Comparison of Minimally Invasive Valve Surgery: Hemi-Sternotomy vs. Right Anterolateral Thoracotomy Incision.

Objective: This study aims to compare patient data from two different surgical approaches for minimally invasive valve surgery: hemi-sternotomy and right anterolateral thoracotomy. The primary objective is to determine the safety and efficacy of both surgical incisions. Methods: Between December 2019 and December 2022, a total of 90 patients underwent minimally invasive valve surgery at our center. Among them, 36 patients received the hemi-sternotomy incision with an average age of 45.86 ± 14.83, and 54 patients received the right anterolateral thoracotomy with an average age of 56.77 ± 14.83 years. In the hemi-sternotomy group, 21 patients underwent aortic valve surgery, and 15 had mitral valve surgery, while in the right anterolateral thoracotomy group, 30 patients underwent aortic valve surgery, and 15 patients had mitral valve surgery. Results: No deaths or significant bleeding occurred in the hemi-sternotomy group. However, in the right anterolateral thoracotomy group, one patient died from continuous low cardiac output syndrome after surgery, and one patient suffered a femoral artery dissection. All other patients were discharged without complications. The aortic clamp time and the cardiopulmonary bypass time were significantly lower in the hemi-sternotomy group compared to the right anterolateral thoracotomy group. Conversely, the two groups had no significant differences in intubation time, 24-hour drainage, hospitalization time, and blood transfusion. On the second day after surgery, serum c-TNT and NT-PROBNP levels significantly increased in both groups, but they were significantly higher in the right anterolateral thoracotomy group than in the hemi-sternotomy group. However, on the fifth day after surgery, serum c-TNT and NT-PROBNP levels decreased significantly in both groups, with no significant differences between them. Conclusions: Minimally invasive valve surgery, whether performed with right anterolateral thoracotomy or hemi-sternotomy, is safe and effective after the learning curve. Patients can benefit from these advances in minimally invasive cardiac surgery, and surgeons can easily master these techniques.

[Emergent Transcatheter Aortic Valve Implantation for Degenerated Surgical Aortic Valve Under Local Anesthesia:Report of a Case].

An 89-year-old man who had undergone aortic valve replacement with a 21 mm Mosaic bioprosthetic valve at another hospital 14 years ago was admitted to the emergency room for a sudden respiratory distress two days prior and was diagnosed with severe aortic regurgitation( AR) caused by valve insufficiency and acute heart failure secondary to low cardiac function. Upon admission, he was found to have severe hypoxia with PaO2 of 40 mmHg range, and transcatheter aortic valve replacement (TAVI, TAV in SAV) with a 20 mm SAPIEN3 was performed under local anesthesia for fear of hypotension while under general anesthesia. After confirming that AR had completely disappeared, the patient was intubated and discharged from the operating room on a mechanical ventilator. The patient was weaned from the ventilator on the second postoperative day and was transferred to the other hospital for rehabilitation, 48 days postoperatively. Although there is no report on the comparative study of anesthesia methods for emergency transcatheter aortic valve implantation( TAVI), TAVI under regional anesthesia is minimally invasive with a lower risk for hypotension than general anesthesia. Therefore, we believe it is useful for patients with acute heart failure and hypotension. In addition, it is important to use a balloon expandable valve with excellent implantability to complete the procedure in a short time.

Choosing transcatheter aortic valve replacement in porcelain aorta: outcomes versus surgical replacement.

OBJECTIVES: Porcelain aorta complicates aortic valve replacement and is an indication for transcatheter approaches. No study has compared surgical and transcatheter valve replacement in the setting of porcelain aorta. We characterize porcelain aorta patients undergoing aortic valve replacement and the association of aortic calcification and outcomes. METHODS: Patients undergoing aortic valve replacement with porcelain aorta were identified. Aortic calcium volume was determined using 3D computed tomography thresholding techniques. Propensity scoring was performed to assess the effect of surgical versus transcatheter approaches. Risk factors for composite major hospital complications (death, stroke and dialysis) were identified using random forest machine learning. RESULTS: From January 2006 to January 2015, 164 patients with porcelain aorta underwent aortic valve replacement [105 (64%) surgical replacement, 59 (36%) transcatheter replacement]. Propensity scoring matched 29 pairs (49% of transcatheter patients). Before matching, 5-year survival was 41% [(43% surgical, 35% transcatheter, P(log-rank) = 0.9]. After matching, mortality for surgical versus transcatheter replacement was 3.4% (n = 1) vs 10% (n = 3), stroke 14% (n = 4) vs 3.4% (n = 1) and dialysis 6.9% (n = 2) versus 11% (n = 3). Matched 5-year survival was 40% after surgical replacement and 29% after transcatheter replacement [P(log-rank) = 0.4]. Total aortic calcium volume was greater in transcatheter than surgical patients [18 (8.0) vs 17 (7.7) ml] and was associated with more major hospital complications after either approach. CONCLUSIONS: Surgical and transcatheter approaches are complementary options for aortic stenosis with porcelain aorta. Surgical valve replacement remains an effective treatment for patients requiring concomitant procedures. Quantifying aortic calcium volume is a helpful risk predictor in all patients with porcelain aorta.

