30 patients in the HG group. There were no significant difference in 30-day mortality between the two groups. The 6-month and 1-year mortality, however, was 3.8-fold and 2.8-fold higher in the LG group than in the HG group (37.8% vs. 10.3%, P = 0.01 and 37.8% vs. 13.3%, respectively, P = 0.01). Univariable predictors for 6-month mortality were: STS Score, aortic valve area, and aortic mean pressure gradient. However, only STS Score (HR 1.08, 1.04-1.12, P < 0.001) remained as independent predictor in the multivariable analysis. Six months after TAVI, hemodynamical (EF > 50%) and clinical (NYHA class I) improvements were shown in both HG and LG groups. CONCLUSIONS: LF/LG AS does not influence procedural mortality after TAVI but exhibits a strong impact on 6-month and 1-year mortality. The survivors, however, exhibit considerable hemodynamical and clinical improvements. Therefore, risk stratification and TAVI benefit should be weighted in every patient with LF/LG AS.

Sex-related differences in 2197 patients undergoing isolated surgical aortic valve replacement.

OBJECTIVES: The aim of this study is to evaluate gender-related differences in clinical presentation and mortality in patients undergoing isolated surgical aortic valve replacement (SAVR). METHODS: We performed a retrospective analysis of all patients undergoing isolated SAVR from 2000 to 2011 in our center. Patient data were compared with regard to gender including baseline characteristics, 30-day, and late mortality. Kaplan-Meier survival curves were used to analyze long-term survival up to 10 years follow-up. Independent risk factors for 30-day and late mortality were identified using a Cox regression model. RESULTS: Two thousand one hundred ninety-seven patients were included, 1290 (58.7%) male patients and 907 (41.3%) female patients. Female patients were older (70 ± 11 vs. 64 ± 13 years, p < 0.001), presented with higher logistic EuroSCORE (7.5 ± 5.8 vs. 5.6 ± 6%, p = 0.006), and more common NYHA class III or IV (71 vs. 65%, p = 0.05). Male patients presented more often with LV dysfunction (7.5 vs. 2.8%, p < 0.001) and endocarditis (4.1 vs. 1.7%, p < 0.001) than female patients. Intraoperatively, female patients were more likely to have had a complete sternotomy (65 vs. 52%, p < 0.001) and SAVR with a bioprosthesis (87 vs. 78%, p < 0.001). Female patients exhibited a higher 30-day mortality (4.4 vs. 1.6%, p < 0.001) and late mortality (13 vs. 9.6%, p = 0.04) than male patients. After adjustment for baseline characteristics, only female gender was an independent predictor for 30-day mortality (HR 2.2, 95% CI 0.98 to 5.2, p = 0.05) and age as independent predictor for late mortality (HR 1.07, 95% CI 1.03 to 1.1, p < 0.001). CONCLUSION: Female patients were older and sicker and may therefore exhibit higher 30-day and late mortality than male patients. Female gender per se was a predictor for 30-day but not for late mortality.

Outcomes of patients undergoing third-time aortic or mitral valve replacement.

BACKGROUND AND AIM: Third-time valve surgery is rare and to date little is known about the surgical outcome. We reviewed our experience with third-time aortic valve replacement (AVR) and third-time mitral valve replacement (MVR) during an eight-year period. METHODS: From 2001 to 2013, 32 patients were referred for third-time AVR or third-time MVR to our institution. In this retrospective analysis, patients were evaluated for postoperative morbidity including: hemodialysis, cerebrovascular event, pacemaker implantation, and 30-day and mid-term mortality. RESULTS: Third-time replacement was for failed aortic valves in 20 (62.5%) patients and for failed mitral valves in 12 (37.5%) patients. Patients' mean age at the time of surgery was 56.3 ± 19 years. The mean interval between the first and the second procedure was 10 ± 7.8 years and between second and third replacement 7.3 ± 5.6 years. The failed prostheses included nine (28%) bioprostheses and 23 (72%) mechanical prostheses. The reasons for replacement were: infective valve endocarditis (31.3%), prosthesis dysfunction (37.3%), and paravalvular leakage (26%). The 30-day mortality was 18.8% and during follow-up was 31.3%. Hemodialysis was needed for eight patients (25.8%), pacemaker implantation for eight patients (25.8%), and cerebrovascular event occurred in four patients (13.3%). In patients with prosthetic valve endocarditis (n = 10), 30-day and overall mortality were 11.1% and 30%, respectively. CONCLUSION: Third-time aortic or mitral valve replacement is a rare procedure but accompanied with high morbidity and mortality, especially in patients with prosthetic valve endocarditis.

