Prognostic benefits of early vascular surgical intervention in patients with major peripheral vascular complications following transcatheter aortic valve implantation.

OBJECTIVES: This study aimed to analyze the incidence, surgical management of major vascular complications, and outcomes in patients undergoing transfemoral (TF) transcatheter aortic valve replacement (TAVR) at our center after strict selection of the access route, carefully considering all known major predictors. METHODS: Data of 494 consecutive patients with pre-interventional multi-slice computed tomography (CT) of the aorta who had undergone TF TAVR from 2009 to 2019 were analyzed. RESULTS: In total, 23/494 (4.7%) patients had major vascular and access-related complications of peripheral vessels and/or infrarenal aorta. These included hematomas that met the Valve Academic Research Consortium 3-criteria of major vascular complications (7/494, 1.4%), arterial dissections (3/494, 0.6%), pseudoaneurysm (6/494, 1.2%), thrombus of the external iliac artery leading to acute limb ischemia (1/494, 0.2%), fistula (1/494, 0.2%), and perforation (5/494, 1.0%). In total, 17/23 (73.9%) major vascular complications required immediate endovascular and/or open surgery. In 16/17 (94%) cases, only 1 surgical procedure was performed. The long-term survival of patients with and without major vascular complications of the peripheral vessels was determined after 2 years. CONCLUSIONS: Early vascular surgery intervention reversed the mortality disadvantage in patients with major complications of the peripheral vessels after TAVR. This underscores the importance of immediate vascular surgery stand-by as an indispensable requirement.

Augmentation of the posterior mitral leaflet in secondary mitral valve insufficiency, mid-term results.

OBJECTIVES: We evaluate the mid-term results of mitral valve (MV) repair with patch augmentation of the posterior leaflet in secondary mitral regurgitation. METHODS: Patients were included after diagnosis of a severe symptomatic secondary MV insufficiency with grade III and IV according to the Carpentier classification IIIb. Indication for a patch augmentation technique was a dilatation of the left ventricle leading to a displacement of the papillary muscles, causing restricted leaflet motion and a marked leaflet tenting height. Data were collected prospectively between December 2011 and March 2020. RESULTS: In total, 174 patients (mean age: 65 ± 12 years) received an MV repair with patch augmentation of the posterior leaflet and a true-sized remodelling annuloplasty (mean size 30.8 mm). Causes of the MV incompetence were dilatative cardiomyopathy in 126 patients and ischaemic myocardial disease in 48 patients. Concomitant bypass surgery was performed in 28 patients, and the tricuspid valve was repaired in 68 patients. The mean follow-up was 40 ± 28.2 months. There was no 30-day mortality. In-hospital mortality was 1.2% (n = 2); late mortality was 10.9% (n = 19). At 8 years, overall survival was 62.48%, freedom from moderate or severe recurrent mitral regurgitation was 91.9% and freedom from reoperation due to MV insufficiency was 97.1%. CONCLUSIONS: Augmentation of the posterior MV leaflet in addition to remodelling annuloplasty is a safe and reproducible mitral reconstruction technique that renders sustainable MV competence.

Risk of perioperative coronary stent stenosis or occlusion in patients with previous percutaneous coronary intervention undergoing coronary artery bypass grafting surgery.

OBJECTIVES: There is an ongoing discussion about how to treat coronary stents during bypass surgery: Should patent stents be left alone and the stented vessels be ungrafted, or should every stented coronary artery receive a bypass graft? This study aims to determine the relevance of perioperative stent stenosis or occlusion on postoperative outcomes up to 3 years postoperatively. METHODS: Patients undergoing coronary artery bypass grafting surgery (CABG) (±concomitant procedures) with previous percutaneous coronary intervention from 4 centres were prospectively included in this observatory study between April 2015 and June 2017. A coronary angiography was conducted between the fifth and seventh postoperative days. The preoperative and postoperative angiograms were assessed in a core laboratory, assessing the patencies of coronary stents and bypass grafts. The core lab investigators were blinded to the patients' characteristics and perioperative course. RESULTS: A total of 107 patients were included in the study. In the postoperative coronary angiography, 265 bypass grafts and 189 coronary stents were examined angiographically. Ninety-seven percent of preoperatively patent stents remained patent. New coronary stent stenoses were observed in 5 patients (4.7%). All 5 patients were asymptomatic and managed conservatively. Bypass stenoses were observed in 12 patients (11%), of whom were managed conservatively, 4 underwent percutaneous coronary intervention and 1 underwent redo-CABG. Two years postoperatively, 97% of patients were alive. Patients with new stent stenosis tended to have a better survival compared with patients with bypass stenosis (100% vs 73%; P = 0.09) up to 3 years postoperatively. CONCLUSIONS: Perioperative coronary stent stenosis occurs rarely. It is safe to leave a patently stented coronary vessel without bypass grafting.

