Clinical performance of a novel bioprosthetic surgical aortic valve in a German high-volume center.

BACKGROUND AND AIM: Bioprosthetic surgical aortic valve replacement (SAVR) is increasingly adopted in younger patients. We aimed to analyze mid-term follow-up data after SAVR to assess the performance of the prosthesis. METHODS: Data were collected from a single-center series of 154 patients, who underwent SAVR with a bioprosthetic heart valve with the RESILIA tissue at our Heart Centre in Siegburg. All procedural and midterm patient outcomes were documented. RESULTS: Patients had a mean age of 56.8 ± 9.9 years, 35.7% were female, and the mean logistic European system for cardiac operative risk evaluation (EuroSCORE) was 3.4 ± 3.6%. Diabetes (12.3%), atrial fibrillation (10.4%), and chronic obstructive pulmonary disease (COPD) (5.8%) were common comorbidities. The mean surgery duration was 163.8 ± 73.4 min, with the 23 mm (34.4%) and 25 mm (33.8%) heart valves being most frequently implanted. At 3-year follow-up, mean pressure gradient was 13.9 ± 5.9 mmHg, peak gradient was 23.6 ± 7.7 mmHg, and effective orifice area (EOA) was 1.9 ± 0.4 cm². No patient died during the operation, 3 (2.1%) patients within 30 days, and 4 (2.7%) thereafter with an overall mortality of n = 7. Of the surviving patients, 97.8% were in New York Heart Association (NYHA) class I/II and none had structural valve deterioration (SVD). CONCLUSION: Results of our single-center study indicate favorable procedural outcomes. The safety outcomes confirm preliminary earlier results of this novel bioprosthesis but include more patients and a longer midterm follow-up.

Prognostic impact of echocardiographic mean transvalvular gradients in patients with aortic stenosis and low flow undergoing transcatheter aortic valve implantation.

BACKGROUND: Blunted left ventricular hemodynamics reflected by a low stroke volume index (SVI) ≤35 mL/m2 body surface area (low flow [LF]) in patients with severe aortic stenosis (AS) are associated with worse outcomes even after correction of afterload by transcatheter aortic valve implantation (TAVI). These patients can have a low or high transvalvular mean pressure gradient (MPG). We investigated the impact of the pre-interventional MPG on outcomes after TAVI. METHODS: Patients with LF AS were classified into those with normal (EF ≥ 50%; LF/NEF) or reduced ejection fraction (EF < 50%; LF/REF) and were then stratified according to an MPG < or ≥ 40 mmHg. Patients with SVI >35 mL/m2 (normal flow; NF) served as controls. RESULTS: 597 patients with LF/NEF, 264 patients with LF/REF and 975 patients with NF were identified. Among all groups those patients with a low MPG were characterized by higher cardiovascular risk. In patients with LF/REF, functional improvement post-TAVI was less pronounced in low-MPG patients. One-year survival was significantly worse in LF AS patients with a low vs. high MPG (LF/NEF 16.5% vs. 10.5%, p = 0.022; LF/REF 25.4% vs. 8.0%, p = 0.002), whereas no differences were found in NF patients (8.7% vs. 10.0%, p = 0.550). In both LF AS groups, a low pre-procedural MPG emerged as an independent predictor of mortality. CONCLUSIONS: In patients with LF AS, an MPG cut-off of 40 mmHg defines two patient populations with fundamental differences in outcomes after TAVI. Patients with LF AS and a high MPG have the same favorable prognosis as patients with NF AS.

Does the severity of low-gradient aortic stenosis classified by computed tomography-derived aortic valve calcification determine the outcome of patients after transcatheter aortic valve implantation (TAVI)?

