The effect of transcatheter aortic valve implantation approaches on mortality.

OBJECTIVES: We aimed to evaluate the effect of transcatheter aortic valve implantation (TAVI) approaches on mortality and identify effect modifiers and predictors for mortality. BACKGROUND: Alternative access routes to transfemoral (TF) TAVI include the surgical intra-thoracic direct-aortic (DA) and transapical (TA) approach. TA TAVI has been associated with a higher mortality rate. We hypothesized that this is related to effect modifiers, in particular the left ventricular ejection fraction (LVEF). METHODS: This multicentre study derived its data from prospective registries. To adjust for confounders, we used propensity-score based, stabilized inverse probability weighted Cox regression models. RESULTS: In total, 5,910 patients underwent TAVI via TF (N = 4,072), DA (N = 524), and TA (N = 1,314) access. Compared to TF, 30-day mortality was increased among DA (HR 1.87, 95%CI 1.26-2.78, p = .002) and TA (HR 3.34, 95%CI 2.28-4.89, p < .001) cases. Compared to TF, 5-year mortality was increased among TA cases (HR 1.50, 95%CI 1.24-1.83, p < .001). None of the variables showed a significant interaction between the approaches and mortality. An impaired LVEF (≤35%) increased mortality in all approaches. CONCLUSIONS: The surgical intra-thoracic TA and DA TAVI are both associated with a higher 30-day mortality than TF TAVI. TA TAVI is associated with a higher 5-year mortality than TF TAVI. The DA approach may therefore have some advantages over the TA approach when TF access is not feasible.

Cystic echinococcosis in unaccompanied minor refugees from Afghanistan and the Middle East to Germany, July 2016 through June 2017.

Cystic echinococcosis (CE) is not covered by current refugee screening protocols. After we had detected CE among several refugees attending our clinic from Afghanistan and the Middle East, serological examinations for CE were performed for apparently healthy unaccompanied minor refugees from these regions.

Transcatheter aortic valve implantation in failed bioprosthetic surgical valves.

IMPORTANCE: Owing to a considerable shift toward bioprosthesis implantation rather than mechanical valves, it is expected that patients will increasingly present with degenerated bioprostheses in the next few years. Transcatheter aortic valve-in-valve implantation is a less invasive approach for patients with structural valve deterioration; however, a comprehensive evaluation of survival after the procedure has not yet been performed. OBJECTIVE: To determine the survival of patients after transcatheter valve-in-valve implantation inside failed surgical bioprosthetic valves. DESIGN, SETTING, AND PARTICIPANTS: Correlates for survival were evaluated using a multinational valve-in-valve registry that included 459 patients with degenerated bioprosthetic valves undergoing valve-in-valve implantation between 2007 and May 2013 in 55 centers (mean age, 77.6 [SD, 9.8] years; 56% men; median Society of Thoracic Surgeons mortality prediction score, 9.8% [interquartile range, 7.7%-16%]). Surgical valves were classified as small (≤21 mm; 29.7%), intermediate (>21 and <25 mm; 39.3%), and large (≥25 mm; 31%). Implanted devices included both balloon- and self-expandable valves. MAIN OUTCOMES AND MEASURES: Survival, stroke, and New York Heart Association functional class. RESULTS: Modes of bioprosthesis failure were stenosis (n = 181 [39.4%]), regurgitation (n = 139 [30.3%]), and combined (n = 139 [30.3%]). The stenosis group had a higher percentage of small valves (37% vs 20.9% and 26.6% in the regurgitation and combined groups, respectively; P = .005). Within 1 month following valve-in-valve implantation, 35 (7.6%) patients died, 8 (1.7%) had major stroke, and 313 (92.6%) of surviving patients had good functional status (New York Heart Association class I/II). The overall 1-year Kaplan-Meier survival rate was 83.2% (95% CI, 80.8%-84.7%; 62 death events; 228 survivors). Patients in the stenosis group had worse 1-year survival (76.6%; 95% CI, 68.9%-83.1%; 34 deaths; 86 survivors) in comparison with the regurgitation group (91.2%; 95% CI, 85.7%-96.7%; 10 deaths; 76 survivors) and the combined group (83.9%; 95% CI, 76.8%-91%; 18 deaths; 66 survivors) (P = .01). Similarly, patients with small valves had worse 1-year survival (74.8% [95% CI, 66.2%-83.4%]; 27 deaths; 57 survivors) vs with intermediate-sized valves (81.8%; 95% CI, 75.3%-88.3%; 26 deaths; 92 survivors) and with large valves (93.3%; 95% CI, 85.7%-96.7%; 7 deaths; 73 survivors) (P = .001). Factors associated with mortality within 1 year included having small surgical bioprosthesis (≤21 mm; hazard ratio, 2.04; 95% CI, 1.14-3.67; P = .02) and baseline stenosis (vs regurgitation; hazard ratio, 3.07; 95% CI, 1.33-7.08; P = .008). CONCLUSIONS AND RELEVANCE: In this registry of patients who underwent transcatheter valve-in-valve implantation for degenerated bioprosthetic aortic valves, overall 1-year survival was 83.2%. Survival was lower among patients with small bioprostheses and those with predominant surgical valve stenosis.