Health-related quality of life and functional outcome in cardiac surgical patients aged 80 years and older: a prospective single center study.

BACKGROUND: An increasing number of octogenarians are referred for cardiac surgical procedures. In this subset of patients, information on the health-related quality of life (HrQoL) is critical for decision making. However, there is a paucity of prospective data. Thus, we sought to prospectively evaluate the HrQoL in octogenarians undergoing cardiac surgery. METHODS: A prospective HrQoL analysis was performed in 106 elective patients (median age 83.0 ± 2.6 years, range 80-91.8 years, 59.4% male) undergoing cardiac surgery. The standardized SF-36 Health Survey questionnaire was answered preoperatively, and three and 12 months postoperatively. Preoperative data, perioperative outcome, and postoperative morbidity were analyzed. RESULTS: SF-36 scores for physical functioning (44.3 ± 2.3 vs. 52.0 ± 2.7; p < 0.001), role physical (25.2 ± 3.3 vs. 41.5 ± 4.1; p < 0.001), bodily pain (57.8 ± 3.2 vs. 70.7 ± 2.8; p < 0.01), general health (54.9 ± 1.7 vs. 59.6 ± 1.7; p < 0.001), vitality (41.1 ± 2.1 vs. 50.6 ± 2.1; p < 0.001), and mental health (67.5 ± 2.0 vs. 72.4 ± 1.9; p < 0.05) significantly improved from baseline to three months. Social functioning (75.4 ± 2.6 vs. 76.1 ± 2.5; p = 0.79) and role emotional (56.8 ± 4.5 vs. 58.0 ± 4.6; p = 0.29) improved slightly without reaching statistical significance. Correspondingly, at three months, physical component scores increased significantly compared to baseline (34.3 ± 1.0 vs. 39.4 ± 1.0; p < 0.001). SF-36 scores remained stable between three months and one year. No significant change was seen in the mental component score from baseline to three months (48.6 ± 1.2 vs. 49.8 ± 1.1; p = 0.18). CONCLUSIONS: Physical HrQoL is significantly improved in octogenarians three months after cardiac surgery remaining stable at one year postoperatively when compared to baseline.

Incidence and predictors of acute kidney injury in patients undergoing transcatheter aortic valve implantation.

BACKGROUND: Acute kidney injury (AKI) can occur in up to one third of patients after surgical aortic valve replacement and can be associated with increased mortality. Little data exist, however, about the incidence, predictors, and prognostic implications of AKI after transcatheter aortic valve implantation (TAVI). OBJECTIVES: The aim of this study was to examine the incidence, predictors, and prognostic implications of AKI after TAVI. METHODS: Between January 2007 and January 2010, we prospectively enrolled 234 consecutive patients who underwent TAVI with the Medtronic CoreValve System (Medtronic CoreValve, Minneapolis, Minnesota) or Edwards SAPIEN (Edwards Lifesciences, Inc, Irvine, CA) heart valve. Acute kidney injury was defined according to the risk, injury, failure, loss, end-stage criteria. Patients with preoperative end-stage renal failure requiring dialysis were excluded. Baseline characteristics and procedural-related factors were examined as predictors for AKI in a multivariable regression model. RESULTS: Acute kidney injury was identified in 46 (19.6%) of 234 patients, and 24 (10.3%) of 234 patients required renal replacement therapy. The unadjusted in-hospital mortality rate was 15.2% in those patients without AKI and 7.7% in those with AKI (P = .015). Univariable logistic regression analysis identified preoperative serum creatinine, preoperative blood urea nitrogen, peripheral vascular disease, and blood transfusion to be associated with AKI. Preoperative serum creatinine level remained as the only independent predictor of AKI (OR 3.7 95%, CI 1.24-11.3, P = .019). The amount of contrast used (in milliliters) was not associated with AKI (OR 1.8 95%, CI 0.94-3.5, P = .07). CONCLUSION: In this study, we observed that one fifth of patients developed AKI after TAVI and that AKI was associated with increased in-hospital mortality. Preoperative serum creatinine level was identified as the only predictor of AKI.