Long-term outcomes after valve-sparing anatomical aortic root reconstruction in acute dissection involving the root.

OBJECTIVES: To evaluate long-term results after valve-sparing surgery of acutely dissected aortic root in which a restoration of root anatomy adjusted to the existing aortic annulus diameter, rather than any kind of downsizing, was performed. METHODS: Among 286 consecutive patients operated on because of type A aortic dissection during the last 17 years were 100 patients (35.0%), mean age 63 ± 13 years (range, 29-88 years), in whom an anatomical restoration of the involved root was performed. Twenty-eight patients presented with severe (3+ or 4+), 37 with mild to moderate (2+), and 24 with mild (1+) insufficiency. In 5 patients, the valve was bicuspid. In all patients, a curative root repair with replacement of all dissected aortic wall was performed, containing a selective replacement of pathologic/dissected aortic sinuses, which were 1, 2, or all 3 sinuses in 62, 32, and 6 patients, respectively. Concomitant cusp repair was necessary in 18 patients. RESULTS: Thirty-day mortality was 1.0%. Survival was estimated starting with surgery and was 89.4 ± 3.4% (95% confidence interval, 80.5-94.4) and 68.8 ± 6.4% (95% confidence interval, 54.4-79.5) at 5 and 12 years, respectively. No patient required reoperation on the aortic root and/or valve during the follow-up period of 70 ± 50 (range, 3-202) months. A freedom from any aortic valve/root reintervention and/or relevant (>2+) aortic insufficiency at 12 years was 100%. CONCLUSIONS: Selective replacement of pathologic sinuses offers an anatomophysiological albeit curative restoration of acutely dissected aortic root resulting in excellent and durable outcomes in selected patients with acute aortic dissection.

Incidence of acute thermal esophageal injury after atrial fibrillation ablation guided by prespecified ablation index.

INTRODUCTION: Ablation index (AI), a novel parameter defining energy application at single ablation lesions, calculated by integration of ablation time, energy, catheter stability, and contact force, has been documented to be associated with effective lesions and higher ablation efficacy. Using a prespecified target AI in addition to acute lesion efficacy may affect local collateral damage like esophageal thermal injury when used for guiding radiofrequency (RF) ablation at the posterior left atrial (LA) wall. METHODS AND RESULTS: Consecutive patients undergoing first AF ablations using AI were included. Ablation energy was reduced to 25 W when ablating at posterior LA wall. Two different individually defined AI target values were used (300 and 350 for posterior wall ablation). Esophageal endoscopy (EE) was performed 1 to 3 days after ablation procedure to document and categorize endoscopically detected esophageal thermal lesion (EDEL). Two-hundred and eleven consecutive patients with postprocedural EE were included. Incidence of EDEL was 14% (29 of 211 patients; mild category 1 lesions in 22 of 29 patients (76%) and severe category 2 lesions (ulcers > 5 mm) in 7 of 29 patients (24% of EDEL group, 3% of total group). Ablation time at posterior LA wall (9.5 vs 9.0 minutes [P = .67]) was comparable in patients with and without EDEL. CONCLUSION: LA posterior wall RF ablation adopting AI ≤350 was associated with 14% esophageal thermal injury including 3% of severe esophageal thermal ulcers. This incidence is comparable to historic control groups with non AI-guided AF ablation.

Five-Year Outcome After Off-Pump or On-Pump Coronary Artery Bypass Grafting in Elderly Patients.

