Early- and mid-term outcomes following redo surgical aortic valve replacement in patients with previous transcatheter aortic valve implantation.

OBJECTIVES: The aim of this study was to analyse the early- and mid-term outcomes after redo surgical aortic valve replacement (SAVR) in patients with previous transcatheter aortic valve implantation (TAVI). METHODS: Retrospective single-centre analysis of early- and mid-term outcomes following redo SAVR in patients with previous TAVI between 2013 and 2020. Primary outcomes were in-hospital mortality and mid-term survival. RESULTS: During the study period, a total of 5756 patients underwent TAVI. Among them, 28 (0.5%) patients required redo SAVR after TAVI. During periods 2013-2016 and 2017-2020, 4/2184 (0.2%) patients and 24/3572 (0.7%) patients required SAVR after TAVI, respectively. The median logistic EuroSCORE was significantly higher at the time of SAVR than at the time of the index TAVI (5.9% vs 11.6%; P < 0.001). The median elapsed time between TAVI and redo SAVR was 7 months (3.5-14 months). Infective endocarditis (IE) was the most frequent indication for surgery [19 (67.8%) patients]. A total of 11 (39.3%) patients underwent isolated SAVR and 17 (60.7%) SAVR + additional cardiac surgical procedures. The overall in-hospital mortality was 14.3% (4/28). In-hospital mortality was 15.8% (3/19) among IE patients and 11.1% (1/9) among non-IE patients (P = 0.7). Overall estimated survival was 66.5%, 59.9% and 48.0% at 12, 18 and 24 months, respectively. Patients with IE showed a trend towards a lower estimated mid-term survival compared to non-IE patients [41.6% (95% confidence interval: 22.0-78.0%) vs 58.3% (95% confidence interval: 30.0-100%) survival at 24 months (P = 0.3)]. CONCLUSIONS: SAVR can be successfully performed in patients with prior TAVI despite the increased surgical risk and technical difficulty. IE is associated with decreased mid-term survival.

Management of aortic root in type A dissection: Bentall approach.

BACKGROUND: We analyzed the results of the modified Bentall procedure in a high-risk group of patients presenting with acute type A aortic dissection (ATAAD). METHODS: ATAAD patients undergoing a modified Bentall between 1996 and 2018 (n = 314) were analyzed. Mechanical composite conduits were used in 45%, and biological ones using either a bioprosthesis implanted into an aortic graft (33%) or xeno-/homograft root conduits (22%) in the rest. Preoperative malperfusion was present in 34% of patients and cardiopulmonary resuscitation required in 9%. RESULTS: Concomitant arch procedures consisted of hemiarch in 56% and total arch/elephant trunk in 34%, while concomitant coronary artery surgery was required in 20%. The average cross-clamp and cardiopulmonary bypass times were 126 ± 43 and 210 ± 76 min, respectively, while the average circulatory arrest times were 29 ± 17 min. A total of 69 patients (22%) suffered permanent neurologic deficit, while myocardial infarction occurred in 18 cases (6%) and low cardiac output syndrome in 47 (15%). The in-hospital mortality rate was 17% due to intractable low cardiac output syndrome (n = 29), major brain injury (n = 16), multiorgan failure (n = 6), and sepsis (n = 2). The independent predictors of in-hospital mortality were critical preoperative state (odds ratio [OR], 5.6; p < .001), coronary malperfusion (OR, 3.6; p = .002), coronary artery disease (OR, 2.6; p = .033), and prior cerebrovascular accident (OR, 5.6; p = .002). CONCLUSIONS: The modified Bentall operation, along with necessary concomitant procedures, can be performed with good early results in high-risk ATAAD patients presenting.

Loop neochord versus leaflet resection techniques for minimally invasive mitral valve repair: long-term results.

