The influence of mitral valve pathology on the concomitant tricuspid valve repair.

BACKGROUND: The influence of the etiology of mitral valve (MV) lesion on outcomes of concomitant repair for functional tricuspid regurgitation (TR) is not well studied. Our objectives were to compare long-term survival and TR recurrence after tricuspid valve (TV) repair concomitant with surgery for rheumatic versus degenerative MV disease. METHODS: We included 480 patients who had concomitant MV and TV surgery from 2009 to 2019. We grouped the patients into Group 1 (n = 345; rheumatic MV) and Group 2 (n = 135; degenerative MV). Propensity score matching identified 104 matched pairs. RESULTS: There was no significant difference in survival between groups before (p = .46) or after matching (p = .09). There was no difference in the recurrence of moderate TR (subdistributional hazard ratio [SHR]: 1.22 [0.77-1.95], p = .40). Recurrent TR was significantly associated with the preoperative TR grade (SHR: 1.8 [1.5-2.16], p < .001); body mass index (SHR: 1.05 [1.03-1.08], p < .001), and the use of flexible versus rigid TV prosthesis (SHR: 0.64 [0.41-0.99], p = .042). Recurrence of TR was higher with MV replacement compared with repair (SHR: 1.69 [1.03-2.78], p = .038). The change in the degree of TR did not differ between groups before matching (OR: 0.77 [0.56-1.04], p = .09) or after matching (OR: 0.98 [0.67-1.44]; p = .93). CONCLUSION: Outcomes of concomitant TR repair were comparable in rheumatic and degenerative mitral pathology. Type of the TV prosthesis and TR grade affected TR recurrence. MV repair could be associated with a lower recurrence of TR compared with replacement.

Using tissue mitral valves in younger patients: A word of caution.

BACKGROUND: The debate about the optimal mitral valve prosthesis continues. We aimed to compare the early and late outcomes, including stroke, bleeding, survival, and reoperation after isolated mitral valve replacement (MVR) using tissue versus mechanical valves. METHODS: This retrospective cohort study included 291 patients who had isolated MVR from 2005 to 2015. Patients were grouped into the tissue valve group (n = 140) and the mechanical valve group (n = 151). RESULTS: There were no differences in duration of mechanical ventilation, hospital stay, and hospital mortality between groups. Fifteen patients required cardiac rehospitalization, nine in the tissue valve group, and six in the mechanical valve group (p = .44). Stroke occurred in nine patients, five with tissue valves, and four with mechanical valves (p = .66). Bleeding occurred in 22 patients, seven patients with tissue valves, and 15 patients with mechanical valves (p = .09). Freedom from reoperation was 95%, 93%, 84%, 67% at 3, 5, 7, and 10 years for tissue valve and 97%, 96%, 96%, and 93% for mechanical valves, respectively (p˂ .001). The median follow-up was 84 months (Q1: Q3: 38-139). Survival at 3, 5, 7, and 10 years was 94%, 91%, 89%, 86% in tissue valves and 96%, 93%, 91%, 91% in mechanical valves, respectively (p = .49). CONCLUSIONS: Tissue valve degeneration is still an issue even in the new generations of mitral tissue valves. The significant risk of reoperation in patients with mitral tissue valves should be considered when using those valves in younger patients. Mechanical valves remain a valid option for all age groups.

Residual versus recurrent mitral regurgitation after transcatheter mitral valve edge-to-edge repair.