Mediastinal transposition of the greater omentum for treatment of infected prostheses of the ascending aorta and aortic arch.

OBJECTIVES: The aim of this study was to evaluate the outcomes of transposition of the omentum into the mediastinum to support the replacement of infected aortic grafts or to cover infected aortic grafts that are not amenable for surgical replacement. METHODS: All patients with thoracic aortic graft infections who underwent mediastinal transposition of the omentum at our institution between 2005 and 2023 were included in this study. Mediastinal transposition of the omentum was performed either after replacement of the infected graft ('curative concept') or solely as bailout procedure by wrapping the infected graft ('palliative concept'). The diagnosis, including computed tomography scans during follow-up, was made according to the criteria of the Management of Aortic Graft Infection Collaboration. RESULTS: The patient cohort consisted of 31 patients. Both in-hospital and 1-year mortality were 0% (n = 0) for the curative concept (n = 9) compared to 23% (n = 5) and 41% (n = 9) for the palliative concept (n = 22), respectively. There was no graft infection-associated death or recurrence of infection after 3 years in the curative group. Survival was 52% at 3 years in the palliative group, with freedom of infection in 59% of the patients (n = 13). CONCLUSIONS: Transposition of the omentum and wrapping of the infected aortic prosthetic graft is a useful bailout strategy for patients who are ineligible for replacement of an infected aortic graft. However, mortality stays high. For radical treatment of aortic graft infections, it may prove an effective supportive therapy and represents an important tool in the armamentarium of cardiac surgeons.

Temporary right ventricular mechanical support in high-risk left ventricular assist device recipients versus permanent biventricular or total artificial heart support.

Early planned institution of temporary right ventricular assist device (RVAD) support with the CentriMag (Levitronix LLC, Waltham, MA, USA) in left ventricular assist device (LVAD) recipients was compared with permanent biventricular assist device (BVAD) or total artificial heart (TAH) support. Between 2007 and 2011, 77 patients (age range: 25-70 years) with preoperative evidence of biventricular dysfunction (University of Pennsylvania score >50; University of Michigan score >5) were included. Forty-six patients (38 men; median age 54.5 years, range: 25-70 years) underwent LVAD placement combined with temporary RVAD support (group A); in 31 patients (25 men; median age 56.7 years, range: 28-68 years), a permanent BVAD or TAH implantation (group B) was performed. Within 30 days, 12 patients from group A (26.08%) and 14 patients from group B (45.1%) died on mechanical support (P = 0.02). Thirty patients (65.2%) in group A were weaned from temporary RVAD support and three (6.5%) underwent permanent RVAD (HeartWare, Inc., Framingham, MA, USA) placement. A total of 26 patients (56.5%) were discharged home in group A versus 17 (54.8%) in group B (P = 0.56). Three patients (8.5%) received heart transplantation in group A and six (19.3%) in group B (P = 0.04). In group A, 90-day and 6-month survival was 54.3% (n = 25) versus 51.6% (n = 16) in group B (P = 0.66). In group A, 1-year survival was 45.6% (n = 21) versus 45.1% (n = 14) in group B (P = 0.81). The strategy of planned temporary RVAD support in LVAD recipients showed encouraging results if compared with those of a similar permanent BVAD/TAH population. Weaning from and removal of the temporary RVAD support may allow patients to be on LVAD support only despite preoperative biventricular dysfunction.

Uncomplicated postoperative course after transfusion of 176 units of blood products during a single cardiovascular surgery.

A patient with massive perioperative bleeding after repeat aortic surgery for proximal aortic redissection, anastomotic disruption, and prosthetic infection after recent surgery for acute type A aortic dissection was managed with, in total, 176 units of blood products during a 25-hour operating room session. The postoperative course was completely uneventful. Enduring and continuous hemostasis with mediastinal gauze packing, volume replacement, and timely blood product substitution may overcome temporary coagulopathy in desperate surgical circumstances.