OBJECTIVES: Non-leaflet resection techniques including loop chordal replacement are being used with increasing frequency, but the long-term results of these techniques are still unknown. The aim of this study was to compare the long-term results of loop neochord replacement with leaflet resection techniques in patients undergoing minimally invasive mitral valve (MV) repair for MV prolapse. METHODS: Between 1999 and 2014, 2134 consecutive MV prolapse patients underwent minimally invasive MV repair with isolated loop (n = 1751; 82.1%) or resection techniques (n = 383, 17.9%) at our institution. Follow-up data were available for 86% of patients with a mean follow-up time of 6.1 ± 4.3 years. RESULTS: The 30-day mortality was 0.8% for all patients (loop: 0.7%, resection: 1.6%; P = 0.09). Leaflet resection was associated with more moderate or more mitral regurgitation on predischarge echocardiography (P = 0.003). The 1-, 5- and 10-year survival rates were 98 ± 1%, 95 ± 1% and 86 ± 2% for the loop technique versus 97 ± 1%, 92 ± 1% and 81 ± 2% for resection patients, respectively (P = 0.003). Significant predictors for late mortality were MV repair technique (P = 0.004), left ventricular ejection fraction (P < 0.001), age (P < 0.001) and myocardial infarction (P < 0.001). Freedom from MV reoperation at 1, 5 and 10 years was 98 ± 1%, 97 ± 1%, 97 ± 1% and 97 ± 1%, 97 ± 1%, 96 ± 1% for patients operated on with the loop technique and leaflet resection (P = 0.4). CONCLUSIONS: In our patient cohort, MV repair with loop chordal replacement is associated with less early recurrent mitral regurgitation and very good long-term results when compared to classical leaflet resection techniques for MV prolapse and is therefore an excellent option for such patients.

Five-year outcomes following complex reconstructive surgery for infective endocarditis involving the intervalvular fibrous body.

OBJECTIVES: Destruction of the intervalvular fibrous body (IFB) due to infective endocarditis (IE) warrants a complex operation involving radical debridement of all infected tissue, followed by double valve replacement (aortic and mitral valve replacement) with patch reconstruction of the IFB. This study assesses the 5-year outcomes in patients undergoing this complex procedure for treatment of double valve IE with IFB involvement. METHODS: A total of 127 consecutive patients underwent double valve replacement with reconstruction of the IFB for active complex IE between January 1999 and December 2018. Primary outcomes were 3-year and 5-year survival, as well as 5-year freedom from reoperation. RESULTS: Patients' mean age was 65.3 ± 12.9 years. Preoperative cardiogenic shock and sepsis were present in 17.3% and 18.9%, respectively. The majority of patients (81.3%) had undergone previous cardiac surgery. Overall, 30-day and 90-day mortality rates were 28.3% and 37.0%, respectively. The 3- and 5-year survival rates for all patients were 45.3 ± 5.1% and 41.8 ± 5.8%, and for those who survived the first 90 postoperative days 75.8 ± 6.1% and 70.0 ± 8.0%, respectively. The overall 5-year freedom from reoperation was 85.1 ± 5.7%. Preoperative predictors for 30-day mortality were Staphylococcus aureus [odds ratio (OR) 1.65; P = 0.04] and left ventricular ejection fraction (LVEF) <35% (OR 12.06; P = 0.03), for 90-day mortality acute kidney injury requiring dialysis (OR 6.2; P = 0.02) and LVEF <35% (OR 9.66; P = 0.03) and for long-term mortality cardiogenic shock (hazard ratio 2.46; P = 0.01). CONCLUSIONS: Double valve replacement with reconstruction of the IFB in patients with complex IE is a challenging operation associated with high morbidity and mortality, particularly in the first 90 days after surgery. Survival and freedom from reoperation rates are acceptable thereafter, particularly considering the severity of disease and complex surgery.

Prospective multicentre evaluation of a novel, low-profile transapical delivery system for self-expandable transcatheter aortic valve implantation: 6-month outcomes.