Fast-track anesthesia in lateral mini-thoracotomy for transapical transcatheter valve implantation.

BACKGROUND: Patients who undergo transapical transcatheter aortic/mitral valve implantation are at higher risk of morbidity and mortality than those undergoing transvascular procedures. In addition, these patients have prolonged intensive care and hospital courses. Fast-track anesthesia could reduce perioperative complications and admission stays in such patients. METHODS: This retrospective single-center study, evaluates six high-risk patients undergoing transapical valve implantation between 01/2020 till 01/2021. All patients received a paravertebral block (PVB) as part of a fast-track approach. The airway was secured with a Gastro-double-lumen laryngeal mask which includes one orifice was for ventilation and one for the transesophageal echocardiography probe. Anesthesia was maintained with a volatile anesthetic (Sevoflurane MAC 1%). Immediately post procedure, all patients were awakened and admitted to the intermediate/intensive-care unit. RESULTS: Three patients were females, mean age =71±6 years, patients' risk profiles were high (mean Log. EuroSCORE-I 22% & STS-PROM 10%). No incidents of re-intubation, atelectasis/pneumonia, low output syndrome, stroke, dialysis, pacemaker implantation or operative mortality were reported. One patient (16.7%) underwent re-exploration for bleeding and developed a wound infection. Postoperative pain scores showed that no patient required additional analgesics after the initial eight hours post procedure. Mean postoperative intermediate/intensive-care stay was 13.8±3.2 hours and patients were mobilized early and discharged to the normal ward. CONCLUSIONS: Fast-track anesthesia using paravertebral-blockade for transcatheter transapical valve replacement in high-risk patients is a possible anesthetic approach. An effective PVB, in addition to a double-lumen laryngeal mask, provide an alternative strategy to conventional general anesthesia. These promising results could encourage further consideration of this approach in similar cardiac surgery patients.

Impact of Non-Valvular Non-Coronary Concomitant Procedures on Outcomes of Surgical Aortic Valve Replacement in Intermediate Risk Patients.

INTRODUCTION: advanced age and concomitant procedures could increase the risk of perioperative complications during surgical aortic valve replacement (SAVR). We aimed to evaluate results of elderly patients undergoing SAVR and evaluate the impact of concomitant non-valvular, non-coronary procedures on the outcomes. METHODS: A retrospective single-centre study, evaluating 464 elderly patients (mean age = 75.6 ± 4 years) undergoing either isolated-SAVR (I-SAVR = 211) or combined-SAVR (C-SAVR = 253) between 01/2007 and 12/2017. Combined-SAVR involved non-valvular, non-coronary procedures. Study endpoints are postoperative results concerning the VARC-II criteria, valve dysfunction, long-term freedom from redo-AVR and survival. RESULTS: males were 52.8%. Patients had an intermediate risk profile (mean EuroSCORE-II (%) 5.2 ± 5). Postoperative results reported no significant differences in incidence of re-exploration for bleeding (6.6% vs. 6.7%, p = 1.0), stroke (0.9% vs. 0.4%, p = 0.59), dialysis (6.2% vs. 9.5%, p = 0.23) and pacemaker implantation (3.3% vs. 2.8%, p = 0.79) between I-SAVR and C-SAVR groups. Thirty-day (2.4% vs. 7.1% p = 0.03), one-year (5.7% vs. 13.8%, p = 0.003) and overall mortality (24.6% vs. 37.5%, p = 0.002) were lower in the isolated-SAVR group. Re-AVR was indicated in 1.7% of patients due to endocarditis. CONCLUSIONS: SAVR in elderly patients offers good outcomes with increased life quality and rare re-operation for structural valvular deterioration. Mortality rates were significantly higher when SAVR was combined with another "non-valvular, non-coronary" procedure.