"UFO procedure" for massive aortic and mitral annular calcification involving left atrial and ventricular myocardium: a potential radical solution.

BACKGROUND: The "UFO procedure" was initially developed as a surgical option to enlarge the aortic annulus in patients requiring valve replacement. This technique can be employed to treat extensive endocarditis located in the intervalvular fibrous body (IVFB). One of the indications for a "UFO procedure" is massive aortic and mitral valve calcification. It is a challenging surgical procedure with a high risk of intraoperative complications. We present a 76-year-old male patient with massive aortic and mitral valve calcification involving the left atrium, the left ventricle and the left ventricular outflow tract. Both valves exhibited severe stenosis and moderate to severe regurgitation. The left ventricle was hypertrophic and the left ventricular ejection fraction was > 55%. The patient was prediagnosed with persistent atrial fibrillation. The risk of death following heart surgery (EuroSCORE II) was calculated as 9.21%. We successfully performed a so-called "UFO procedure" including replacement of both valves without annular decalcification to avoid atrioventricular dehiscence. We enlarged the IVFB and replaced the non-coronary sinus of Valsalva with doubled bovine pericardium. The left ventricular outflow tract was decalcified. The patient was transferred to a local hospital on the 13th postoperative day. CONCLUSION: Successful surgical treatment to this extent was demonstrated for the first time. Due to the high perioperative mortality, the surgical treatment of patients with this constellation would be refused in most cases. In our patient, the preoperative imaging showed extreme calcification of both valves and the surrounding myocardium. Excellent preoperative planning and a highly experienced surgical team is necessary.

Hemodynamic characteristics of Edwards Sapien aortic valve prosthesis assessed with transesophageal echocardiography.

BACKGROUND AND AIM OF THE STUDY: Transcatheter aortic valve implantation (TAVI) has become the therapy of choice in high-risk patients with aortic stenosis. Transesophageal echocardiography provides important anatomic and functional information before, during, and after any procedure. The study aim was to determine the hemodynamic properties of 23 and 26 mm Edwards Sapien (ES) valves immediately after implantation, and to compare these data to those previously reported for surgically implanted valves. METHODS: A total of 284 patients treated with transapical TAVI (90 patients with ES 23 mm valves, 194 with ES 26 mm valves) for severe aortic stenosis was analyzed. Quantitative echocardiographic data were obtained both pre- and post-procedure, and stored. Measurements were also made of the aortic annulus diameter, and the effective orifice area (EOA) was also calculated. In addition, the effective energy loss coefficient, as a parameter of left ventricular (LV) workload assessment, was determined. For risk estimation of prosthesis-patient mismatch (PPM), the EOA was indexed by body surface area; typically, an iEOA value < 0.65 cm2/m2 was considered indicative of PPM. RESULTS: The LV systolic function, assessed as biplane ejection fraction (EF) was improved significantly (pre-procedure 53 +/- 17% versus post-procedure 59 +/- 14%; p < 0.0001). The improvement was more pronounced in patients with a reduced preoperative function (correlation between AEF and EF pre; R = -0.55, p < 0.00001). The peak post-procedure pressure gradients in the 23 mm and 26 mm groups were 11.9 +/- 6.3 and 9.5 +/- 5.2 mmHg, respectively, the mean pressure gradient was 6.3 +/- 3.4 and 5.0 +/- 2.6 mmHg, and the EOA was 1.55 +/- 0.36 and 1.85 +/- 0.42 cm2. In 7.2% of all patients (10.1% in the 23 mm group and 5.8% in the 26 mm group; p = 0.30), the post-procedure iEOA was below the borderline value for PPM. CONCLUSION: The main hemodynamic characteristics of the Edwards Sapien valves were low peak and mean pressure gradients, and a low incidence of PPM after TAVI. The EOA was highly comparable with that of stented and stentless biological prostheses used for conventional aortic valve surgery. An ability to maintain these favorable hemodynamic characteristics of the ES valves during a long-term follow up would serve as a strong argument to extend the indication for TAVI to lower-risk patients.

Transcatheter aortic valve implantation into a stentless prosthetic valve with a low position of the left main coronary artery.