OBJECTIVES: Aortic valve calcification (AVC) determined by computed tomography has emerged as a complementary measure of aortic stenosis (AS) severity and as a predictor of adverse events. Thus, AVC can guide further treatment decisions in patients with low-gradient AS (LG-AS). We compared the symptomatic and prognostic outcome of patients with low vs. high AVC after transcatheter aortic valve implantation (TAVI). METHODS: Patients with an aortic valve area index ≤ 0.6 cm2/m2 and a mean pressure gradient (MPG) < 40 mmHg were classified as low-flow, low-gradient AS (LFLG-AS; stroke volume index [SVI] ≤ 35 ml/m2, left ventricular ejection fraction [LVEF] < 50%, n = 173), paradoxical LFLG-AS (pLFLG-AS, SVI ≤ 35 ml/m2, LVEF ≥ 50%, n = 233), or normal-flow, low-gradient AS (NFLG-AS, SVI > 35 ml/m2, LVEF ≥ 50%, n = 244); patients with MPG ≥ 40 mmHg (n = 1142) served as controls. Patients were further categorized according to published AVC thresholds. RESULTS: Demographic characteristics and cardiovascular risk were not different between patients with high vs. low AVC in any of the subgroups. Patients with low AVC had a lower MPG. Symptom improvement at 30 days was observed in the majority of patients but was less pronounced in LFLG-AS patients with low vs. those with high AVC. Kaplan-Meier 1-year survival curves were identical between patients with low and high AVC in all three LG-AS groups. CONCLUSIONS: The severity of LG-AS based on AVC has no impact on 1-year prognosis once TAVI has been performed. KEY POINTS: • Aortic valve calcification (AVC) determined by computed tomography has emerged as a complementary measure of aortic stenosis (AS) severity and is of prognostic value in selected patients. • Patients with inconsistent echocardiographic measures can be classified as having severe or nonsevere AS by the computed tomography-derived AVC score. • The prognostic value of AVC in patients with low-gradient AS is abrogated after correction of afterload by TAVI.

Does Preoperative Sinus Rhythm Influence Surgical Ablation's Perioperative Safety in Patients with Atrial Fibrillation?

BACKGROUND: Despite excellent data on lowering long-term stroke and all-cause mortality rates, currently, only 25-40% of atrial fibrillation (AF) patients undergo simultaneous surgical ablation therapy (SA) during cardiac surgery. Surgeon's fear exposing their patients to an additional, unjustified, and disproportionate risk when performing SA in AF patients presenting with sinus rhythm (SR) before surgery. To clarify the influence of preoperative SR before SA for AF, we conducted a subgroup analysis of the German Cardiosurgical Atrial Fibrillation (CASE-AF) register. METHODS: Between September 2016 and August 2020, 964 AF patients with an underlying cardiac disease were scheduled for surgery with SA and enrolled in the CASE-AF register. Data prospectively were collected and analyzed retrospectively. We divided the entire cohort into an SR-group (38.2%, N = 368) and an AF-group (61.8%, N = 596), based on preoperative heart rhythm. RESULTS: Over half of the patients were moderately affected by their AF, with no difference between the groups (European Heart Rhythm Association class ≥IIb: SR-group 54.2% versus AF-group 58.5%, P = .238). The AF-group had a higher preoperative EuroSCORE II (4.8 ± 8.0% versus 4.2 ± 6.3%, P = .014). In-hospital mortality (SR-group 0.8% versus AF-group 1.7%, P = .261), major perioperative adverse cardiac and cerebrovascular events (SR-group 2.7% versus AF-group 3.5%, P = .500), and the new pacemaker implantation rate (SR-group 6.0% versus AF-group 5.9%, P = .939) were low and showed and no group difference. Logistic regression analysis showed a protective effect for preoperative SR to perioperative complications in AF patients undergoing SA (odds ratio (OR) 0.72 (95% CI 0.52 - 0.998); P = .0485). CONCLUSIONS: Concomitant SA in AF patients presenting in SR before cardiac surgery is safe, has a low perioperative risk profile, and should be carried out with almost no exceptions.

Transcatheter/Hybrid Aortic Valves in the Young.

Transcatheter aortic valve implantation (T-AVI) has been established as an alternative to conventional aortic valve replacement. The number of procedures is steadily rising and has reached comparable implant rates to conventional aortic valve replacement. The success of T-AVI is easily explained by their true minimally invasive nature, ease of use, and excellent hemodynamics. Whilst their use was initially limited to high-risk patients, current trends show that more and more intermediate-risk patients are now treated with theses prostheses. The question arises whether children would also benefit from this type of procedure. Percutaneous transcatheter pulmonary valve replacement is already becoming an important adjunct in the treatment of older children with failing right ventricular outflow tract conduits. Recently, several valve-in-valve procedures have been performed using T-AVI in failing bioprosthetic valves in young patients. There has also been a report of successful transcatheter neoaortic valve replacements in young patients after Fontan palliation. As an alternative to transcatheter valves, so called hybrid or sutureless rapid deployment aortic valves have recently been introduced into clinical practice. Although this concept is old, the current generation of these prostheses has been redesigned based on modern experiences with transcatheter valves. Current outcomes demonstrate that aortic valve replacement with sutureless valves could be a promising option for aortic stenosis, by facilitating minimally invasive surgery and minimizing cardiopulmonary bypass and cross clamping time. Therefore, the sutureless valve could prove to be an important alternative to conventional bioprosthetic aortic valve replacement in children too. In the current review, we provide an overview of the different types of transcatheter and sutureless aortic valve substitutes, discuss their advantages and short comings, and outline their clinical performance and potential benefits in a young patient population.