BACKGROUND: The number of MtraClip procedures is increasing, and consequently, the number of patients with residual or recurrent mitral regurgitation (MR). We aimed to characterize patients who had residual versus recurrent MR after MitraClip and report the outcomes of different treatment strategies. METHODS: From 2012 to 2020, 167 patients had MitraClip. Out of them, 16 patients (9.5%) had residual mitral regurgitation (MR), and 27 patients (16.2%) had recurrent MR. RESULTS: The median age in patients with residual MR was 67.5 (59-73) years versus 69 (61-78) years in patients with recurrent MR (p = .87). The etiology of mitral valve disease was functional in 13 patients (81.3%) and 22 patients (84.6%) in residual versus recurrent MR patients (p > .99). Cardiac resynchronization therapy-defibrillator implantation was higher in patients with residual MR (p = .02). Survival was 93.7% at 1 year, 76.4% at 3 years versus 92.5% at 1 year, and 84.5% at 3 years in residual versus recurrent MR (p = .69). Two patients in the residual MR group had re-clip, and three had surgery, and in the recurrent MR group, one patient had re-clip, and two patients had surgery (p = .23). Patients who had re-clip were older (p = .09). Surgery was associated with 100% survival at 5 years, 63% after medical therapy and the worst survival was reported in re-clip patients (p = .007). CONCLUSION: The outcomes of patients with residual versus recurrent mitral regurgitation after MitraClip were comparable. Survival could be improved with surgery compared with medical therapy and re-clip.

Routine use of del Nido cardioplegia compared with blood cardioplegia in all types of adult cardiac surgery procedures.

BACKGROUND AND AIM OF STUDY: Several studies reported the safety and potential benefits of single-dose Del Nido cardioplegia (DNC) in selected adult cardiac surgery (ACS) procedures. However, studies are scarce on routine use of DNC in more complex procedures and patients with a high risk profile. We sought to compare DNC with cold blood cardioplegia (BC) in all types of ACS including complex procedures. METHODS: Data for 305 consecutive unselected patients who underwent ACS procedures (July/2017 to November/2019) were included. DNC was routinely used whenever is available (n = 231) and if not available, cold BC is used (n = 74). All categories of ACS procedures (primary or redo) were included. Repeated measures analysis was performed to compare baseline, peak, and trough Troponins levels in both groups. Linear regression analysis was used to identify independent predictors of peak Troponins level. RESULTS: The two groups were comparable in baseline characteristics including euro score (ES II), risk profile, and surgical complexity. DNC was associated with lower cardiopulmonary bypass (CPB) and cross-clamp times, cardioplegia volume, and number of cardioplegia doses (p < .001). Importantly, DNC was associated with lower postoperative Troponin level (p = .001), shorter duration of inotropic support (p = .02), and shorter intensive care unit stay (p = .04). On linear regression analysis, DNC was an independent predictor of lower postoperative peak Troponin (t = -3.5, p < .001). CONCLUSIONS: Routine use of DNC in all types of ACS procedures compared with BC was associated with significantly shorter CPB and clamp times, significantly lower postoperative troponin release, and shorter duration of inotropic support.

Multiple mycotic arterial aneurysms involving the left anterior descending coronary artery following mitral and aortic valve endocarditis: A case report.

We present a 57-year-old man with recent Streptococcus viridans endocarditis on mitral and aortic valves who had a mycotic aneurysm of the left anterior descending (LAD) coronary artery and associated superior mesenteric and cerebral artery aneurysms. The patient had preoperative renal failure and the infection was controlled with ceftriaxone. Mitral and aortic valve replacement were performed using tissue valves and the LAD aortic aneurysm was ligated and the patient had saphenous venous graft to the LAD. The postoperative course was complicated by pleural effusion and the patient had antibiotic therapy for 6 weeks postoperatively.

Reinterventions after transcatheter edge to edge mitral valve repair: Is early clipping warranted?

BACKGROUND: Reintervention after transcatheter edge to edge repair using MitraClip is still challenging. We aimed to report our experience in reinterventions after MitraClip procedures and describe the outcomes. METHODS: From 2012 to 2020, 167 patients had a transcatheter edge to edge repair; 10 of them needed reinterventions. At the time of the first MitraClip, the median EuroSCORE was 4.29 (2.62-7.52), and the ejection fraction was 30 (20-40)%. RESULTS: Emergency mitral valve replacement (MVR) was performed in two patients, elective MVR in three, cardiac transplantation in two, and repeat clipping in threepatients. The median time from MitraClip to the reintervention was 4.5 (2-13) months. One patient required extracorporeal membrane oxygenation support after elective MVR. Repeat clipping failed to control mitral regurgitation grade in all patients. Clip detachment was reported in five patients (50%). The median follow-up after the reintervention was 19.5 (9-75) months, and mortality occurred in two patients who had repeat clipping (20%). CONCLUSIONS: MVR after MitraClip is feasible with low morbidity and mortality. Repeat mitral valve clipping had a high failure rate. Mitral repair was not feasible in all patients in our series, and the use of MitraClip to delay surgical interventions may not be feasible if mitral repair is an option.

del Nido Cardioplegia in Adult Patients: A Propensity-Matched Study of 102 Consecutive Patients.