BACKGROUND: The 30-day and 1-year follow-up analysis of the GOPCABE trial (German Off-Pump Coronary Artery Bypass Grafting in Elderly Patients) revealed no significant difference in the composite end point consisting of death, stroke, myocardial infarction, new renal replacement therapy, or repeat revascularization. The 5-year follow-up data of this trial are reported here. METHODS: From June 2008 to September 2011, a total of 2539 patients aged ≥75 years were randomly assigned to undergo off-pump or on-pump coronary artery bypass grafting (CABG) at 12 centers in Germany. The primary outcome was all-cause mortality at 5 years. The secondary 5-year outcomes were a composite of death, myocardial infarction, and repeat revascularization. Furthermore, the impact of complete versus incomplete revascularization was assessed. RESULTS: After a median follow-up of 5 years, 361 patients (31%) assigned to off-pump CABG and 352 patients (30%) assigned to on-pump CABG had died (hazard ratio off-pump/on-pump CABG, 1.03; 95% CI, 0.89-1.19; P=0.71). The composite outcome of death, myocardial infarction, and repeat revascularization occurred in 397 (34%) after off-pump and in 389 (33%) after on-pump CABG (hazard ratio, 1.03; 95% CI, 0.89-1.18; P=0.704). Incomplete revascularization occurred in 403 (34%) patients randomly assigned to off-pump and 354 (29%) patients randomly assigned to on-pump CABG ( P<0.001). Five-year survival rates were 72% (95% CI, 67-76) with incomplete versus 76% (95% CI, 74-80) with complete revascularization (log-rank test: P=0.02) after off-pump CABG and 72% (95% CI, 67-76) versus 77% (95% CI, 74-80) after on-pump CABG (log-rank test: P=0.03), respectively. Cox regression analysis revealed a hazard ratio incomplete/complete revascularization of 1.19 (95% CI, 1.01-1.39; P=0.04). CONCLUSIONS: In elderly patients ≥75 years of age, the 5-year survival rates and the combined outcome of death, myocardial infarction, and repeat revascularization, as well, were similar after on-pump and off-pump CABG. Incomplete revascularization was associated with a lower 5-year survival rate, irrespective of the type of surgery. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov . Unique identifier: NCT00719667.

Operative and Long-Term Outcomes After Curative Repair of Acute Dissection Involving the Proximal Aorta.

BACKGROUND: The aim of the study was to evaluate operative and long-term results after acute type A aorta dissection (AAAD) operation, in which complete resection of all dissected aortic segments (curative repair) was achieved. METHODS: Among 205 consecutive patients operated on between 2002 and 2014 because of AAAD were 88 patients (42.9%), in whom the dissection did not extend into the downstream aorta. The distal extension of the dissection ended before the origin of the innominate artery in 50 patients of the study cohort (56.8%) or extended throughout the arch, necessitating a total/subtotal arch replacement to achieve a curative distal repair in 38 remaining patients (43.2%). The aortic root was involved in 52 patients (59.1%) and was repaired using valve-sparing repair (31) or replacement with a valve composite graft (21). Combination of root and open arch surgery was reported in 46 patients (52.3%). RESULTS: Thirty-day and in-hospital mortalities were 3.4% and 5.7%, respectively. Survival was estimated starting with the operation and was 81.9% ± 4.5% and 56.6% ± 8.7% at 5 and 10 years, respectively. No patient required reoperation on the aortic root and/or distal thoracoabdominal aorta; however 2 cardiac reoperations were unrelated to the primary surgical procedure. Moreover, the freedom of aortic and/or sudden/unknown death was 100%. CONCLUSIONS: Curative aortic repair can be achieved in a relevant share of AAAD patients and is mostly limited by the distal extension of dissection. This kind of repair is advisable, whenever possible, because it can provide very low risk of aortic complications and/or reoperations over time.

Transfemoral versus transapical transcatheter aortic valve implantation: a single-centre experience.

OBJECTIVES: Transapical transcatheter aortic valve implantation (TAVI) is associated with increased mortality as compared to the transfemoral (TF) access. Possible mechanisms include different patient risk profiles as well as an intrinsic injury caused by the access route itself. METHODS: All consecutive patients scheduled for TAVI between January 2009 and June 2016 at a single centre were evaluated. A comparison of 30-day mortality and morbidity rates for patients undergoing TF or transapical (TA) TAVI was performed according to the criteria of the Valve Academic Research Consortium 2. RESULTS: During the investigated period, 1130 patients (TF: n = 619, TA: n = 511) were scheduled for TAVI. TA patients had a higher operative risk profile (logistic EuroSCORE: 24% vs 17%; P < 0.001). Unadjusted 30-day mortality rate was higher in TA than in TF patients, albeit this difference was not significant [TA: 6.7%, TF: 4.8%; odds ratio (OR) 1.3 (0.8-2.3); P = 0.216]. The multivariate logistic regression analysis revealed the logistic EuroSCORE and institutional experience, but not the access mode as independent predictors of 30-day mortality. Major access-site complications occurred with a similar frequency in both groups [TA: 9.4%; TF: 9.2%; OR 1.02 (0.68-1.53); P = 0.915]. Unadjusted long-term mortality rate was higher after TA TAVI. After adjustment, the Cox regression analysis revealed similar long-term mortality rates after TF and TA TAVI [hazard ratio 1.1 (0.88-1.36)]. CONCLUSIONS: The increased mortality of patients undergoing TA TAVI is associated with the patient risk profile and the institutional experience but not with the access mode itself.