OBJECTIVES: We assessed the safety and efficacy of a novel low-profile, 22-Fr transapical delivery system together with the ACURATE neo™ resheathable transcatheter heart valve. METHODS: This prospective, single-arm, multicentre study enrolled 60 patients with severe symptomatic aortic stenosis and high surgical risk ineligible for transfemoral access. Primary end points were 6-month mortality and procedural success. RESULTS: The mean age of patients was 79.8 ± 4.7 years, and the patients had severe comorbidities including coronary artery disease (71.7%), diabetes (38.3%), atrial fibrillation (30.0%) and chronic obstructive pulmonary disease (21.7%); logistic EuroSCORE-I, -II and the Society of Thoracic Surgeons (STS) scores were 20.9 ± 8.9%, 6.1 ± 5.0% and 4.3 ± 2.9%, respectively. A non-rib spreading approach using soft tissue retractors only was used in 88.3% of patients (n = 53). Resheathing and repositioning of transcatheter heart valve were performed in 6.7% of cases (n = 4); the device implantation time was 3 ± 2 min. Apical access site complications occurred in 1.7% (n = 1). Procedural success was 98.3% (n = 59), and procedural success in the absence of major adverse cardiac and cerebrovascular events at 30 days was 90.0% (n = 54). At 30 days, cardiovascular and overall mortality were 8.3% (n = 5), stroke rate was 1.7% (n = 1), and 17.2% of patients (n = 10) received a permanent pacemaker implant. No paravalvular leakage ≥2+ was observed, and the mean transvalvular gradient was 5.9 ± 2.7 mmHg. At 6 months, survival was 84.3% with sustained haemodynamic results. CONCLUSIONS: This study indicates safety and efficacy of transapical aortic valve implantation using a novel low-profile delivery system. High procedural success, short implantation times and a low rate of apical access site complications underline the favourable safety profile and ease of use. Clinical trial registration: ClinicalTrials.gov: NCT02950428.

Suprasternal Transcatheter Aortic Valve Replacement in Patients With Marginal Femoral Access.

OBJECTIVE: Recently, the PARTNER 2A trial reported results of transcatheter aortic valve replacement versus surgical aortic valve replacement in 2032 intermediate-risk patients at 2 years. Two hundred thirty-six patients (24%) required an access route other than transfemoral. Compared with transfemoral and surgical aortic valve replacement, nontransfemoral transcatheter aortic valve replacement was associated with a numerically higher rate of death and disabling stroke at 30 days. This underscores the need for a better alternative surgical approach for patients with marginal femoral access. We reviewed our multicenter experience with minimally invasive suprasternal transcatheter aortic valve replacement. METHODS: Consecutive patients with symptomatic severe aortic stenosis at high or intermediate risk for surgical aortic valve replacement underwent suprasternal transcatheter aortic valve replacement. A commercially available transcatheter heart valve was deployed under fluoroscopic guidance through the innominate artery or ascending aorta. Using a 3-cm skin incision just above the sternal notch, the Aegis Transit System (Aegis Surgical Ltd, Galway, Ireland) provided illuminated access to the mediastinum without bone disruption. Through a purse-string suture placed in the innominate artery or ascending aorta, transcatheter aortic valve replacement proceeded similarly to the direct aortic approach. RESULTS: Thirty patients at six medical centers successfully underwent suprasternal transcatheter aortic valve replacement. Implanted valves included 2 CoreValve and 12 Evolut-R (Medtronic, Inc, Minneapolis, MN USA), as well as 10 SAPIEN 3 and 6 SAPIEN XT (Edwards Lifesciences, Corp, Irvine, CA USA) with sizes ranging from 23 to 31 mm. Median procedure time was 90 minutes and median hospital stay was 4 days. Postoperatively, new permanent pacemaker (n = 3) was the most common Vascular Academic Research Consortium 2 complication. CONCLUSIONS: These data demonstrate the early clinical feasibility of suprasternal transcatheter aortic valve replacement. Key advantages of this approach include direct access to the innominate artery and ascending aorta, precise sheath control, and confident arterial closure. Additional experience is warranted to confirm these favorable results.

Incidence, predictors and clinical outcomes of residual stenosis after aortic valve-in-valve.