The Safety and Efficacy of Transcatheter Pulmonary Valve Replacement Combined with Electrophysiology Procedures.

The objective of this study was to evaluate the safety and efficacy of combining transcatheter pulmonary valve replacement (TPVR) and electrophysiology (EP) procedures. A retrospective review was undertaken to identify TPVR and EP procedures that were concomitantly performed in the cardiac catheterization laboratory at University of Iowa Stead Family Children's Hospital from January 2011 to October 2019. Procedural and follow-up data were compared between patients who underwent TPVR and EP procedures in the same setting to those who received TPVR or EP procedure separately and that were similar in age and cardiac anatomy. A total of 8 patients underwent combined TPVR and EP procedures. One patient was excluded due to lack of adequate control, leaving seven study subjects (57% female; median age at time of procedure 16 years). The median follow-up time was 11.5 months (range 2-36 months). Patients who received combined TPVR and EP had shorter recovery times (combined: median 18.9 h; IQR 18.35-19.5 vs separate: median 27.98 h; IQR 21.42-39.25; p-value 0.031), shorter hospital length of stay (combined: median 27.5 h; IQR 26.47-31.4 vs separate: median 38.4 h; IQR 33.42-51.50; p-value 0.016), and a 51% reduction in total hospital charges (combined: median $171,640; IQR 135.43-219.22 vs separate: median $333,560 IQR 263.20-400.98; p-value 0.016). There were no significant differences in radiation dose or procedure time between the combined and control groups. The median radiation time for those who had the combination procedure was 30.5 min [IQR 29.6-47.9], and the median dose area product was 215 mGy [IQR 158-935]. In conclusion, combining TPVR and EP procedures is feasible, safe, and economically advantageous.

[TAVI simplification: A focus]. / Simplification des procédures TAVI : mise au point.

After a first procedure carried out in 2002 by Pr Cribier's, Transcatheter Aortic Valve Replacement or TAVR revolutionized the management of aortic stenosis with a constant increase in the number of procedures performed worldwide. Experience of operators and teams and evolution of the technique has been accompanied by a drastic reduction in complications in patients at lower surgical risk. In parallel, the procedure was considerably simplified, carried out more and more under local anesthesia, with percutaneous femoral approach, secondary radial approach, prosthesis implantation without predilatation, rapid pacing on left ventricle wire and early discharge. Thus, the "simplified" TAVR adopted in most centers nowadays is a real revolution of the technique. However, simplified TAVR must be accompanied upstream by a rigorous selection of patients who can benefit from a minimalist procedure in order to guarantee its safety.

Beating aortic valve replacement surgery as an alternative to transcatheter aortic valve implantation in a patient with severe aortic stenosis and left ventricular dysfunction.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is the standard treatment for high-risk patients with aortic stenosis (AS); however, alternative treatments for patients who are ineligible for TAVI are controversial. CASE PRESENTATION: 56 year-old female who required 6 γ dobutamine support due to congestive heart failure was diagnosed as severe aortic stenosis with bicuspid valve. Echocardiography revealed left ventricular ejection fraction (LVEF) was 15%. The patient was relatively young for TAVI, and TAVI was not licensed for patient presenting with a bicuspid aortic valve in places other than the limited institutions in Japan. On pump beating aortic valve replacement (AVR) was performed with selective antegrade coronary artery blood perfusion. She resumed a completely normal lifestyle by 3 weeks after the operation. CONCLUSIONS: A relatively young patient for TAVI who was diagnosed as aortic stenosis with severely reduced ejection fraction and bicuspid valve is reported. Beating AVR with a continuously selective antegrade-perfusion was achieved safely with good clinical results in a patient with severely reduced left ventricular (LV) function. Beating AVR can be considered as a potential alternative for patients who are ineligible for conventional surgical aortic valve replacement (SAVR) and TAVI.

Effect of Shenmai injection on cognitive function after cardiopulmonary bypass in cardiac surgical patients: a randomized controlled trial.