Bentall procedure after previous aortic valve or complete root replacement: Usefulness of self-assembled aortic valve conduit.

OBJECTIVES: The aim of this study was to evaluate surgical results of complete aortic root replacement using self-assembled valve composite graft in the setting of destroyed aortic annulus after previous valve replacement. METHODS: Aortic root pathology being addressed by complete root replacement was combined with partial or complete absence of annular tissue in 112 consecutive patients. Eighty-eight had undergone a previous replacement of the aortic valve and 24 had undergone root replacement with a valved conduit. Altogether, 31 patients (27.7%) presented with acute endocarditis, which was the indication for surgery in 75% of patients with prior root replacement. In all patients, the root replacement or re-replacement was performed with a self-assembled valved conduit using mechanical (n = 74) or, in patients with an advanced age, biological (n = 38) valve prostheses. RESULTS: In-hospital mortality was 11.6%, including a 30-day mortality of 6.3%. Resternotomy for bleeding was necessary in 5.4% of patients and about one-quarter did not need any blood transfusion. Estimated survival at 1, 5, and 10 years was 84.8% ± 3.4%, 75.7% ± 4.3%, and 57.1% ± 6.5%, respectively. Freedom from any valve-related events at 10 years was 86.2% ± 4.1%. During the follow-up time (mean, 63 ± 47 months), there was only 1 reoperation necessary 9 years after surgery (replacement of deteriorated biological valve prosthesis within the vascular tube leaving the conduit untouched). CONCLUSIONS: A self-assembled composite graft allows safe proximal fixation of the conduit in patients with destroyed aortic annulus, resulting in sufficient proximal anastomosis and a very low incidence of aorta-related reoperations.

Off-Pump Coronary Artery Bypass Grafting and Stroke-Exploratory Analysis of the GOPCABE Trial and Methodological Considerations.

BACKGROUND: Coronary artery bypass grafting (CABG) without cardiopulmonary bypass (off-pump CABG) may reduce severe adverse events including stroke. METHODS: In the German Off-Pump Coronary Artery Bypass Grafting in Elderly patients trial, the rate of major adverse cardiovascular events was compared in 2,394 elderly (≥ 75 years) patients undergoing CABG with (on-pump) or without (off-pump) cardiopulmonary bypass. This exploratory post-hoc analysis investigated the impact of surgical aortic manipulation on the rate of stroke. RESULTS: There was no significant difference in the rate of stroke within 30 days after surgery between both groups (off-pump: 2.2%; on-pump: 2.7%; odds ratio [OR]: 0.83 [0.5-1.38]; p = 0.47). Within the off-pump group, different degrees of aortic manipulation did not lead to significant different stroke rates (tangential clamping: 2.3%; OR 0.86 [0.46-1.60]; clampless device: 1.8%; OR 0.67 [0.26-1.75]; no aortic manipulation: 2.4%; OR 0.88 [0.37-2.14]). An aggregate analysis including more than 10,000 patients out of the four recent major trials also yielded comparable stroke rates for on- and off-pump CABG (off-pump: 1.4%; on-pump: 1.7%; OR 0.87 [0.64-1.20]). CONCLUSION: Within recent prospective randomized multicenter trials off-pump CABG did not result in lower stroke rates. The possible intrinsic benefit of off-pump CABG may be offset by the complexity of the operative therapy as well as the multiple pathomechanisms involved in perioperative stroke.

Reconstructive aortic valve surgery in the elderly: Techniques and outcomes.

OBJECTIVES: The aim of the study was to evaluate operative techniques and long-term results after aortic valve or root repair in patients aged 75 years or more. METHODS: Between November 2002 and January 2016, a total of 815 patients underwent aortic valve or root repair. Among them were 100 patients aged 75 years or more (mean, 78 ± 3; range, 75-88 years), including 17 patients operated on an emergency basis because of acute aortic dissection. None/trivial, mild, moderate, and severe insufficiency grades were presented in 9, 23, 27, and 41 patients, respectively. The surgery comprised root repair, cusp repair, and a combination of both in 45, 16, and 39 patients, respectively. RESULTS: Early (30-day) mortality and the rate of permanent neurologic deficit were 2% for each. The follow-up was 99% complete, resulting in 427 patient/years. During the follow-up period (mean duration, 4.3 ± 3.2; range, 0.02-11.1 years), only 1 patient developed a relevant aortic insufficiency and required aortic valve reoperation. There were 24 late deaths, which occurred on average 50.0 ± 40.6 months (range, 2.4-135.0) after surgery at the average patient age of 82 ± 5 years (range, 75-90). Estimated survival at 5 and 8 years was 76.4% ± 5.1% and 71.3% ± 5.9%, respectively, and was similar to those of the sex- and age-matched general population. CONCLUSIONS: Reconstructive aortic valve surgery is a suitable and justifiable surgical option in selected elderly patients undergoing operation by surgeons with considerable experience in this kind of surgery. It offers low cardiac and valve-related mortality and morbidity, leading to life expectancy applicable to the patients' ages.