OBJECTIVE: We aimed to analyse the incidence of prosthesis-patient mismatch (PPM) and elevated gradients after aortic valve in valve (ViV), and to evaluate predictors and associations with clinical outcomes of this adverse event. METHODS: A total of 910 aortic ViV patients were investigated. Elevated residual gradients were defined as ≥20 mm Hg. PPM was identified based on the indexed effective orifice area (EOA), measured by echocardiography, and patient body mass index (BMI). Moderate and severe PPM (cases) were defined by European Association of Cardiovascular Imaging (EACVI) criteria and compared with patients without PPM (controls). RESULTS: Moderate or greater PPM was found in 61% of the patients, and severe in 24.6%. Elevated residual gradients were found in 27.9%. Independent risk factors for the occurrence of lower indexed EOA and therefore severe PPM were higher gradients of the failed bioprosthesis at baseline (unstandardised beta -0.023; 95% CI -0.032 to -0.014; P<0.001), a stented (vs a stentless) surgical bioprosthesis (unstandardised beta -0.11; 95% CI -0.161 to -0.071; P<0.001), higher BMI (unstandardised beta -0.01; 95% CI -0.013 to -0.007; P<0.001) and implantation of a SAPIEN/SAPIEN XT/SAPIEN 3 transcatheter device (unstandardised beta -0.064; 95% CI -0.095 to -0.032; P<0.001). Neither severe PPM nor elevated gradients had an association with VARC II-defined outcomes or 1-year survival (90.9% severe vs 91.5% moderate vs 89.3% none, P=0.44). CONCLUSIONS: Severe PPM and elevated gradients after aortic ViV are very common but were not associated with short-term survival and clinical outcomes. The long-term effect of poor post-ViV haemodynamics on clinical outcomes requires further evaluation.

Transcatheter aortic valve implantation using the ACURATE TA™ system: 1-year outcomes and comparison of 500 patients from the SAVI registries.

OBJECTIVES: The ACURATE TA TM system is a self-expanding transcatheter heart valve system designed for transapical access which has been proven to be safe and effective in the controlled setting of clinical trials. The SAVI-1 and SAVI-2 registries aimed to assess whether these promising outcomes can be translated into all-comers clinical routine. METHODS: From November 2011 to 2012 (SAVI-1), and November 2013 to 2014 (SAVI-2), a total of 500 patients were enrolled in the prospective, all-comers, multicentre, multinational SAVI registries. Patients were treated according to the standard of care at their respective hospitals. We report and compare 30-day and 1-year clinical outcomes between SAVI-1 and -2. RESULTS: Patients were 80.8 ± 6.1 years old, the mean logistic EuroSCORE-I was 23.4 ± 14.3%. Valves were deployed under rapid pacing in 71.3% of the procedures in SAVI-1, and in 3.6% in SAVI-2. There was no relevant difference in clinical and echocardiographic outcomes between SAVI-1 and SAVI-2. Overall mortality at 30 days and 1 year was 6.8% and 19.9%, the stroke rate was 2.2% and 3.7%, respectively; 10.2% of patients had received a permanent pacemaker, and no transcatheter valve-related complications after discharge were observed. Paravalvular leakage ≥2+ was reported in 1.9% of the patients at the early follow-up, and in 2.6% at the 1-year follow-up. CONCLUSIONS: The SAVI-registries have confirmed that transapical implantation using the ACURATE TA TM device is safe and effective in an all-comers setting with low complication rates and stable performance outcomes at short-term and 1 year; outcomes were similar between SAVI-1 and -2.

Outcomes of Dialysis-Dependent Patients After Cardiac Operations in a Single-Center Experience of 483 Patients.

BACKGROUND: The aim of this study was to determine the preoperative predictors of in-hospital and medium-term mortality in patients with dialysis-dependent chronic renal failure (DD CRF) undergoing cardiac operations. METHODS: Between January 1996 and June 2014, 483 consecutive patients with DD CRF underwent cardiac surgical procedures. The mean age was 65 ± 11 years, and 32. 3% were women. Isolated coronary artery bypass grafting (CABG) or isolated valve operations were performed in 39.8% and 32.3%, of patients, respectively. Combined surgical procedures (CABG with valve operations) were necessary in 20.3% of patients. Endocarditis was an indication for surgical intervention in 11% of patients. Urgent or emergent operations were performed in 49.3% of patients. RESULTS: The in-hospital mortality was 15.3%. Postoperative respiratory failure, gastrointestinal complications, low cardiac output, stroke, and sepsis occurred in 25.7%, 12.4%, 11.8%, 5.6%, and 5.2% of patients, respectively. The independent predictors of in-hospital mortality were combined mitral and aortic valve pathologic conditions (odds ratio [OR], 3.7, 95% CI, 1. 5-9; p = 0.003), chronic obstructive pulmonary disease (OR, 2.6; 95% CI, 1.1-5.9; p = 0. 03), peripheral vascular disease (OR, 2.3; 95% CI, 1.04-4; p = 0.003), left ventricular ejection fraction (LVEF) <30% (OR, 2.9; 95% CI, 1.3-6. 4; p = 0.008), and active endocarditis (OR, 2.2; 95% CI, 1.04-4.6; p = 0.04). The estimated 2-, 4-, and 6-year survival was 50.1% ± 2%, 34.3% ± 2%, and 20.3% ± 2%, respectively. Previous cerebrovascular accident, active endocarditis, previous cardiac operations, and combined aortic/mitral valve pathologic conditions were independent predictors of medium-term mortality. CONCLUSIONS: Patients with DD CRF undergoing cardiac operations have high perioperative and medium-term mortality, particularly in the presence of combined aortic and mitral valve pathologic conditions, active endocarditis, and poor left ventricular function.