BACKGROUND: Postoperative cognitive dysfunction (POCD) is a common complication after cardiac surgery that influences the clinical outcomes and quality of life of patients. This study aimed to evaluate the effects of Shenmai injection (SMI) on POCD of patients who underwent cardiac valve replacement under cardiopulmonary bypass (CPB). METHODS: This prospective, randomized, controlled trial was conducted from September 2014 to January 2017. Eighty-eight patients receiving cardiac valve replacement under CPB were randomized into the control (C) or the SMI (S) group. SMI (0.6 mL/kg) was administered intravenously from the time of anesthesia induction to the beginning of CPB. Cognitive function was assessed at 3 days before surgery and 3 days, 7 days, and 1 month after surgery using the Beijing version of the Montreal Cognitive Assessment (MoCA-BJ) score. The serum levels of neuroglobin (Ngb), hypoxia-inducible factor-1α (HIF-1α), and neuron-specific enolase (NSE) were measured at 30 min after induction (T0), immediately after the endonasal temperature rewarmed to 36 °C (T1), and 1 h (T2), 6 h (T3), 24 h (T4), 48 h (T5), and 72 h (T6) after CPB. RESULTS: Compared with the baseline values at T0, the serum Ngb levels in group C were significantly decreased at T1-2 and then increased at T3-6, while the levels in group S were decreased at T1-2 and increased at T4-6, compared to group C (p < 0.05). The serum HIF-1α levels at T1-4 and the serum NSE levels at T1-6 were significantly increased in both groups (p < 0.05). The serum levels of Ngb at T3, HIF-1α at T1-3, and NSE at T3-4,6 were lower in group S, compared to group C (p < 0.01). The MoCA-BJ scores were decreased at 3 and 7 days after surgery in both groups, and the MoCA-BJ scores in group S were higher than those in group C at 3 and 7 days after surgery (p < 0.01). CONCLUSION: Cognitive function is impaired postoperatively in patients who have undergone cardiac valve replacement under CPB. In addition, treatment with the traditional Chinese medicine SMI decreases the serum levels of Ngb, HIF-1α, and NSE as well as attenuates cognitive dysfunction. TRIAL REGISTRATION: This trial was registered with Clinicaltrials.gov as ChiCTR-TRC-14004373 on March 11, 2014.

Positive impact of retrograde autologous priming in adult patients undergoing cardiac surgery: a randomized clinical trial.

BACKGROUND: Adult cardiac surgery with extracorporeal circulation is known to be associated with increased risk of blood transfusion leading to adverse outcomes. Procedures like retrograde autologous priming (RAP) may reduce these negative side effects. This randomized prospective study was initiated to assess whether RAP using specifically designed RAP bag (Terumo) has immediate effects on patient outcome. METHODS: One hundred eighteen adults undergoing elective CABG or elective aortic valve replacement were randomly assigned by a computer program into two groups: the RAP group (n = 54) in which the retrograde autologous priming was applied and the non-RAP (n = 64) group in which the same setting was used without the possibility to save priming volume. Patient demographics, preoperative characteristics and postoperative outcomes were analyzed for both groups. RESULTS: The primary endpoint defined as rate of intraoperative blood transfusion was significantly reduced in the RAP-group (p = 0.04). The absolute risk reduction for RAP managed patients was 13.5 percent points. There were no significant differences in operation time and blood loss. No deaths and no myocardial infarctions were observed. The number of patients needed to treat to prevent at least one red blood cell transfusion was around 8 (NNT = 7.42). CONCLUSIONS: Retrograde autologous priming is a safe and less invasive procedure which achieves clear benefits for adult cardiac surgery patients. In the light of increasing red blood cell transfusion risks and costs and the wish of patients to avoid a transfusion implementation of retrograde autologous priming is an interesting option. TRIAL REGISTRATION: German Clinical Trials Register ID: DRKS00013512 , registered 04 December 2017.

[Aortic stenosis is a common disease which requires individualized treatment]. / Aortastenos ­ en vanlig sjukdom som kräver individualiserad handläggning.

Aortic stenosis is the most common valvular heart disease and the prevalence increases with age. Common symptoms include dyspnea, angina, and syncope. Echocardiography is a cornerstone in diagnosis of aortic stenosis. Severe aortic stenosis is defined as peak aortic jet velocity ≥4 m/s, a mean transvalvular gradient ≥40 mmHg, and/or an aortic valve area <1.0 cm2. The two-year mortality in patients with symptomatic aortic stenosis is 50 percent without intervention. The only efficient treatment is intervention, either open heart valve replacement or percutaneous transcatheter implantation of an aortic valve prosthesis (TAVI), which both provide symptomatic relief and improved survival. