Aortic Valve Reconstruction with Ozaki Technique

Abstract Modern bioprostheses offer a complete and definitive solution to elderly patients who need aortic valve surgery. Nonetheless, the scenario is more demanding when dealing with younger and less fragile patients. In this setting, any prosthetic aortic valve replacement can provide only a suboptimal solution and its related issues have not been fixed yet. The answer to the needs of this special population is the enhancement and refinement of the surgical technique. The Ozaki technique relies on custom-tailored autologous aortic cusps individually sutured in the aortic position. This approach has been showing optimal results if performed after a dedicated training period.

Aortic Valve Reconstruction with Ozaki Technique.

Modern bioprostheses offer a complete and definitive solution to elderly patients who need aortic valve surgery. Nonetheless, the scenario is more demanding when dealing with younger and less fragile patients. In this setting, any prosthetic aortic valve replacement can provide only a suboptimal solution and its related issues have not been fixed yet. The answer to the needs of this special population is the enhancement and refinement of the surgical technique. The Ozaki technique relies on custom-tailored autologous aortic cusps individually sutured in the aortic position. This approach has been showing optimal results if performed after a dedicated training period.

Aortic Valve Replacement Via Right Anterior Mini-Thoracotomy: the Conventional Procedure Performed Through a Smaller Incision.

Minimally invasive aortic valve replacement has gained consent due to its good results in terms of minimized surgical trauma, faster rehabilitation, pain control and patient compliance. In our experience, we have tried to replicate the conventional and gold standard approach through a smaller incision. Sparing the right internal thoracic artery, avoiding rib fractures and performing total central cannulation is important to make this procedure minimally invasive from a biological point of view too. In addition, the total central cannulation is pivotal to simplify perfusion and drainage. Moreover, a complete step-by-step procedure optimization and-when possible-the use of sutureless prosthesis help to reduce the cross-clamping and perfusion times. After more than 1000 right anterior thoracotomy (RAT) aortic valve replacements, we have found tips and tricks to make our technique more effective.

Aortic valve replacement via right anterior mini-thoracotomy: the conventional procedure performed through a smaller incision

Abstract Minimally invasive aortic valve replacement has gained consent due to its good results in terms of minimized surgical trauma, faster rehabilitation, pain control and patient compliance. In our experience, we have tried to replicate the conventional and gold standard approach through a smaller incision. Sparing the right internal thoracic artery, avoiding rib fractures and performing total central cannulation is important to make this procedure minimally invasive from a biological point of view too. In addition, the total central cannulation is pivotal to simplify perfusion and drainage. Moreover, a complete step-by-step procedure optimization and-when possible-the use of sutureless prosthesis help to reduce the cross-clamping and perfusion times. After more than 1000 right anterior thoracotomy (RAT) aortic valve replacements, we have found tips and tricks to make our technique more effective.

Extended hockey stick aortotomy for Perceval valve implantation: How to reshape the aortic root.

The Perceval valve is a true sutureless aortic bioprosthesis. Overall, excellent performances have been demonstrated in terms of hemodynamic outcomes, safety, and versatility of use; furthermore, as a sutureless valve option, it has shown to reduce the surgical burden, shortening the operative times, and simplifying minimally invasive procedures. Since the valve has got a high frame profile, the recommended implantation technique requires a high and transverse aortotomy. In case of unplanned Perceval valve implantation, when an extended aortotomy is required, we have come up with a simple technique to reshape the aortic root before the valve is delivered in place: symmetry is pivotal to prevent folding issues and to improve the annular sealing. Although we discuss an out-of-recommendation use, in our experience that technique has shown to be safe and effective.

Cardiac surgery in the time of the novel coronavirus: Why we should think to a new normal.

On 11 March 2020, the World Health Organization declared the SARS-CoV-2 outbreak a pandemic. At the time of writing, 24 May 2020 more than 5 million individuals have been tested positive and the death toll was over 330 000 deaths worldwide. The initial data pointed out the tight bond between cardiovascular diseases and worse health outcomes in COVID19-patients. Epidemiologically speaking, there is an overlap between the age-groups more affected by COVID-related death and the age-groups in which Cardiac Surgery has its usual base of patients. The Cardiac Surgery Departments have to think to a new normal: since the virus will remain endemic in the society, dedicated pathways or even dedicated Teams are pivotal to treat safely the patients, in respect of the safety of the health care workers. Moreover, we need a keen eye on deciding which pathologies have to be treated with priority: Coronary artery Disease showed a higher mortality rate in patients affected by COVID19, but it is, however, reasonable to think that all the cardiac pathologies affecting the lung circulation-such as symptomatic severe mitral diseases or aortic stenosis-might deserve a priority access to treatment, to increase the survival rate in case of an acquired-Coronavirus infection later on.

Absolute and relative risk prediction in patients candidate to isolated aortic valve replacement: should we change our mind?

OBJECTIVE: The European System for Cardiac Operative Risk Evaluation (EuroSCORE) calculator performance in 30-day outcome prediction after isolated aortic valve replacement (AVR) was evaluated to assess its absolute reliability and usefulness as selection criteria to percutaneous aortic valve implantation (PAVI). METHODS: We carried out a retrospective statistical analysis on 379 patients (group 0) consecutively submitted to isolated AVR in the past 10 years of surgical activity. We discriminated two periods of 5 years each, so we considered two subgroups of patients: group 1 (200 patients operated during 1999-2003); group 2 (179 patients operated during 2004-2008). We used receiver operating characteristics (ROC) curves for discriminatory power analysis. Model calibration was evaluated with the Hosmer-Lemeshow goodness-of-fit test and Pseudo R(2) analysis. RESULTS: The overall expected mortality rate at the logistic calculator was 9.37% compared with an observed 10-year mortality of 5.2% (p=0.006). Absolute risk prediction in group 1 fitted the observed outcome (p=0.24) while expected mortality in group 2 was significantly higher than observed (p=0.005). Applying threshold values used as PAVI selection criteria (logistic EuroSCORE >20 or >15), against 29% and 24.3% expected mortality rate, respectively, we registered a significant difference in the observed values (11.4%, p=0.022; 8.6%, p=0.005, respectively). The Hosmer-Lemeshow test demonstrated a lack of model fit in the overall group (p=0.019). ROC analysis revealed a sufficient discriminatory power for either total population (logistic area under curve (AUROC) 0.706; 95% confidence interval (CI): 0.604-0.809; p=0.002) and group 1 (logistic AUROC 0.752; 95% CI: 0.643-0.860; p=0.002). Group 2 showed a lack of risk stratification (logistic AUROC 0.613; 95% CI: 0.401-0.824; p=0.348). CONCLUSIONS: EuroSCORE appears to be an invalid model in absolute and relative risk prediction for isolated AVR. On this basis, its use in selecting candidates to PAVI should be carefully weighted. Correct stratification and sufficient calibration of absolute risk estimate of high-risk patients are, therefore, mandatory in the aim of assigning those patients who show risk factors really responsible for the worst surgical outcome to new techniques. The goal should be reached by exploring the weight of each independent predictor of death in each single institution involved in PAVI procedures, evaluating local surgical results in terms of absolute risk and analysing those variables significantly affecting relative risk.