Haemodynamic benefits of rapid deployment aortic valve replacement via a minimally invasive approach: 1-year results of a prospective multicentre randomized controlled trial.

OBJECTIVES: Aortic valve replacement (AVR) via minimally invasive surgery (MIS) may provide clinical benefits in patients with aortic valve disease. A new class of bioprosthetic valves that enable rapid deployment AVR (RDAVR) may facilitate MIS. We here report the 1-year results of a randomized, multicentre trial comparing the outcomes for MIS-RDAVR with those for conventional AVR via full sternotomy (FS) with a commercially available stented aortic bioprosthesis. METHODS: A total of 100 patients with aortic stenosis were enrolled in a prospective, multicentre, randomized comparison trial (CADENCE-MIS). Key exclusion criteria included AVR requiring concomitant procedures, ejection fraction of <25% and recent myocardial infarction or stroke. Patients were randomized to undergo MIS-RDAVR via upper hemisternotomy (EDWARDS INTUITY) or AVR via FS with a commercially available stented valve. Procedural, early and late clinical outcomes were assessed for both groups. Haemodynamic performance was evaluated by an echocardiography CoreLaboratory. RESULTS: Technical success was achieved in 94% of MIS-RDAVR patients. MIS-RDAVR was associated with significantly reduced cross-clamp times compared with FS (41.3 ± 20.3 vs 54.0 ± 20.3 min, P < 0.001). Clinical and functional outcomes were similar at 30 days and 1 year postoperatively for both groups. While both groups received a similarly sized implanted valve (22.9 ± 2.1 mm MIS-RDAVR vs 23.0 ± 2.1 mm FS-AVR; P = 0.91), MIS-RDAVR patients had significantly lower peak gradients 1 year postoperatively (16.9 ± 5.3 vs 21.9 ± 8.6 mmHg; P = 0.033) and a trend towards lower mean gradients (9.1 ± 2.9 vs 11.5 ± 4.3 mmHg; P = 0.082). In addition, MIS-RDAVR patients had a significantly larger effective orifice area 1 year postoperatively (1.9 ± 0.5 vs 1.7 ± 0.4 cm2; P = 0.047). Paravalvular leaks, however, were significantly more common in the MIS-RDAVR group (P = 0.027). CONCLUSIONS: MIS-RDAVR is associated with a significantly reduced cross-clamp time and better valvular haemodynamic function than FS-AVR. However, paravalvular leak rates are higher with MIS-RDAVR.

Symetis valve implantation in failing freestyle with close proximity between coronary Ostia and annulus.

Transcatheter treatment of patients with degenerated aortic valve stentless prosthesis and low proximal coronary ostia to the aortic annulus remain a challenge because of the elevated risk for coronary obstruction. Newer generation transcatheter aortic valve devices that engage and pull the aortic valve calcium towards the aortic annulus may be beneficial in these patients. We present a case of successful treatment of a degenerated tubular stentless prosthesis with low coronary ostia with a Symetis Acurate TA prosthesis.

Minimal invasive aortic valve replacement surgery is associated with improved survival: a propensity-matched comparison.