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.

OBJECTIVES: Recent 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. METHODS: A comprehensive literature search was performed using PubMed, Embase and the Cochrane Central Register of Controlled trials through June 2016. RESULTS: Five 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; P = 0.62], 30-day cardiovascular mortality rate (OR 1.59, 95% CI 0.52-4.88; P = 0.41) and 1-year mortality rate (OR 1.16, 95% CI 0.85-1.59; P = 0.34) 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; P = 0.04) 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. CONCLUSIONS: Combined TAVI+PCI showed similar rates of death from any cause at 30 days and 1 year 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.

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%, P = 0.05) and atrial fibrillation (11.7% vs 15.9%, P = 0.01) 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 (P < 0.05). Finally, the incidence of early deaths (1.5% vs 2.2%, P = 0.14), stroke (1.4% vs 2%, P = 0.20), myocardial infarction (0.4% vs 0.5%, P = 0.65), renal injury (4.5% vs 6%, P = 0.71), respiratory complications (9% vs 10.1%, P = 0.45), re-exploration for bleeding (4.9% vs 4.1%, P = 0.27) and pacemaker implantation (3.3% vs 4.1%, P = 0.31) 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.

Impact of previous cardiac surgery in patients undergoing transcatheter aortic valve implantation: a systematic review.

INTRODUCTION: Redo surgical aortic valve replacement after prior cardiac surgery is usually related to a higher risk of mortality and morbidity. Transcatheter aortic valve implantation (TAVI) became an alternative therapy for those patients in the past couple of years. EVIDENCE ACQUISITION: We aimed in this study to analyze the outcomes of patients undergoing TAVI after a prior cardiac surgery especially those who underwent coronary artery bypass grafting (CABG) and to see if TAVI offers any advantages for those patients than conventional surgical aortic valve replacement. EVIDENCE SYNTHESIS: We searched for relevant articles in Medline and abstracted clinical information based on pre-defined criteria and endpoints. Data of nine studies including the baseline characteristics, implantation data, postoperative outcomes and major adverse cardiac complications, which were published between 2011 and 2015 were collected and evaluated. From all reviewed studies, 769 patients had a prior cardiac surgery and underwent TAVI for symptomatic severe aortic stenosis. Of these, 738 patients (96%) had prior CABG. Patients' age ranged from 78±3 to 82±5.8 years. The STS and EuroSCORE ranged from 4.5±3% to 14.7±12.3% and 25.6±16.2% to 37±18%, respectively. In all reviewed studies the 30-day mortality was about 5.6% and was not significantly higher compared to patients with no history of prior cardiac surgery. The total incidence of stroke was about 3.6%, myocardial infarction was 1.7%, acute kidney injury was 13.8% and permanent pacemaker implantation was about 14.2%. CONCLUSIONS: However, patients presented with severe aortic valve disease after a previous cardiac surgery exhibited a higher preoperative STS and EuroSCORE than those without previous cardiac surgery. The 30-day mortality was not significantly higher in comparison to those patients without history of prior cardiac surgery. According to that, transcatheter aortic valve implantation should be considered as an attractive alternative for those patients.

Surgical mitral valve intervention following a failed MitraClip procedure.

The MitraClip procedure has shown promising results in patients with high surgical risk. However, data concerning outcomes of open mitral valve surgery for failed MitraClip procedures are sparse. In a retrospective clinical investigation, baseline characteristics, intraoperative and histopathological findings, surgical indications and results of patients who required surgery after a failed MitraClip procedure were collected. Between March 2010 and May 2016, 25 patients presented at our department with severe mitral valve regurgitation following a failed MitraClip procedure. Leaflet destruction or severe adhesions between leaflets and the implanted clip were the commonest intraoperative findings. Upon surgery, the mitral valve was either repaired (n=5, 20%) or replaced (n=20, 80%) with a biological prosthesis. Four patients who had presented in cardiogenic shock prior to the operation died within the first 30 days. In the majority of cases, mitral valve replacement is preferred over repair due to severe leaflet damage following the MitraClip procedure. Only those patients who present in cardiogenic shock are at extremely high risk for in-hospital mortality.