Recently during a transcatheter aortic valve implantation (TAVI), we were faced with a problem that seemed to be untreatable by TAVI. It was difficult to decide whether to perform atypical TAVI or to convert to conventional redo aortic valve surgery in an extremely high-risk patient with a degenerated stentless aortic bioprosthesis.

Rescue transcatheter aortic valve implantation and simultaneous percutaneous coronary intervention on cardiopulmonary bypass in a patient with an extreme risk profile.

We report on successful emergency transcatheter aortic valve implantation combined with percutaneous coronary revascularization in a polymorbid and preterminal patient in profound cardiogenic shock and with multiorgan failure. The risk scores were almost unbelievably high (Society of Thoracic Surgeons mortality score, 83.9%; Society of Thoracic Surgeons morbidity and mortality score, 96.8%; logistic EuroSCORE, 96.7%). Two and a half years after the procedure, the patient is doing very well.

The 'beating-heart butterfly technique' for repair of basal post-infarction ventricle septum defect.

Ischaemic ventricular septal defect is a serious complication of acute myocardial infarction with poor outcome. We present the 'beating-heart butterfly' technique to close the ventricular septal defect with a double-layered pericardial patch sewn to the intact septum under beating-heart cardiopulmonary bypass in 4 highest-risk patients. This technique combined with a liberal postoperative mechanical circulatory support and open-chest treatment allowed excellent results with 12 months of survival in all patients.

Transapical aortic valve implantation and 'off-pump' arterial coronary bypass in a patient with a porcelain aorta.

A simple hybrid procedure, namely transapical aortic valve implantation combined with 'off-pump' coronary artery bypass using an internal thoracic artery, was performed in a patient with porcelain aorta, aortic valve stenosis and coronary artery disease. This approach does not require cardiopulmonary bypass, and avoids aortic or peripheral arterial cannulation and clamping of the aorta. This hybrid approach can be regarded as a 'new technique' being applied to an 'old idea'.

A transapical or transluminal approach to aortic valve implantation does not attenuate the inflammatory response.

BACKGROUND: Cardiopulmonary bypass (CPB) and cardiac surgery cause an inflammatory response, as measurable by an increase in the concentration of C-reactive protein (CRP), a nonspecific inflammation marker. Previous publications have demonstrated typical perioperative CRP concentration profiles in cases of uncomplicated aortic valve replacement (AVR) with CPB. A regression analysis for modifying factors showed that chronic disease (heart failure, diabetes, and pulmonary disease), along with obesity and sex, all tend to influence the CRP response. We analyzed the inflammatory response to aortic valve implantation (AVI) with interventional techniques, mainly transapical but also transfemoral and transaxillary approaches, in a retrospective case-control study design. METHODS: Sixty-eight patients who underwent AVI by the transapical (59 patients), transfemoral (7 patients), or transaxillary (2 patients) approach were matched by age, sex, body mass index (BMI), and chronic-disease state (absence or presence of diabetes, pulmonary disease, and renal impairment) with 68 patients who underwent conventional AVR with CPB. We compared the 2 groups with respect to perioperative CRP concentration, EuroSCORE, and outcome data (time to extubation and 30-day mortality). All data were collected prospectively and analyzed retrospectively. RESULTS: The 2 groups-the study population (interventional) and the control population (conventional)-were similar in age, sex distribution, BMI, and chronic-disease status. As expected, the study population had a significantly higher median EuroSCORE. The 2 groups had similar postoperative CRP profiles over time, but the interventional group had significantly higher peak concentrations on days 2, 3, and 4. The short-term outcomes, as assessed by ventilation time and 30-day mortality, were similar for the 2 groups. CONCLUSIONS: Using an interventional transcatheter approach to AVI (thereby eliminating CPB from the procedure and reducing surgical trauma) does not attenuate the patient's innate inflammatory response.

Transcatheter aortic valve implantation and simultaneous closure of ostium secundum atrial septal defect.

We were faced with a difficult question: how to treat a high-risk patient with severe aortic valve stenosis and a secundum atrial septal defect (ASD II). An 85-year-old woman with progressive dyspnea and pedal edema and in New York Heart Association class IV was treated with concomitant transapical aortic valve implantation and transcatheter closure of the ASD II. The combined procedure and postoperative course were completely uneventful. At 2 years after the clinical follow-up, the patient is doing well. This case report demonstrates, for the first time, the feasibility, safety, and effectiveness of simultaneous application of 2 transcatheter methods--aortic valve implantation and closure of an ASD II. As surgeons, we should consider percutaneous treatment of combined structural heart disease in patients at high risk for conventional surgery.