OBJECTIVES: To compare early and long-term outcomes of minimally invasive surgery (MIS) versus full sternotomy (FS) isolated aortic valve replacement (AVR). METHODS: We retrospectively analysed all patients who underwent isolated bioprosthetic AVR between 2003 and March 2012 at our institution. Matching was performed based on a propensity score, which was obtained using the output of a logistic regression on relevant preoperative risk factors. Mean follow-up was 3.1±2.7 years (range 0-9.0 years) and was 99.8% complete. RESULTS: A total of 2051 patients (FS, 1572; MIS, 479) underwent isolated bioprosthetic AVR during the study period. MIS patients were significantly younger (67.8±11.2 vs 70.4±9.4 years) and had a lower logistic EuroSCORE (6.6±6.4 vs 11.2±13.4%, both P<0.001). Propensity matching resulted in 477 matched patients from each group, with no significant differences in any of the preoperative variables. Aortic cross-clamp times were significantly longer in MIS patients (59.4±16.0 vs 56.9±14.6 min, P=0.008). Nonetheless, MIS AVR was associated with a significantly lower incidence of intra-aortic balloon pump usage (0.4 vs 2.1%, P=0.042) and in-hospital mortality (0.4 vs 2.3%, P=0.013), while FS patients had a lower rate of re-exploration for bleeding (1.5 vs 4.2%, P=0.019). Five- and 8-year survival post-AVR was significantly higher in MIS patients (89.3±2.4% and 77.7±4.7% vs 81.8±2.2% and 72.8±3.1%, respectively, P=0.034). Cox regression analysis revealed MIS (hazard ratio: 0.47, 95% confidence interval: 0.26-0.87) as an independent predictor of long-term survival. CONCLUSION: MIS AVR is associated with very good early and long-term survival, despite longer myocardial ischaemic times. MIS AVR can be performed safely with results that are at least equivalent to those achieved through an FS.

Cross-sectional survey on minimally invasive mitral valve surgery.

BACKGROUND: Minimally invasive mitral valve surgery (MIMVS) has become a standard technique to perform mitral valve surgery in many cardiac centers. However, there remains a question regarding when MIMVS should not be performed due to an increased surgical risk. Consequently, expert surgeons were surveyed regarding their opinions on patient factors, mitral valve pathology and surgical skills in MIMVS. METHODS: Surgeons experienced in MIMVS were identified through an electronic search of the literature. A link to an online survey platform was sent to all surgeons, as well as two follow-up reminders. Survey responses were then submitted to a central database and analyzed. RESULTS: The survey was completed by 20 surgeons. Overall results were not uniform with regard to contraindications to performing MIMVS. Some respondents do not consider left atrial enlargement (95% of surgeons), complexity of surgery (75%), age (70%), aortic calcification (70%), EuroSCORE (60%), left ventricular ejection fraction (55%), or obesity (50%) to be contraindication to surgery. Ninety percent of respondents believe more than 20 cases are required to gain familiarity with the procedure, while 85% believe at least one MIMVS case needs to be performed per week to maintain proficiency. Eighty percent recommend establishment of multi-institutional databases and standardized surgical mentoring courses, while 75% believe MIMVS should be incorporated into current training programs for trainees. CONCLUSIONS: These results suggest that MIMVS has been accepted as a treatment option for patients with mitral valve pathologies according the expert panel. Initial training and continuing practice is recommended to maintain proficiency, as well as further research and formalization of training programs.

Learning minimally invasive mitral valve surgery: a cumulative sum sequential probability analysis of 3895 operations from a single high-volume center.

BACKGROUND: Learning curves are vigorously discussed and viewed as a negative aspect of adopting new procedures. However, very few publications have methodically examined learning curves in cardiac surgery, which could lead to a better understanding and a more meaningful discussion of their consequences. The purpose of this study was to assess the learning process involved in the performance of minimally invasive surgery of the mitral valve using data from a large, single-center experience. METHODS AND RESULTS: All mitral (including tricuspid, or atrial fibrillation ablation) operations performed over a 17-year period through a right lateral mini-thoracotomy with peripheral cannulation for cardiopulmonary bypass (n=3907) were analyzed. Data were obtained from a prospective database. Individual learning curves for operation time and complication rates (using sequential probability cumulative sum failure analysis) and average results were calculated. A total of 3895 operations by 17 surgeons performing their first minimally invasive surgery of the mitral valve operation at our institution could be evaluated. The typical number of operations to overcome the learning curve was between 75 and 125. Furthermore, >1 such operation per week was necessary to maintain good results. Individual learning curves varied markedly, proving the need for good monitoring or mentoring in the initial phase. CONCLUSIONS: A true learning curve exists for minimally invasive surgery of the mitral valve. Although the number of operations required to overcome the learning curve is substantial, marked variation exists between individual surgeons. Such information could be very helpful in structuring future training and maintenance of competence programs for this kind of surgery.