Patient-tailored aortic root repair in adult marfanoid patients: Surgical considerations and outcomes.

OBJECTIVE: The aim of the study was to evaluate the operative and functional results after individual, patient-tailored aortic root repair in marfanoid patients. METHODS: Among 518 patients who underwent operation between 2002 and January 2016, using patient-tailored aortic root repair with isolated sinus replacement, 42 patients fulfilled the original Ghent criteria. None/trivial, mild, moderate, and severe insufficiency grades were present in 5, 16, 10, and 11 patients, respectively. RESULTS: The repair was adjusted to the existing aortic annulus diameter. Replacement of 1, 2, or 3 sinuses of Valsalva was performed in 1, 14, and 27 patients, respectively. Concomitant cusp repair was performed in 17 patients (40.5%), and 10 patients (23.8%) underwent arch repair (total in 3). All patients survived surgery, and the follow-up (mean, 6.1 ± 3.1; range, 0.8-14.2 years) was 100% complete. No patient had a change in the form or size of the aortic neo-root, especially the size of aortic annulus and sinotubular junction during the follow-up time. No and trivial/mild insufficiency were present in 22 and 18 patients, respectively, and 2 patients with recurrent aortic insufficiency caused by cusp pathology underwent aortic valve replacement 43 and 66 months after the primary surgery, respectively. Thus, the estimated survival free from aortic valve/root reoperation for any reason at 5 and 8 years was 96.8% ± 3.2% and 91.4% ± 6.0%, respectively. CONCLUSIONS: Patient-tailored root repair using isolated sinus replacement is an effective and durable method of valve-sparing repair in select marfanoid patients with a satisfactory quality of aortic cusps, which seems to be decisive for long-term valve function.

Female sex is not a risk factor for post procedural mortality in coronary bypass surgery in the elderly: A secondary analysis of the GOPCABE trial.

OBJECTIVE: Female sex is considered a significant risk in cardiac surgery and is included in the majority of scores for risk assessment. However, the evidence is controversial and older women undergoing cardiac surgery have not specifically been investigated. We assessed the influence of female sex on surgical risk (30-day mortality) in a secondary analysis of the GOPCABE trial (German Off-Pump Coronary Artery Bypass grafting in the Elderly (GOPCABE) trial, comparing on- to off-pump) and also evaluated its impact on risk prediction from commonly used risk scores. METHODS: We performed logistic regression analyses on the GOPCABE trial population, where patients were randomized to either on- or off-pump CABG. The study was performed in 12 cardiac surgery centers in Germany and analyzed 2394 patients having undergone CABG at age ≥75 years (1187 on-pump, 1207 off-pump). Of the 2394 patients, 755 (32%) were women. The logistic EuroSCORE and the German KCH score were calculated as expected (E) mortality and values were compared to observed (O) 30-day mortality (O/E ratio). RESULTS: There was no difference in mortality or major cardiovascular adverse events after 30 days between men and women for both on- and off-pump CABG (men: on- vs. off-pump OR = 0.90, 95%-CI: [0.63;1.27]; women: on- vs. off-pump OR = 1.07, 95%-CI: [0.62;1.87]). Therefore, groups were combined for further analyses. Both men and women had considerable and similar comorbidities. Expected mortality was significantly higher for women than for men (logistic EuroSCORE: 8.88±6.71% vs. 7.99±6.69%, p = 0.003; KCH score: 4.42±3.97% vs. 3.57±3.65%, p = 0.001). However, observed mortality rates (O) tended to be even lower in women (2.1% vs. 3.0%). The O/E ratio was closer to 1 in men than in women (0.84 vs. 0.47). Excluding female sex from the risk models increased O/E ratio to 0.69. CONCLUSIONS: Female sex is not a risk factor in coronary bypass surgery in the GOPCABE population. The result is the same for on- and off-pump surgery. Since female sex is a component of most risk scores, the findings may identify a potential inaccuracy in current surgical risk assessment, specifically for elderly women. TRIAL REGISTRATION: Clinicaltrials.gov GOPCABE trial No. NCT00719667.