Safety of transcatheter aortic valve implantation in a hospital with visiting on-site cardiac surgery.

OBJECTIVES: To describe the feasibility and safety of transcatheter aortic valve implantation (TAVI) with a visiting on-site cardiac surgery program for surgical back-up. BACKGROUND: Both European and American guidelines recommend institutional cardiac surgery back-up for TAVI. However, the conversion to cardiac surgery is very rare, many complications of TAVI can be managed by catheter techniques and a visiting team can also provide surgical stand-by. Therefore, the need for institutional cardiac surgery (by a surgeon who routinely performs conventional surgical valve replacement at the institution performing TAVI) has been questioned. METHODS: A retrospective review of consecutive TAVI cases with visiting on-site cardiac surgery was performed. Key demographic, echocardiographic, and procedural data were collected prospectively. RESULTS: A total of 97 patients (81.9 ± 6.3 years) with high-risk criteria (log Euroscore 21.6 ± 14.4, chronic renal failure 39.2%, severe systolic dysfunction 24.7%) underwent TAVI with visiting on-site cardiac surgery at our institution. Local anesthesia with or without conscious sedation was used in 94.8% of patients. Procedural technical success was 100%, with 2 episodes of tamponade (both treated with pericardiocentesis) and a 16.5% vascular complication rate (all treated conservatively or percutaneously). Thirty-day mortality was 3.1%, with 5.2% rate of stroke and 8.2% rate of major bleeding. There were no conversions to surgery. CONCLUSIONS: TAVI can be done safely in the setting of a hospital with visiting on-site cardiac surgery. This requires careful patient selection, experienced operators and surgeons in experienced centers with well-established criteria and processes of care. In this setting, it may be an option for hospitals without institutional cardiac surgery.

Transcatheter aortic valve implantation--update and evidence.

Transcatheter aortic valve implantation (T-AVI) has become the standard of care for high-risk patients suffering from severe aortic valve stenosis. More than 60,000 implants have been performed to date. While the first-generation T-AVI devices had some specific issues, the advancements in these first-generation devices and the development of second-generation devices significantly reduced the incidence of peri-procedural complications. The two major access routes are the transfemoral (TF) and the transapical (TA) approach. Both approaches have their advantages and should be considered equal alternatives for finding the best treatment option for the individual patient. Currently there are discussions about extending the indication to patients with lower risk profiles. However, there is no real evidence to justify an expansion, as results of surgical aortic valve replacement in low and intermediate risk patients are excellent.

Predictors for prolonged hospital stay after transcatheter mitral valve repair with the MitraClip.

OBJECTIVE: The aim is to find predictors for a prolonged LOHS after MitraClip implantation. BACKGROUND: Due to its less invasive nature, average length of hospital stay (LOHS) after the MitraClip procedure is shorter compared to mitral valve surgery. However, some patients have a prolonged LOHS. METHODS: Records of consecutive patients who underwent MitraClip procedure were reviewed. A total of 41 consecutive patients with MitraClip implantation (76 ± 9 years, 59% men) were included. Median hospital stay was 7 days. Hospitalization lasting longer than 7 days was considered prolonged. RESULTS: Procedural success was achieved in 88% of the cases. In-hospital death occurred in 4 of 41 patients (10%). Patients with a prolonged hospital stay (46%) had a higher EuroSCORE I (22.7% [IQR 10.3-28.3] vs. 6.7% [IQR 3.5-18.3], P = 0.017), a higher STS mortality score (6.1%[(IQR 3.7-7.5] vs. 2.6% [IQR 1.4-4.8]; P = 0.043) and a higher STS long-length-of-stay score (18.9% [IQR 11.3-22.5] vs. 9.6% [IQR 6.2-16.1]; P = 0.039) as well as a lower estimated glomerular filtration rate (eGFR) (41 ml/min/1.73 m(2) [IQR 19-52] vs. 56 ml/min/1.73 m(2) [IQR 49-62]; P = 0.008) than those whose did not. In the multivariate model, lower eGFR was identified as predictor for a prolonged hospitalization. CONCLUSION: Lower pre-procedure eGFR is independently associated with a longer hospitalization.

