A Comprehensive Review of Management Strategies for Bicuspid Aortic Valve (BAV): Exploring Epidemiology, Aetiology, Aortopathy, and Interventions in Light of Recent Guidelines.

OBJECTIVE: bicuspid aortic valve (BAV) stands as the most prevalent congenital heart condition intricately linked to aortic pathologies encompassing aortic regurgitation (AR), aortic stenosis, aortic root dilation, and aortic dissection. The aetiology of BAV is notably intricate, involving a spectrum of genes and polymorphisms. Moreover, BAV lays the groundwork for an array of structural heart and aortic disorders, presenting varying degrees of severity. Establishing a tailored clinical approach amid this diverse range of BAV-related conditions is of utmost significance. In this comprehensive review, we delve into the epidemiology, aetiology, associated ailments, and clinical management of BAV, encompassing imaging to aortic surgery. Our exploration is guided by the perspectives of the aortic team, spanning six distinct guidelines. METHODS: We conducted an exhaustive search across databases like PubMed, Ovid, Scopus, and Embase to extract relevant studies. Our review incorporates 84 references and integrates insights from six different guidelines to create a comprehensive clinical management section. RESULTS: BAV presents complexities in its aetiology, with specific polymorphisms and gene disorders observed in groups with elevated BAV prevalence, contributing to increased susceptibility to other cardiovascular conditions. The altered hemodynamics inherent to BAV instigate adverse remodelling of the aorta and heart, thus fostering the development of epigenetically linked aortic and heart diseases. Employing TTE screening for first-degree relatives of BAV patients might be beneficial for disease tracking and enhancing clinical outcomes. While SAVR is the primary recommendation for indicated AVR in BAV, TAVR might be an option for certain patients endorsed by adept aortic teams. In addition, proficient teams can perform aortic valve repair for AR cases. Aortic surgery necessitates personalized evaluation, accounting for genetic makeup and risk factors. While the standard aortic replacement threshold stands at 55 mm, it may be tailored to 50 mm or even 45 mm based on patient-specific considerations. CONCLUSION: This review reiterates the significance of considering the multifactorial nature of BAV as well as the need for further research to be carried out in the field.

Redo aortic valve replacement versus valve-in-valve trans-catheter aortic valve implantation: a UK propensity-matched analysis.

This study sought to compare the morbidity and mortality of redo aortic valve replacement (redo-AVR) versus valve-in-valve trans-catheter aortic valve implantation (valve-in-valve TAVI) for patients with a failing bioprosthetic valve. A multicenter UK retrospective study of redo-AVR or valve-in-valve TAVI for patients referred for redo aortic valve intervention due to a degenerated aortic bioprosthesis. Propensity score matching was performed for confounding factors. From July 2005 to April 2021, 911 patients underwent redo-AVR and 411 patients underwent valve-in-valve TAVI. There were 125 pairs for analysis after propensity score matching. The mean age was 75.2±8.5 years. In-hospital mortality was 7.2% (n=9) for redo-AVR versus 0 for valve-in-valve TAVI, p=0.002. Surgical patients suffered more post-operative complications, including intra-aortic balloon pump support (p=0.02), early re-operation (p<0.001), arrhythmias (p<0.001), respiratory and neurological complications (p=0.02 and p=0.03) and multi-organ failure (p=0.01). The valve-in-valve TAVI group had a shorter intensive care unit and hospital stay (p<0.001 for both). However, moderate aortic regurgitation at discharge and higher post-procedural gradients were more common after valve-in-valve TAVI (p<0.001 for both). Survival probabilities in patients who were successfully discharged from the hospital were similar after valve-in-valve TAVI and redo-AVR over the 6-year follow-up (log-rank p=0.26). In elderly patients with a degenerated aortic bioprosthesis, valve-in-valve TAVI provides better early outcomes as opposed to redo-AVR, although there was no difference in mid-term survival in patients successfully discharged from the hospital.

Surgical Complexity and Outcome of Patients Undergoing Re-do Aortic Valve Surgery.

Objectives: Re-do aortic valve surgery carries a higher mortality and morbidity compared with first time aortic valve replacement (AVR) and often requires concomitant complex procedures. Transcatheter aortic valve replacement (TAVR) is an option for selective patients. The aim of this study is to present our experience with re-do aortic valve procedures and give an insight into the characteristics of these patients and their outcomes. Methods: Retrospective review of 80 consecutive re-do aortic valve procedures. Results: Mean patients' age was 51.80±18.73 years. Aortic regurgitation (AR) was present in 51 (65.4%) patients and aortic stenosis (AS) in 38 (48.7%). Indications for reoperation were: infective endocarditis (IE) (23.8%), bioprosthetic degeneration (12.5%), mechanical valve dysfunction (5%), paravalvular leak (6.2%), patient-prosthesis mismatch (3.8%), native valve disease (25%), aortic aneurysm, pseudoaneurysm and dissection (35%), aortic root/homograft degeneration (27.5%). Forty-one (51.2%) patients underwent re-do AVR, 39 (48.8%) re-do complex aortic valve surgery (28 root, 23 ascending aorta and 6 hemiarch procedures) and 37.5% concomitant procedures. A bioprosthesis was implanted in 43.8%, a mechanical valve in 37.5%, a composite graft in 2.5%, a Biovalsalva graft in 6.2% and a homograft in 10% of patients. In-hospital mortality was 3.8% and incidence of major complications was low. Conclusions: A significant proportion of patients were young (61%<60 y), required complex aortic procedures (49%) or presented with contraindications for TAVR (mechanical valve, AR, IE, proximal aortic disease, need for concomitant surgery). Re-do aortic surgery remains the only treatment for such challenging cases and can be performed with acceptable mortality and morbidity in a specialised aortic centre.