Omission of predilation in balloon-expandable transcatheter aortic valve implantation: retrospective analysis in a large-volume centre.

AIMS: We aimed to evaluate the effect of omitting predilation on feasibility, procedural results and safety in balloon-expandable TAVI. METHODS AND RESULTS: We performed an analysis of all 680 patients scheduled for a balloon-expandable TAVI prosthesis between January 2011 and August 2016. Patients treated with or without predilation were compared. Procedure times decreased from 85.6±42.9 to 56.7±26.1 minutes (p<0.001), fluoroscopy times from 9.5±5.7 to 6.2±3.9 minutes (p<0.001) and contrast volume from 131.9±60.8 to 85.4±37.4 ml (p<0.001) without predilation. Intraprocedural CPR was significantly more frequent in the predilation group (5.3% vs. 1.4%, p=0.01). Stroke rate was low at 1.5% and with no detectable difference. Applying VARC-2 definitions, the combined endpoints device success (88.3% vs. 92.4%, p=0.07) and clinical efficacy (88.7% vs. 92.4%, p=0.11) were comparable with or without prior valvuloplasty, while early safety was less frequent with predilation (85.2% vs. 90.2%, p=0.04). At 30 days, all-cause mortality and cardiovascular mortality were 6.8% with predilation vs. 2.9% without predilation (p=0.03) and 5.3% vs. 1.4% (p=0.01). CONCLUSIONS: TAVI without prior valvuloplasty is feasible without apparent adverse impact in patients receiving a balloon-expandable TAVI prosthesis. The omission of predilation is associated with shorter procedure time, less radiation exposure and lower rates of intraprocedural resuscitation.

Hemodynamic Improvement at Three Months after MitraClip® Treatment in End-Stage Heart Failure Patients with Functional Mitral Regurgitation.

BACKGROUND: Functional mitral regurgitation (FMR) is common in patients with advanced heart failure and impaired left ventricular function. The study aim was to examine functional and hemodynamic effects at three months after MitraClip® implantation in high-risk surgical patients with FMR. METHODS: A group of 93 patients was rejected for surgical treatment by heart-team decisions due to an inacceptable risk for conventional mitral valve surgery. Between October 2011 and May 2015, 89 of these patients (96%) were treated successfully with MitraClip implantation. A subsequent complete follow up was performed over three months in 32 patients with FMR, including pro-brain natriuretic peptide (pro-BNP) measurements, six-minute walk test, echocardiography, and right heart catheterization. RESULTS: The patients (mean age 73 ± 7 years) presented with a mean left ventricular ejection fraction (LVEF) of 32 ± 13%, and mitral regurgitation (MR) grade ≥3 in 30 of 32 cases (93%). All patients suffered from severe FMR and were highly symptomatic (NYHA functional class III or IV). The mean logistic EuroSCORE was 33%. MitraClip implantation resulted in a significant clinical improvement and reverse cardiac remodelling with a decrease in LV end-diastolic and LV endsystolic diameters, while LVEF was unchanged. In addition, a statistically relevant reduction of systolic, diastolic and mean pulmonary artery pressures (PAPsystolic -7.2 mmHg, p = 0.011; PAPdiastolic -4.5 mmHg, p = 0.003; and PAPmean -5.3 mmHg, p = 0.007) were measured, while the cardiac index (+0.3 l/min/m2, p <0.001) and cardiac output (+0.5 l/min, p <0.001) were increased significantly. The 30-day mortality was 8.6% (n = 8). CONCLUSIONS: Among the study population, MitraClip implantation led to clinical improvement, reverse cardiac remodeling, and a sustained hemodynamic benefit during the three-month follow up period.

Multicentre analysis of current strategies and outcomes in open aortic arch surgery: heterogeneity is still an issue.