Acute right atrial thrombus formation after extracorporeal life support removal during LVAD-implantation.

A 58-year-old male underwent LVAD-Implantation after ECLS explantation. After removal of ECLS (A) transesophageal echocardiography revealed thrombus in the inferior vena cava (B) and right atrium (C). The thrombus was removed with a second pump run including RVAD-Implantation. (D) The diameter of thrombus formations was 6 × 1 cm and 5 × 1.5 cm.

Long-term discontinuation of warfarin in a patient with HeartMate 3 left ventricular assist device without thromboembolic events.

The gold standard therapy for end-stage heart failure is cardiac transplantation. However, in the face of a donor shortage, a mechanical assist device such as the left ventricular assist device HeartMate 3 (Abbott Laboratories, Abbott Park, IL, USA) serves as bridging therapy to transplantation and/or destination therapy. Current guidelines recommend anticoagulation with a vitamin K antagonist in combination with low-dose aspirin. We herein report a challenging anticoagulation regimen in a patient with a HeartMate 3 in whom systemic anticoagulation with warfarin was not feasible for 4 years because of low compatibility and a rare X-factor deficiency. This is a rare hematological disorder, estimated to affect approximately 1 in every 500,000 to 1,000,000 people in the general population. The patient finally received a modified anticoagulation regimen involving the combination of rivaroxaban and clopidogrel without warfarin. Under this regimen, the patient remained free of thromboembolic complications for 4 years with in situ placement of the left ventricular assist device. This case illustrates that under specific circumstances, long-term absence of warfarin therapy is feasible in patients with a HeartMate 3.

Totally Endoscopic Replacement of the Ascending Aorta and the Aortic Root including the Aortic Valve via Right Mini-Thoracotomy: A Multicenter Study.

Background: Recently, minimally invasive access via right anterolateral mini-thoracotomy (RAMT) has been gaining popularity in cardiac surgery. This approach is also an option for surgeons performing aortic surgery. The aim of this study is to present our surgical method, highlighting the total endoscopic minimally invasive approach via RAMT for replacement of the ascending aorta (AAR) with or without involvement of the aortic root and the aortic valve. Methods: Clinical data of 44 patients from three participating institutions with AAR with or without involvement of the aortic valve or aortic root via RAMT between April 2017 and February 2024 were retrospectively analyzed. According to surgical procedure, patients were divided into two groups, in the AAR and in the Wheat/Bentall group with concomitant valve or root replacement. Operative time, length of ventilation, perioperative outcome, length of intensive care unit (ICU) as well as postoperative hospital stay, and mid- and long-term results were retrospectively analyzed. Results: Mean age was 61.4 ± 10.7 years old with a frequency of male gender of 63.6%. Mean cardiopulmonary bypass (CBP) time and aortic cross-clamping time was 94.9 ± 32.5 min and 63.8 ± 25.9 min, respectively. CPB and aortic clamp time were significantly lower in AAR group. In the first 24 h, the mean drainage volume was 790.3 ± 423.6 mL. Re-thoracotomy due to bleeding was zero. Sternotomy was able to be avoided in all patients. Patients stayed 35.9 ± 23.5 h at ICU and were discharged 7.8 ± 3.0 days following surgery from hospital. Mean ventilation time was 5.8 ± 7.6 h. All patients survived and 30-day mortality was 0.0%. At a median follow-up time of 18.2 months, all patients were alive. The results were similar in both groups. Conclusions: The full endoscopic RAMT approach with 3D visualization is a safe, feasible and promising technique that can be transferred in the field of aortic surgery without compromising surgical quality, postoperative outcomes, or patient safety when performed by an experienced team in a high-volume center.

First experiences with automated annular suturing device in totally endoscopic aortic and mitral valve replacement.