Outcomes of Redo Transcatheter Aortic Valve Replacement for the Treatment of Postprocedural and Late Occurrence of Paravalvular Regurgitation and Transcatheter Valve Failure.

BACKGROUND: Transcatheter aortic valves can degenerate in a manner similar to surgical bioprostheses. METHODS AND RESULTS: Clinical and echocardiographic outcomes of patients who underwent redo transcatheter aortic valve replacement (TAVR) procedures >2 weeks post procedure were collected from 14 centers. Among 13 876 patients, 50 (0.4%) underwent redo TAVR procedure at participating centers. Indications for redo TAVR were moderate-severe prosthetic aortic valve stenosis (n=10, 21.7%), moderate-severe central prosthetic aortic valve regurgitation (n=13, 28.3%), and moderate-severe paraprosthetic aortic valve regurgitation (n=25, 50.0%). The index TAVR was most commonly a Medtronic CoreValve (N=38, 76.0%), followed by Edwards SAPIEN-type valves (n=12, 24.0%) and Portico (n=1, 2.0%). The redo TAVR device was most commonly a CoreValve/Evolut R (n=29, 58.0%), followed by a SAPIEN-type valve (n=20,40.0%) or a Boston Lotus valve (n=1, 2.0%). In 40 patients (80.0%), redo TAVR was performed using the identical device type or that of the succeeding generation. Valve performance was uniformly good after redo TAVR (mean transvalvular gradient post redo TAVR: 12.5±6.1 mm Hg). At hospital discharge, all patients remained alive, with 1 nondisabling stroke (2.0%) and 1 life-threatening bleed (2.0%). Permanent pacemaker implantation was required in 3 out of 35 patients without a prior pacemaker (8.6%). Late survival was 85.1% at a median follow-up of 1589 days (range: 31-3775) after index TAVR and 635 days (range: 8-2460) after redo TAVR. CONCLUSIONS: Redo TAVR for the treatment of postprocedural and late occurrence of paravalvular regurgitation and transcatheter aortic valve prosthesis failure seems to be safe, and it is associated with favorable acute and midterm clinical and echocardiographic outcomes.

Muscular ventricular septal defect in a newborn with truncus arteriosus communis: perventricular transcatheter closure under echocardiographic guidance only, a case report.

We report a case of a 3.5-kg newborn presenting with a muscular ventricular septal defect (VSD) in the setting of truncus arteriosus communis (common arterial trunk). Reparative surgery using a hybrid approach included perventricular closure of the muscular VSD on the beating heart.

Acute kidney injury after transcatheter aortic valve implantation: incidence, predictors and impact on mortality.

There is a paucity of data describing acute kidney injury (AKI) following transcatheter aortic valve implantation and its impact on mortality remains unknown. We therefore evaluate the incidence, predictors and impact of AKI following transcatheter aortic valve implantation. We searched MEDLINE for studies from 2008 to 2013, evaluating AKI after transcatheter aortic valve implantation. All studies were compared according to the incidence, predictors and impact of AKI following transcatheter aortic valve implantation. AKI was diagnosed according to the Valve Academic Research Consortium definition using the RIFLE criteria. Thirteen studies with more than 1900 patients were included. AKI occurred in 8.3-57% of the patients. The following factors were associated with AKI: blood transfusion; transapical access; preoperative creatinine concentration; peripheral vascular disease; hypertension; and procedural bleeding events. The 30-day mortality rate in patients with AKI ranged from 13.3% to 44.4% and was 2-6-fold higher than in patients without AKI. The amount of contrast agent used was not associated with the occurrence of AKI. AKI is a common complication, with an incidence of 8.3-57% following transcatheter aortic valve implantation. Patients with AKI had higher 30-day and late mortality rates. However, AKI was related to the amount of contrast volume used in only one study.

Transcatheter aortic valve implantation in patients with LV dysfunction: impact on mortality and predictors of LV function recovery.