BACKGROUND: Paediatric del Nido cardioplegia (DNC) has been tested in selected populations of low-risk adult patients. This study examined its use in an unselected medium-to-high-risk adult population and compared the results with a propensity-matched population that received intermittent warm blood cardioplegia (IWBC). METHODS: Data from the last 1,000 consecutive adult patients who underwent a variety of surgical procedures under cardioplegic arrest with the use of IWBC or DNC between 2016 and 2018 were propensity score matched on preoperative clinical and demographic variables. Two (2) main populations were 102 patients who received DNC and another set of matched 102 patients from a total of 1,000 patients who received IWBC, along with a subgroup with an ejection fraction (EF) ≤40% (EFDNC vs EFIWBC). Postoperative outcomes were mortality, peak troponin T, postoperative EF%, and aortic cross-clamp time. RESULTS: There were no preoperative differences amongst the groups in the main cohort (Euroscore II: DNC 4.1±8, IWBC 4.0±7; EF%: DNC 47±10, IWBC 47±11) and in the subgroup (EF%: EFDNC 32±6%, EFIWBC 32±6%; p=0.45). There were also no differences in three of the outcomes. A significant postoperative improvement was noticed in the EF% in the DNC (32±6% 95% CI 29-34 to 39±12 95% CI 34-44; p=0.001) in the EFDNC group. CONCLUSIONS: This initial experience of del Nido cardioplegia proved to be effective in a variety of challenging pathologies in adult populations.

Aborted TAVR following aortic balloon valvuloplasty.

An 80-year-old man with symptomatic severe aortic valve stenosis was referred for transcatheter aortic valve replacement (TAVR) after balloon aortic valvuloplasty (BAV). The TAVR procedure was aborted because of identification of a mobile mass attached to the leading edge of the right cusp of the aortic valve on a transesophageal echocardiography. Surgical aortic valve replacement (SAVR) was performed and this mass was found to be an aortic cusp fenestration rupture that was caused by the BAV.

Should routine pulmonary function tests be performed in patients with left ventricular dysfunction and/or congestive heart failure undergoing cardiac surgery?

BACKGROUND: It is controversial whether pulmonary function testing should be performed routinely in cardiac surgery patients. The aim of our study was to focus on patients who have congestive heart failure, caused by left ventricular dysfunction or left-sided heart valve disease, and study the prognostic value of performing preoperative pulmonary function testing on their postoperative outcomes. METHODS: This is a retrospective propensity score matched study that included 366 patients with congestive heart failure who underwent cardiac surgery and had preoperative pulmonary function test. The patients were divided into two groups: Group 1 who had a normal or mild reduction in pulmonary function tests and group 2 who had moderate to severe reduction in pulmonary function tests. The postoperative outcomes, including pulmonary complications, were compared between the two groups. RESULTS: Pulmonary function tests were normal or mildly reduced in 190 patients (group 1) and moderately to severely reduced in 176 patients (group 2). Propensity matching identified 111 matched pairs in each group with balanced preoperative and operative characteristics. Compared to group 1, Group 2 had longer duration of mechanical ventilation [12 (7.5-16) vs. 9 (6.5-13) hours, p < 0.001], higher postoperative Creatinine [111 (90-142) vs. 105 (81-128) µmol/dl, p = 0.02] and higher hospital mortality (6.31% vs. 0%, p = 0.02). CONCLUSION: Routine Pulmonary Function Testing should be performed in patients with Left ventricular dysfunction and/or congestive heart failure undergoing cardiac surgery since moderate to severe reduction in those patients was associated with longer duration of mechanical ventilation and higher hospital mortality.