OBJECTIVES: To overcome some of the challenges of endoscopic minimally invasive valve surgery, an automated annular suturing device has been used in aortic and mitral valve replacement surgeries. The current study investigates early clinical outcomes of patients who received aortic or mitral valve replacement with the help of the RAM® device as first experiences in minimally invasive valve surgery. METHODS: Between September 2020 and June 2023, 66 consecutive patients (mean age 61.8 ± 11 years) underwent endoscopic minimally invasive aortic or mitral valve replacement through right anterior mini-thoracotomy at 2 cardiac surgery referral centres in Germany. The RAM® device was used in all Patients. 3.5 and 5.0 sizes were used in 16.7% and 83.3% of patients, respectively. Aortic, mitral and double valve surgery was performed in 81.8%, 15.2% and 1.5% of patients, respectively. Clinical data were prospectively entered into our institutional database. RESULTS: Cardiopulmonary bypass time and cross-clamping time were 97.9 ± 20.9 and 66 ± 15.7 min, respectively. Intensive care unit and hospital stays were 1 [1-2] and 9 [7-13] days, respectively. No paravalvular leak and no other intraoperative complications occurred. 30-day and in-hospital mortality were zero. Conversion to sternotomy occurred in 1 (1.5%) patient due to bleeding. CONCLUSIONS: The usage of the RAM® device is a safe, feasible and effective approach to the endoscopic implantation of aortic or mitral valves and yield excellent early outcomes. Larger size studies are needed to evaluate the efficacy and safety of RAM® device.

Comparison of Two Surgical Approaches for Coronary Artery Bypass of Left Anterior Descending Artery.

Background/Objectives: The minimally invasive approach through left mini-thoracotomy is a promising alternative to the median sternotomy for coronary artery bypass. The aim of this study was to compare the short-term outcomes of patients undergoing minimally invasive coronary artery bypass (MIDCAB) with off-pump coronary artery bypass through sternotomy (OPCAB) for single-vessel disease. Methods: From January 2017 to February 2023, 377 consecutive patients aged above 18 years undergoing off-pump bypass of the left anterior descending artery (LAD) with left internal thoracic artery underwent OPCAB. Propensity score matching was then applied. Primary endpoints were in-hospital mortality and 30-day mortality. Results: Prior to matching, 30-day mortality occurred in 2 (0.7%) patients in the MIDCAB group vs. 1 (1%) patient in the OPCAP group (p = 1). Transfusion of red blood cells (RBC) was required in 9.4% and 29% of patients within the MIDCAB and the OPCAB groups, respectively (p < 0.001). Median intensive care stay (ICU) was 1 [1-2] day in the MIDCAB group, vs. 2 [1-3] in the OPCAB (p < 0.001). In the matched cohort, 10% of MIDCAB patients received RBCs vs. 27.5% of OPCAB patients (p = 0.006). Median ICU stay was significantly lower in the MIDCAB group, 1 [1-2] vs. 2 [1-3] days. Conclusions: MIDCAB is as safe and effective as OPCAB for single coronary artery bypass of the LAD with the LITA in select patients. It is associated with a decreased ICU stay and lower transfusion rates when compared with OPCAB.

Impact of aortic valve calcification on the outcome of transcatheter aortic valve implantation: results from the prospective multicenter German TAVI registry.

OBJECTIVES: Transcatheter aortic valve implantation (TAVI) is an emerging technology in patients with severe aortic stenosis. BACKGROUND: Whether the degree of aortic valve calcification impacts the outcome after TAVI has not been thoroughly evaluated. METHODS: We analyzed data from the prospective multicenter German TAVI registry, including 1,365 patients as of July 2010. Patients were divided into three groups, based on the degree of aortic valve calcification: mild (n = 67), moderate (n = 392), and severe (n = 906) valve calcification, determined by visual estimation by the operator. RESULTS: Mean age was 81.7 ± 6.2 years; mean logistic EUROscore was 20.6 ± 13.7%. Patients with severe aortic valve calcification had a higher mean and peak-to-peak gradient before the intervention (P < 0.0001). Technical success was achieved in 97%, similar in each group. The Medtronic CoreValve was implanted in 80.8%, the Sapien Edwards prosthesis in the remaining cases. The duration of the procedure and fluoroscopy was higher in the group with severe calcification (P < 0.01 for procedure and P < 0.05 for fluoroscopy). During the periprocedural period there were no differences among the groups regarding in-hospital death, cerebrovascular events, myocardial infarction, thromboembolic events, aortic dissection, or severe vascular complications. Furthermore, there was no significant difference in postprocedural aortic mean gradient (7.0 mm Hg vs. 5.6 mm Hg vs. 6.3 mm Hg; P = 0.07), in residual aortic regurgitation (74% vs. 72% vs. 68%; P = 0.3) or postprocedure pacemaker implantation (38% vs. 30.4% vs. 34.2%; P = 0.35). During 30-day follow up there was no difference in regard to the number of death, strokes, and myocardial infarctions. CONCLUSIONS: Our results of a real-world registry suggest that the extent of aortic valve calcification does not influence the success or procedural outcome significantly.