OBJECTIVES: The study was conducted to evaluate, on the basis of a multicentre analysis, current results of elective open aortic arch surgery performed during the last decade. METHODS: Data of 1232 consecutive patients who underwent aortic arch repair with reimplantation of at least one supra-aortic artery between 2004 and 2013 were collected from 11 European cardiovascular centres, and retrospective statistical examination was performed using uni- and multi-variable analyses to identify predictors for 30-day mortality. Acute aortic dissections and arch surgeries not involving the supra-aortic arteries were not included. RESULTS: Arch repair involving all 3 arch arteries (total), 2 arch arteries (subtotal) or 1 arch artery (partial) was performed in 956 (77.6%), 155 (12.6%) and 121 (9.8%) patients, respectively. The patients' characteristics as well as the surgical techniques, including the method of cannulation, perfusion and protection, varied considerably between the clinics participating in the study. The in-hospital and 30-day mortality rates were 11.4 and 8.8% for the entire cohort, respectively, ranging between 1.7 and 19.0% in the surgical centres. Multivariable logistic regression analysis identified surgical centre, patient's age, number of previous surgeries with sternotomy and concomitant surgeries as independent risk factors of 30-day mortality. The follow-up of the study group was 96.5% complete with an overall follow-up duration of 3.3 ± 2.9 years, resulting in 4020 patient-years. After hospital discharge, 176 (14.3%) patients died, yielding an overall mortality rate of 25.6%. The actuarial survival after 5 and 8 years was 72.0 ± 1.5% and 64.0 ± 2.0, respectively. CONCLUSIONS: The surgical risk in elective aortic arch surgery has remained high during the last decade despite the advance in surgical techniques. However, the patients' characteristics, numbers of surgeries, the techniques and the results varied considerably among the centres. The incompleteness of data gathered retrospectively was not effective enough to determine advantages of particular cannulation, perfusion, protection or surgical techniques; and therefore, we strongly recommend further prospective multicentre studies, preferably registries, in which all relevant data have to be clearly defined and collected.

Acute aortic dissection involving the root: operative and long-term outcome after curative proximal repair.

OBJECTIVES: The aim of the study was to evaluate operative and long-term results after surgery of acute aortic dissection involving the root, in which the proximal repair consisted of curative resection of all dissected aortic sinuses and was performed using either valve-sparing root repair or complete root replacement with a valve conduit. METHODS: Between August 2002 and March 2013, 162 consecutive patients (mean age 63 ± 14 years) underwent surgery for acute type A aortic dissection. Eighty-six patients with an involvement of the aortic root underwent curative surgery of the proximal aorta consisting of valve-sparing root repair (n = 54, 62.8%) or complete valve and root replacement using composite valve grafts (n = 32, 37.2%). In patients with root repair, all dissected aortic walls were resected and root remodelling using the single patch technique (n = 53) or root repair with valve reimplantation (n = 1) was performed without the use of any glue. All perioperative data were collected prospectively and retrospective statistical examination was performed using univariate and multivariate analyses. RESULTS: The mean follow-up was 5.2 ± 3.5 years for all patients (range 0-12 years) and 6.1 ± 3.3 years for survivors. The 30-day mortality rate was 5.8% (5 patients), being considerably lower in the repair sub-cohort (1.9 vs 12.5%). The estimated survival rate at 5 and 10 years was 80.0 ± 4.5 and 69.1 ± 6.7%, respectively. No patient required reoperation on the proximal aorta and/or aortic valve during the follow-up time and there were only two valve-related events (both embolic, one in each group). Among those patients with repaired valves, the last echocardiography available showed no insufficiency in 40 and an irrelevant insufficiency (1+) in 14. CONCLUSIONS: Curative repair of the proximal aorta in acute dissection involving the root provides favourable operative and long-term outcome with very low risk of aortic complications and/or reoperations, regardless if a valve-sparing procedure or replacement with a valve conduit is used. Valve-sparing surgery is frequently suitable, providing excellent outcome and very high durability.

Preoperative atrial fibrillation and outcome in patients undergoing on-pump or off-pump coronary bypass surgery: lessons learned from the GOPCABE trial.

OBJECTIVES: Patients undergoing coronary bypass grafting (CABG) are at higher risk if they suffer from atrial fibrillation (AF). It was suggested that performing CABG without the use of cardiopulmonary bypass (off-pump) would reduce perioperative risk. We assessed the influence of preoperative AF on outcome in a randomized cohort of patients above the age of 75 undergoing either on-pump or off-pump CABG. METHODS: The German Off-Pump Coronary Artery Bypass grafting in the Elderly trial, a randomized, controlled multicentre trial conducted at 12 German institutions, enrolled 2303 patients between 2008 and 2011. The presence of AF was recorded at admission and discharge. There was no record on the rhythm status during hospital stay. RESULTS: AF at admission was present in 5% in the on-pump (121/1158) and 5% in the off-pump (112/1145) group. The number of patients with AF at discharge was not different between these two groups (10% on pump, 10% off pump). As expected, AF patients had worse preoperative conditions, which had a negative impact on outcome: The combined end-point of death, infarction, stroke, dialysis and revascularization occurred more often (13 vs 8%, P = 0.008) and 30-day mortality was significantly higher (6 vs 2%, P = 0.003) in AF patients. However, the operative technique used for CABG did not affect these outcome parameters. CONCLUSIONS: AF at admission is a significant risk factor for elderly patients undergoing coronary bypass grafting. However, this risk is not altered by performing bypass grafting off pump.