The Effect of Gender on Triple Heart Valve Surgery Outcomes; Reinforcing Women's Health.

Female gender is a risk factor in several cardiac surgery risk stratification systems. This study explored the differences in the outcomes following triple heart valve surgery in men vs women. The study included 250 patients (males n = 101; females n = 149) who underwent triple valve surgery from 2009 to 2020. BMI (body mass index) was higher in females (29.6 vs 26.5 kg/m2, P < .001), and diabetes was more common in males (44 vs 42%, P = .012). The ejection fraction was higher in females (55 vs 50%, P < .001). The severity of mitral valve stenosis and tricuspid valve regurgitation was significantly greater in females (33.11 vs 27.72%, P = .003 and 44.30 vs 19.8%, P < .001, respectively). Mitral valve replacement was more common in females (P < .001), and they had lower concomitant coronary artery bypass grafting (P = .001). Bleeding and renal failure were lower in females (P = .021 and <0.001, respectively). Hospital mortality, readmission, and reintervention were not significantly different between genders. By multivariable analysis, male gender was a risk factor for lower survival [HR (hazard ratio): 2.18; P = .024]. Triple valve surgery can be performed safely in both genders, with better long-term survival in females. Female gender was not a risk factor in patients undergoing triple valve surgery.

Comparison of Outcomes After Transcatheter Versus Surgical Repeat Mitral Valve Replacement.

INTRODUCTION: Repeat transcatheter mitral valve replacement (rTMVR) has emerged as a new option for the management of high-risk patients unsuitable for repeat surgical mitral valve replacement (rSMVR). The aim of this study was to compare hospital outcomes, survival, and reoperations after rTMVR versus surgical mitral valve replacement. METHODS: We compared patients who underwent rTMVR (n=22) from 2017 to 2019 (Group 1) to patients who underwent rSMVR (n=98) with or without tricuspid valve surgery from 2009 to 2019 (Group 2). We excluded patients who underwent a concomitant transcatheter aortic valve replacement or other concomitant surgery. RESULTS: Patients in Group 1 were significantly older (72.5 [67-78] vs. 57 [52-64] years, P<0.001). There was no diference in EuroSCORE II between groups (6.56 [5.47-8.04] vs. 6.74 [4.28-11.84], P=0.86). Implanted valve size was 26 (26-29) mm in Group 1 and 25 (25-27) mm in Group 2 (P=0.106). There was no diference in operative mortality between groups (P=0.46). However, intensive care unit (ICU) and hospital stays were shorter in Group 1 (P=0.03 and <0.001, respectively). NYHA class improved significantly in both groups at one year (P<0.001 for both groups). There was no group effect on survival (P=0.84) or cardiac readmission (P=0.26). However, reoperations were more frequent in Group 1 (P=0.01). CONCLUSION: Transcatheter mitral valve-in-valve could shorten ICU and hospital stay compared to rSMVR with a comparable mortality rate. rTMVR is a safe procedure; however, it has a higher risk of reoperation. rTMVR can be an option in selected high-risk patients.

Does preoperative screening with computed tomography of the chest decrease risk of stroke in patients undergoing coronary artery bypass grafting.