Reoperative transapical aortic valve implantation for early structural valve deterioration of a SAPIEN XT valve.

We report on the first repeat transapical aortic "valve-in-valve" implantation for severe aortic stenosis in a degenerated transcatheter valve (Edwards SAPIEN XT; Edwards Lifesciences, Irvine, CA) using a second Edwards SAPIEN XT valve.

Review of a 13-year single-center experience with minimally invasive direct coronary artery bypass as the primary surgical treatment of coronary artery disease.

BACKGROUND AND AIM OF THE STUDY: In this study, we review our experience with 1768 minimally invasive direct coronary artery bypass (MIDCAB) operations. The focus is on long-term outcome with more than 10 years of follow-up. METHODS: All patients undergoing standard MIDCAB between 1996 and 2009 were included. For all 1768 patients, pre-, intra-, and postoperative data could be completed. Long-term follow-up information about health status, major adverse cardiac and cerebrovascular events (MACCE), and freedom from angina was collected annually via questionnaire or personal contact. Five-year follow-up is available for 1313 patients, and 10-year-follow-up is available for 748 patients. A multivariate Cox regression analysis was performed to determine risk factors for long-term outcome. RESULTS: Mean age was 63.4 ± 10.8 years, mean ejection fraction was 60.0% ± 14.2%, and perioperative mortality risk calculated by logistic EuroSCORE was 3.8 ± 6.2%. In 31 patients (1.75%) intraoperative conversion to sternotomy was necessary. Early postoperative mortality was 0.8% (15 patients); 0.4% (7 patients) had a perioperative stroke. Seven hundred twelve patients received routine postoperative angiogram, showing 95.5% early graft patency. Short-term target vessel reintervention was needed in 59 patients (3.3%) (11 percutaneous transluminal coronary angioplasty (PTCA)/stent, 48 re-operation). Kaplan-Meyer analysis revealed a 5-year survival rate of 88.3% (95% confidence interval [CI], 86.6% to 89.9%) and a 10-year-survival rate of 76.6% (95% CI, 73.5% to 78.7%). The freedom from MACCE and angina after 5 and 10 years was 85.3% (95% CI, 83.5% to 87.1%) and 70.9% (95% CI, 68.1% to 73.7%), respectively. CONCLUSIONS: MIDCAB is a safe operation with low postoperative mortality and morbidity. With excellent short-term and long-term results, it is a very good alternative compared to both percutaneous coronary intervention (PCI) and conventional surgery.

Transapical versus conventional aortic valve replacement--a propensity-matched comparison.

INTRODUCTION: The goal of this study was to compare the short- and long-term outcomes after aortic valve (AV) surgery carried out via standard sternotomy/partial sternotomy versus transapical transcatheter AV implantation (taTAVI). PATIENTS AND METHODS: All 336 patients who underwent taTAVI between 2006 and 2010 were compared with 4533 patients who underwent conventional AV replacement (AVR) operations between 2001 and 2010. Using propensity score matching, we identified and consecutively compared 2 very similar groups of 167 patients each. The focus was on periprocedural complications and long-term survival. RESULTS: The 30-day mortality rate was 10.8% and 8.4% (P = .56) for the conventional AVR patients and the TAVI patients, respectively. The percentages of postoperative pacemaker implantations (15.0% versus 6.0%, P = .017) and cases of renal failure requiring dialysis (25.7% versus 12.6%, P = .004) were higher in the TAVI group. Kaplan-Meier curves diverged after half a year in favor of conventional surgery. The estimated 3-year survival rates were 53.5% ± 5.7% (TAVI) and 66.7% ± 0.2% (conventional AVR). CONCLUSION: Our study shows that even with all the latest successes in catheter-based AV implantation, the conventional surgical approach is still a very good treatment option with excellent long-term results, even for older, high-risk patients.