1-Year Patency of Biorestorative Polymeric Coronary Artery Bypass Grafts in an Ovine Model.

Many attempts have been made to inhibit or counteract saphenous vein graft (SVG) failure modes; however, only external support for SVGs has gained momentum in clinical utility. This study revealed the feasibility of implantation, and showed good patency out to 12 months of the novel biorestorative graft, in a challenging ovine coronary artery bypass graft model. This finding could trigger the first-in-man trial of using the novel material instead of SVG. We believe that, eventually, this novel biorestorative bypass graft can be one of the options for coronary artery bypass graft patients who have difficulty harvesting SVG.

The Frozen Elephant Technique Using a Novel Hybrid Prosthesis for Extensive Aortic Arch Disease: A Multicentre Study.

INTRODUCTION: The frozen elephant trunk technique (FET) has become routine for aortic arch and descending aortic repair. New hybrid prosthesis models are constantly being developed to increase effectiveness and durability of aortic repair. Recently, concerns were raised regarding increased post-operative bleeding using a new-generation hybrid prosthesis (E-vita® OPEN NEO, CryoLife Inc. JOTEC GmbH, Hechingen, Germany). We report the outcomes of a multi-centre experience of using the E-vita OPEN NEO. METHODS: All patients undergoing aortic surgery at five European centres using the E-vita OPEN NEO from 2020 to 2022 were included (n = 22). The primary endpoint was the amount of chest drain fluid after 24 h and re-thoracotomy rate for bleeding. RESULTS: Median patient age was 62.5 ± 12.6 years, 50.0% (11/22 patients) were female and 27.3% (6/22) of procedures were re-operative cardiac surgeries. Aortic dissection was present in 54.5% (12/22). The median cardiopulmonary bypass time was 148 min and ischaemia time was 84 min. Mortality at 30 days was 4.5% (1/22) and the stroke rate was 18.2% (4/22). The rate of re-thoracotomy for bleeding was 4.5% (1/22) with a median amount of chest drain fluid within 24 h of 569 (IQR 338-910) ml. There were no device-associated adverse events. CONCLUSIONS: Use of this new-generation hybrid prosthesis for FET was safe and effective. Patient follow-up was largely uneventful given the extent of the procedures performed. In particular, bleeding events were uncommon in this cohort of patients comprising many aortic dissections and re-operative procedures. No increase in oozing was observed.

Sutureless aortic valve replacement: catheter-based transapical versus direct transaortic implantation.

BACKGROUND AND AIM OF THE STUDY: Catheter-based aortic valve implantation leaves the calcified native leaflets in the aortic root. Upon valve deployment, the leaflets are pushed to the side, potentially compromising coronary perfusion, exerting pressure on the conduction system, and limiting the maximum effective orifice area. The study aim was to evaluate the perioperative outcome of an alternative self-expanding sutureless valve that is inserted via a conventional aortotomy, allowing for complete debridement of any calcified native aortic leaflets and annulus. METHODS: A total of 56 patients, all of which required bioprosthetic valve replacement for aortic valve stenosis, was included in the study. Twenty-nine patients underwent isolated catheter-based transapical aortic valve implantation using the Edwards SAPIEN prosthesis, while 27 patients underwent direct transaortic valve replacement, using the self-expandable ATS 3F Enable prosthesis. Implantation of the latter device utilized cardiopulmonary bypass (CPB), such that debridement of the calcified native leaflets was possible in all cases. The in-hospital echocardiographic findings and routine blood laboratory parameters of all patients were evaluated to determine the clinical outcome. RESULTS: The 30-day mortality was 17% in the transapical group and 11% in the transaortic group. Two conversions were performed in each group. One valve migration, one complete heart block and two cases of coronary obstruction occurred in the transapical group. The implantation times were 8 min in the transapical group and 10 min in the transaortic group. Four paravalvular leaks occurred in the transapical group, but none occurred in the transaortic group. CONCLUSION: Aortic valve replacement can be performed safely using either sutureless device. The transaortic approach has the additional advantage of allowing for the resection of native leaflets and for the performance of concomitant procedures. Laboratory investigations demonstrated an elevated creatine kinase MB fraction in the transapical group and comparable inflammatory parameters between groups, despite the use of CPB in the transaortic group.