BACKGROUND: Aortic stenosis patients with left ventricular dysfunction are at increased risk for morbidity and mortality following surgical aortic valve replacement. There are few published data regarding the outcomes of patients with severe aortic stenosis and left ventricular (LV) dysfunction undergoing transcatheter aortic valve implantation (TAVI) and possible predictors of LV recovery. AIMS: To compare the baseline characteristics and outcomes between patients with normal LV function and those with LV dysfunction and to assess the predictors of LV recovery after TAVI. METHODS: We enrolled 505 consecutive patients with severe aortic stenosis who underwent TAVI between November 2007 and January 2010. Patients were stratified according to LV function as follows: normal LV function (ejection fraction [EF] >50%), moderate LV dysfunction (EF 35%-50%) and severe LV dysfunction (EF ≤35%). The baseline characteristics and clinical outcomes, up to 6 months, were subsequently compared among the 3 patient subgroups. Univariable and multivariable logistic regression analyses were used to identify independent predictors of LV recovery. RESULTS: Normal LV function was identified in 324 patients (64%) and LV dysfunction in 181 patients (36%); in those with LV dysfunction, 111 patients (22%) had moderate LV dysfunction and 70 patients (14%) had severe LV dysfunction. As compared to patients with normal LV function, those with severe LV dysfunction were more likely to be male, had higher STS and logistic EuroSCORE, more coronary artery disease/previous coronary artery bypass surgery, higher NT-proBNP levels, lower mean transaortic valve gradients, and smaller aortic valve areas. No significant difference in 30-day mortality was observed between the LV function subgroups. The 6-month mortality, however, was 2-fold higher in patients with severe LV dysfunction (27% vs 15%, respectively; P=.03). Recovery of LVEF to more than 50% was observed in 15% of patients with baseline EF ≤35%. Baseline EF was the strongest independent predictor of LV recovery after TAVI (odds ratio, 85; 95% confidence interval, 19-380; P<.001). CONCLUSIONS: Despite a similar periprocedural outcome, patients with aortic stenosis and severe LV dysfunction exhibit a significantly increased 6-month mortality after TAVI. Survivors with LV dysfunction, however, show a significant potential for LV function recovery.

Erroneous measurement of the aortic annular diameter using 2-dimensional echocardiography resulting in inappropriate CoreValve size selection: a retrospective comparison with multislice computed tomography.

OBJECTIVES: This study sought to assess the differential adherence to transcatheter heart valve (THV)-oversizing principles between transesophageal echocardiography (TEE) and multislice computed tomography (CT) and its impact on the incidence of paravalvular leak (PVL). BACKGROUND: CT has emerged as an alternative to 2-dimensional TEE for THV sizing. METHODS: In our early experience, TEE-derived aortic annular diameters determined THV size selection. CT datasets originally obtained for vascular screening were retrospectively interrogated to determine CT-derived annular diameters. Annular dimensions and expected THV oversizing were compared between TEE and CT. The incidence of PVL was correlated to TEE- and CT-based oversizing calculations. RESULTS: Using TEE-derived annulus measurements, 157 patients underwent CoreValve implantation (23 mm: n = 66; 29 mm: n = 91). The estimated THV oversizing on the basis of TEE was 20.1 ± 8.2%. Retrospective CT analysis yielded larger annular diameters than TEE (p < 0.0001). When these CT diameters were used to recalculate the percentage of oversizing achieved with the TEE-selected CoreValve, the actual THV oversizing was only 10.4 ± 7.8%. Consequently, CT analysis suggested that up to 50% of patients received an inappropriate CoreValve size. When CT-based sizing criteria were satisfied, the incidence of PVL was 21% lower than that with echocardiography (14% vs. 35%; p = 0.003). Adherence to CT-based oversizing was independently associated with a reduced incidence of PVL (odds ratio 0.36; 95% confidence interval: 0.14 to 0.90; p = 0.029); adherence to TEE-based sizing was not. CONCLUSIONS: Retrospective CT-based annular analysis revealed that CoreValve size selection by TEE was incorrect in 50% of patients. The percentage of oversizing with CT was one-half of that calculated with TEE resulting in the majority of patients receiving a THV that was too small.