Background: Stroke is one of the most feared complications post coronary artery bypass with aortic calcifications being the commonest source of embolic stroke. The aim of our study was to determine the clinical impact and usefulness of routine use of plain chest computerised tomography to screen for aortic calcification on incidence of postoperative stroke in coronary artery bypass grafting (CABG) patients. Methods: This is a retrospective case-control study that included four hundred and five patients who underwent primary isolated CABG and had preoperative plain chest computerised tomography as a screening for aortic calcification. Aortic calcification was classified according to the area involved (ascending, arch, arch vessels and descending aorta) and the pattern of calcification. Patients were divided into two groups according to the incidence of postoperative stroke and the aortic calcification distribution was compared between the two groups. Stroke predictors were studies using univariate and multivariate regression analysis. Results: Fourteen patients (3.5%) developed postoperative stroke. There was no difference in preoperative and operative characteristics between patients who developed postoperative stroke and those who did not, except for the history of preoperative stroke or transient ischemic attack (TIA) that was higher in the group who developed postoperative stroke (50.00% vs. 6.19%, P<0.001). Patients who developed postoperative stroke had higher percentage of aortic root calcification (78.57% vs. 64.18%), ascending aortic calcification (28.57% vs. 19.07%) and descending aortic calcification (85.71% vs. 73.71%) but none of them reached statistical significance. History of preoperative stroke or TIA was the only significant predictor of postoperative stroke using both univariate and multivariate regression models. Conclusions: Our study showed the importance of preoperative computed tomography (CT) scan of the chest as a screening tool as it detected a high prevalence of aortic calcification in our patients. However, its impact on prevention of postoperative stroke needs to be investigated further in future prospective studies.

Concomitant intra-aortic balloon pump and veno-arterial extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock.

We aimed to compare the outcomes of ECMO with and without IABP for postcardiotomy cardiogenic shock. The study included 103 patients who needed ECMO for postcardiotomy cardiogenic shock. Patients were grouped according to the use of IABP into ECMO without IABP (n = 43) and ECMO with IABP (n = 60). The study endpoints were hospital complications, successful weaning, and survival. Patients with IABP had lower preoperative ejection fraction (p = 0.002). There was no difference in stroke (p = 0.97), limb ischemic (p = 0.32), and duration of ICU stay (p = 0.11) between groups. Successful weaning was non-significantly higher with IABP (36 (60%) vs 19 (44.19%); p = 0.11). Predictors of successful weaning were inversely related to the high pre-ECMO lactate levels (OR: 0.89; p = 0.01), active endocarditis (OR: 0.06; p = 0.02), older age (OR: 0.95; p = 0.02), and aortic valve replacement (OR: 0.26; p = 0.04). There was no difference in survival between groups (p = 0.80). Our study did not support the routine use of IABP during ECMO support.

Surgical vs Transcatheter Aortic Valve Replacement in Patients With a Low Ejection Fraction.

Currently, there is no preference for surgical (SAVR) vs transcatheter (TAVR) aortic valve replacement in patients with low ejection fraction (EF). The present study retrospectively compared the outcomes of SAVR vs TAVR in patients with EF ≤40% (70 SAVR and 117 TAVR patients). Study outcomes were survival and the composite endpoint of stroke, aortic valve reintervention, and heart failure readmission. The patients who had TAVR were older (median: 75 (25-75th percentiles: 69-81) vs 51 (39-66) years old; P < .001) with higher EuroSCORE II (4.95 (2.99-9.85) vs 2 (1.5-3.25); P < .001). Postoperative renal impairment was more common with SAVR (8 (12.5%) vs 4 (3.42%); P = .03), and they had longer hospital stay [9 (7-15) vs 4 (2-8) days; P < .001). There was no difference between groups in stroke, reintervention, and readmission (Sub-distributional Hazard ratio: .95 (.37-2.45); P = .92). Survival at 1 and 5 years was 95% and 91% with SAVR and 89% and 63% with TAVR. Adjusted survival was comparable between groups. EF improved significantly (ß: .28 (.23-.33); P < 0.001) with no difference between groups (P = .85). In conclusion, TAVR could be as safe as SAVR in patients with low EF.

Results of Surgical Ablation for Atrial Fibrillation in Patients with Rheumatic Heart Disease.