Bio-Bentall procedure versus isolated biological aortic valve replacement: a case-match study.

OBJECTIVES: The aim of the study was to evaluate whether a complete aortic root replacement using a composite graft with biological valve prosthesis carries a higher early or late postoperative risk than isolated valve replacement. METHODS: Between 1998 and 2008, 182 consecutive patients underwent complete aortic root and ascending aorta replacement using a self-assembled composite graft with a biological valve prosthesis located within the vascular tube (modified Bentall procedure). In the same period, 1959 patients received an isolated aortic valve replacement using a biological valve prosthesis. After matching the patients using five variables (sex, age-by 5-year increments, aortic valve defect, concomitant coronary surgery and the year of surgery), 79 perfectly matched pairs were found. Regarding other clinically essential but unmatched preoperative characteristics, there were no relevant differences between the groups. RESULTS: There was no statistically significant difference in the early postoperative mortality (30-day and/or in-hospital), which was 5.1% (4 patients) in the Root Group (RG) and 3.8% (3 patients) in the Valve Group (VG). The follow-up was complete for all patients and contained 499 patient-years in the RG versus 488 in the VG. In total, there were 23 deaths in each group during the follow-up time, which was 6.2 ± 2.8 years for the RG and 6.2 ± 3.2 years for the VG. Hence, the linearized death rate and actuarial survival at 10 years were almost identical. They were 4.66%/year and 63.2 ± 8.3%, respectively, in the RG; compared with 4.71%/year and 58.5 ± 9.3% in the VG. Also the rates of valve-related morbidities were similar except for the tendency of a lower rate of cerebral embolism in the RG. CONCLUSIONS: Complete aortic root replacement with a biological composite graft can be performed by experienced surgeons with an operative risk similar to that of an isolated biological aortic valve replacement. Starting with comparable operative outcomes, both procedures offer almost identical long-term survival. The rates of valve-related events after complete aortic root replacement and isolated valve replacement are also comparable, apart from cerebral embolism, which seems to be less frequent after aortic root replacement.

Impact of surgical experience on outcome in surgery of acute type A aortic dissection.

OBJECTIVES: The study was conducted to evaluate our results of acute aortic dissection repair taking into account the impact of surgical experience in aortic surgery. METHODS: Between August 2002 and March 2013, 162 consecutive patients (mean age: 63 ± 14 years) underwent surgery for acute type A aortic dissection. All patients were operated on by one of the clinic's attending surgeons with wide experience in cardiac surgery (at least 2000 procedures performed personally), however about one-half of the patients (75 patients, 46%) were operated by the aortic team (AT) surgeons with profound experience in complex aortic pathologies. All perioperative data were collected prospectively and retrospective statistical analysis was performed using uni- and multivariate analyses to identify predictors for surgical adverse outcome (AO) containing in-hospital and/or 90-day mortality and new permanent neurological and organ dysfunctions. RESULTS: AO was observed in 36 patients (22.2%) including in-hospital mortality in 22 (13.6%). Multivariate logistic regression analysis identified surgery not performed by the AT as the strongest predictor for AO (odds ratio: 14.1; 95% confidence interval: 3.5-55.6; P < 0.0001) followed by any malperfusion, myocardial infarction and creatinine level. Two groups were built according to the surgery performed by the AT (Group AT) or by the surgeons not on the AT (Group No-AT). The comparison of the groups showed no relevant differences regarding the preoperative characteristics, especially compromised consciousness, malperfusion and extent of dissection. Yet, the outcomes in Group AT vs No-AT were significantly different presenting AO: 8.0 vs 34.5% (P < 0.0001), in-hospital mortality: 4.0 vs and 21.8% (P < 0.001), new permanent neurological deficit: 2.7 vs 11.5% (P = 0.03), even if valve-sparing repairs and complete arch replacements were much more frequent in Group AT. The groups also differed considerably in regard to cannulation and perfusion management, which might play a decisive role in surgical outcome. CONCLUSIONS: Aortic repair in acute type A dissection, when performed by highly specialized aortic surgeons, offers not only much better outcomes but also provides significantly higher rate of curative albeit valve-sparing aortic repairs. Patient-centred care in referral aortic centres with surgery performed by specialized teams should be striven for to improve surgical results in acute aortic dissection surgery.