A prospective study of external stenting of saphenous vein grafts to the right coronary artery: the VEST II study.

OBJECTIVES: External stents significantly reduce intimal hyperplasia and improve lumen uniformity and flow pattern in saphenous vein grafts (SVG) 1 year after coronary artery bypass grafting. However, recent studies have shown that at 1 year there is a lower patency of externally stented SVG to the right coronary artery (RCA) (55-60%) when compared to the left sided coronary arteries (85-90%). In the current study, we investigated whether avoidance of both fixation of the external stent to the anastomoses and the use of metal clips to ligate SVG side branches would improve the early patency of externally stented SVG to the RCA. METHODS: Thirty patients received a SVG to the right territory supported with an external stent. Graft patency was confirmed at the end of surgery in all patients. The primary endpoint was SVG patency assessed by computed tomography angiography (CTA) at 3-6 months. Graft failure was defined as > 50% stenosis. RESULTS: Twenty-nine patients (96.6%) completed the follow up period and CT angiography data was available for a total of 43 SVGs, (29 supported and 14 unsupported SVGs) and 47 arterial grafts. Patency of stented SVGs was 86.2% (25/29 on CTA). All non-stented SVGs to the left territory were patent. Patency rates of the left internal mammary arteries and right internal mammary arteries grafts were 96.6% and 83.3%, respectively. CONCLUSIONS: Avoidance of both metallic clips to ligate side branches and of fixation of venous external support trial (VEST) stents to the anastomoses mark a significant improvement in patency of stented SVG to the right coronary territory.

The relationship between total arterial revascularization and blood transfusion following coronary artery bypass grafting.

BACKGROUND: Blood transfusion adversely affects the outcome of coronary artery bypass grafting (CABG), yet blood transfusion after CABG is still common. Total arterial revascularisation (TAR) is increasingly used in current practice but its impact on postoperative blood transfusion is not known. METHODS: We reviewed the cardiothoracic and blood bank databases and collected data for isolated primary CABG patients from July 2007 to June 2012, excluding patients who had a single graft (n = 148). Perioperative variables of TAR patients (n = 745) were compared with patients who had one or more venous grafts (SVG, n = 1,761) for first-time isolated CABG. The conduits used in TAR patients were predominantly left internal thoracic and radial arteries. Matched group comparison of TAR and SVG patients was performed. The association of TAR with blood transfusion was investigated using multivariate and matched analysis. RESULTS: Of 2,506 patients, the 745 (29.7 %) that had TAR were generally younger, with less complex coronary artery disease and less often diabetic. After correcting for these by 1:1 matching, the mean chest tube drainage and rates of blood transfusion remained significantly lower (p < .0001) in TAR patients. Indeed, red cells, platelets and fresh frozen plasma were significantly less frequently transfused in TAR patients. By multivariate analysis, TAR had an independent effect on reducing blood transfusion after CABG [odds ratio (OR) 0.67, 95 % confidence interval (CI) 0.47-0.97, p = .03]. CONCLUSIONS: TAR achieved predominantly with left internal thoracic and radial arteries substantially reduced blood transfusion rates after primary CABG. Further studies are warranted.

Comparative analysis of clinicopathological and immunohistochemical characteristics of Merkel cell carcinoma.

PURPOSE: To investigate both the clinicopathological and immunohistochemical characteristics of a very rare skin cancer - Merkel cell carcinoma (MCC) - and to review the relevant literature. METHODS: The study group was composed of 12 patients, with mean age 53.08±10.26 years. Multiple subcutaneous masses and lymph node metastases were surgically removed. Paraffin blocks of formaldehyde-fixed tumor tissue were cut and stained for histological, histochemical and immunohistochemical studies. The following antibodies (Dacopatt) were used: Chromogranin A, CK20, CK7, Melan A, CD20 and CD45Ro. RESULTS: The tumors involved the dermis while sparing the epidermis. The most frequently affected sites were sun-exposed skin (8 patients on the head and neck) and the most common histological subtype of MCC was the intermediate variant. Six patients had lymph node metastasis and 2 had locoregional recurrences. Haematogenous lung metastases of MCC and primary located in the trunk were found only in our youngest patient (36-year-old). Immunostaining revealed positive reactivity for neuroendocrine and epithelial markers and negative reactivity for melanoma, B/T lymphomas and small cell metastatic lung carcinoma. CONCLUSION: MCC is a rare malignant primary cutaneous neoplasm with epithelial and neuroendocrine differentiation, demanding wide local excision. The pathological differential diagnosis includes basal cell carcinoma, melanoma, lymphoma, and metastatic small cell lung carcinoma. The diagnosis of MCC is possible only immunohistochemically, by using the wide spectrum of antibodies, characteristic of microscopically similar tumors.