Background: There is conflicting evidence regarding the success of the Maze procedure to restore sinus rhythm in patients with rheumatic heart disease. Hence, the aim of our study was to describe the results of surgical ablation for atrial fibrillation in patients with rheumatic heart disease undergoing cardiac surgery. Methods: This is a retrospective study that included adult patients with rheumatic heart disease who underwent surgical ablation for atrial fibrillation. The ablation lesions were performed using monopolar radiofrequency ablation in all patients. Results: Fifty-seven consecutive patients were included in the study. Cox Maze IV was performed in 44 patients (77%), while left-sided surgical ablation was performed in 10 patients (17%) and pulmonary vein isolation in 3 patients (5%). The percentage of patients who were in sinus rhythm on discharge, at 1-month, at 3-months, 6-months and 12-months follow up were 56%, 54%, 52%, 56% and 46% respectively. Complete heart block occurred in 21 patients (44%), but only 15 of them (26%) required permanent pacemaker insertion. Freedom from composite endpoint of death, stroke, and readmission for heart failure was 78% at one-year follow up. Conclusion: Despite the suboptimal rates of sinus rhythm at the intermediate and long term follow up, surgical ablation of atrial fibrillation in patients with rheumatic heart disease should continue to be performed. Continuation of Class III antiarrhythmic medications and early intervention for recurrent atrial fibrillation is crucial to the success of this procedure and for maintenance of higher rates of sinus rhythm at intermediate and long-term follow up.

Mechanical circulatory support as a bridge to transplant candidacy.

INTRODUCTION: The use of mechanical circulatory support (MCS) in nontransplant eligible candidates remains controversial. Our decision to offer MCS for nontransplant candidates has led to their reevaluation after a period of left ventricular assist device (LVAD) support. METHODS: From 2001 to September 2009, we had 37 patients who received an implantable LVAD, 22 (59%) were not deemed to be transplant eligible at the time of LVAD insertion (bridge to candidacy, BTC group). RESULTS: Fifteen (41%) patients were considered transplant eligible (bridge to transplant, BTT group) at the time of device insertion and received a HeartMate XVE (n = 7), HeartMate 2 (n = 7), or a Novacor LVAS (n = 1). In the BTC group, patients received the HeartMate XVE device (n = 11), HeartMate 2 (n = 5), or the Novacor LVAS (n = 6). The primary criterion for transplant ineligibility was refractory pulmonary hypertension (PH) in 18 patients, 3 patients did not meet our body mass index criteria (>35 kg/m(2)), and 2 patients were dialysis-dependent. Six (27%) BTC patients died on support. Overall, 16/22 patients (73%) were subsequently listed for transplantation, with one listed for combined heart-lung due to refractory PH. Twelve patients (75%) underwent successful heart transplantation. Three patients died during their transplant. Overall posttransplant survival at one year shows lower survival in the BTC group compared to the BTT group (67% vs. 100%, p = 0.05). At two years and three years the survival was lower, but not statistically different (BTC vs. BTT: 67% vs. 90% and 64% vs. 87%, respectively, p = NS). CONCLUSIONS: MCS can successfully convert a large proportion of transplant-ineligible patients into acceptable candidates.

Long-term Outcomes of Tricuspid Valve Repair: The Influence of the Annuloplasty Prosthesis.

BACKGROUND: The ideal tricuspid valve annuloplasty (TVA) prosthesis is controversial. This study aimed to compare the effect of rigid versus flexible TVA prostheses on long-term outcomes after repair of functional tricuspid regurgitation (FTR). METHODS: We included 713 patients who had repair of FTR from 2009 to 2017. Patients were divided into 2 groups according to the type of TVA prosthesis. Group 1 (n = 104) included patients who had repair using rigid rings; group 2 (n = 609) included patients with flexible bands. Median age was 53.5 years (25th through 75th percentiles; range, 42.5-62 years) in group 1 versus 56 years (range, 45-65 years) in group 2 (P = .11). Propensity score matching identified 91 matched pairs for comparison. RESULTS: In the matched pairs, operative mortality was identical (4 in both groups [4.4%]; P ˃ .99). Median follow-up was 55 months (range, 28-83 months). The cumulative incidence of moderate or higher tricuspid regurgitation (TR) in the presence of death as a competing risk was higher in group 2 (subdistribution hazard ratio = 1.63, P = .019; and subdistribution hazard ratio = 1.6, P = .099 before and after matching, respectively). There was a trend of higher pacemaker insertion in group 1 (7 [7.69%] versus 3 [3.3%]; P = .34), which did not reach statistical significance after matching. There was no significant change in the degree of TR over time between groups (odds ratio = 1.21, P = .53; and odds ratio = 1.75, P = .21 before and after matching, respectively). CONCLUSIONS: Both types of TVA prostheses had comparable efficacy in managing FTR; however, freedom from moderate or more TR was higher in the rigid ring group.