Mid-term follow up of a novel bioprosthesis in aortic valve surgery.

BACKGROUND AND AIM OF THE STUDY: The BioPhysio bioprosthesis (Edwards Lifesciences LLC, Irvine, CA, USA) was designed to further improve the hemodynamic performance currently achieved by stented valves. A flexible Nitinol stent that preserves aortic root dynamics, thus maximizing the effective orifice area (EOA), is a key innovation of this prosthesis. The study aim was to provide a clinical evaluation of this new device. METHODS: Between December 2004 and August 2005, a total of 50 patients (27 males, 23 females; mean age 75.8 +/- 5.1 years; range: 55-84 years) received a BioPhysio aortic bioprosthesis. Clinical outcomes, EOAs, mean gradients and regression of left ventricular hypertrophy were evaluated echocardiographically at discharge, and at six, 12, 24, 36, 48, and 60 months after surgery. RESULTS: The 60-month follow up was complete for all patients. No patients died within 30 days of surgery, but the late mortality was 14% (n = 6). There was one sudden unexplained death. One patient developed endocarditis at two years after surgery and underwent reoperation. There were no cases of stroke or renal failure. The BioPhysio prosthesis showed a good hemodynamic performance, with a significant fall in mean gradient to 15.1 +/- 8.3 mmHg, a mean EOA of 1.5 +/- 0.7 cm2, and a mean ejection fraction of 61 +/- 7.2%. There were no cases of aortic regurgitation. The NYHA functional class was improved in all patients, and there was a significant reduction in the left ventricular mass index to 185.7 +/- 49.6 g/m2 at 24 months. CONCLUSION: The clinical performance of the BioPhysio aortic bioprosthesis is comparable to that of regular stentless aortic valves. However, clinical approval for the widespread use of this bioprosthesis was not obtained.

Minimally invasive aortic valve replacement with an expandable bioprosthesis after LVAD implantation as redo surgery.

Left Ventricular Assist Device (LVAD) is currently implanted not only as a bridge to transplant or recovery but also as destination therapy. One factor, affecting the device performance and treatment adequacy negatively is the development of aortic valve insufficiency (AI) after the implantation. Herein, we introduce a minimally invasive partial sternotomy aortic valve replacement with an expandable bio-prosthesis in a 74-year-old LVAD patient with severe AI.

Comparison of Right Anterior Mini-Thoracotomy Versus Partial Upper Sternotomy in Aortic Valve Replacement.

INTRODUCTION: Propensity score analysis of midterm outcomes after isolated aortic valve replacement through right anterior mini-thoracotomy and partial upper sternotomy could provide information about the most beneficial minimally invasive technique for the patient based on the preoperative risk factors. METHODS: Between March 2015 and February 2021, 694 minimally invasive isolated aortic valve surgeries were performed at our institution. Among these, 441 right anterior mini-thoracotomies and 253 partial upper sternotomies were performed. A propensity score analysis was performed in 202 matched pairs. RESULTS: Cardiopulmonary bypass time and cross-clamp time were significantly shorter in the right anterior mini-thoracotomy group than in the partial upper sternotomy group (p = 0.001 and p < 0.001, respectively). Time to first mobilization and hospital stay were significantly shorter in the right anterior mini-thoracotomy group than in the partial upper sternotomy group (p = 0.005, p = 0.001, respectively). A significantly lower incidence of revision surgery was noted in the right anterior mini-thoracotomy group than in the partial upper sternotomy group (p = 0.046). No significant differences in 30-day mortality (p = 1.000) and 1-year mortality (p = 0.543) were noted. Kaplan-Meier survival estimates were 96.3% in the right anterior mini-thoracotomy group and 92.7% in the partial upper sternotomy group after 4 years (log rank 0.169), respectively. CONCLUSIONS: Despite the technical challenges, right anterior mini-thoracotomy can be chosen as first-line strategy for isolated aortic valve replacement. For patients unsuitable for this technique, the partial upper sternotomy remains a safe method that can be performed by a wide range of surgeons.