Early Hemodynamic Profile after Aortic Valve Replacement - A Comparison between Three Mechanical Valves.

INTRODUCTION: There are scarce data comparing different mechanical valves in the aortic position. The objective of this study was to compare the early hemodynamic changes after aortic valve replacement between ATS, Bicarbon, and On-X mechanical valves. METHODS: We included 99 patients who underwent aortic valve replacement with mechanical valves between 2017 and 2019. Three types of mechanical valves were used, On-X valve (n=45), ATS AP360 (n=32), and Bicarbon (n=22). The mean prosthetic valve gradient was measured postoperatively and after six months. RESULTS: Preoperative data were comparable between groups, and there were no differences in preoperative echocardiographic data. Pre-discharge echocardiography showed no difference between groups in the ejection fraction (P=0.748), end-systolic (P=0.764) and end-diastolic (P=0.723) diameters, left ventricular mass index (P=0.348), aortic prosthetic mean pressure gradient (P=0.454), and indexed aortic prosthetic orifice area (P=0.576). There was no difference in the postoperative aortic prosthetic mean pressure gradient between groups when stratified by valve size. The changes in the aortic prosthetic mean pressure gradient of the intraoperative period, at pre-discharge, and at six months were comparable between the three prostheses (P=0.08). Multivariable regression analysis revealed that female gender (beta coefficient -0.242, P=0.027), body surface area (beta coefficient 0.334, P<0.001), and aortic prosthetic size (beta coefficient -0.547, P<0.001), but not the prosthesis type, were independent predictors of postoperative aortic prosthetic mean pressure gradient. CONCLUSION: The three bileaflet mechanical aortic prostheses (On-X, Bicarbon, and ATS) provide satisfactory early hemodynamics, which are comparable between the three valve types and among different valve sizes.

Degree of right ventricular dysfunction dictates outcomes after tricuspid valve repair concomitant with left-side valve surgery.

OBJECTIVES: The effect of different degrees of right ventricular (RV) dysfunction on long-term outcomes after tricuspid valve repair is the subject of ongoing research. We sought to evaluate the effect of preoperative RV dysfunction on mortality and recurrence of tricuspid regurgitation (TR) after tricuspid valve repair for secondary TR concomitant with left-side valve surgery. METHODS: This is a retrospective study, including 548 patients who underwent repair of secondary TR (2009-2017) at a single institution. Patients were grouped according to preoperative right ventricular (RV) systolic function into three groups; normal RV function (group 1, n = 451), mild RV dysfunction (group 2, n = 60) and moderate/severe RV dysfunction (group 3, n = 37). Study endpoints were mortality and recurrence of TR. RESULTS: Group 3 was associated with the highest hospital mortality (10.2%, p = .06). Predictors of moderate or higher grade TR were NYHA class (HR 2.1, p = 0.03); preoperative TR grade (HR 1.9, p < 0.01), mild RV dysfunction (HR 2.4, p < 0.01), isolated RV dilatation (HR 2.0, p < 0.01), and flexible TV repair prostheses (HR 2.4, p = 0.01). Predictors of mortality were renal impairment (HR 3.0, p < 0.01), ejection fraction (HR 0.97, p = 0.02), pulmonary artery systolic pressure (HR 1.02, p = 0.02), preoperative TR grade (HR 1.7, p < 0.01), and moderate/severe RV dysfunction (HR 3.1, p = 0.01). CONCLUSION: Compared to normal and mild degree of RV dysfunction, moderate and severe RV dysfunction were independent predictors of poor long-term survival. Isolated RV dilatation increased the recurrence of TR. RV dysfunction and dilatation could be indications of tricuspid valve repair.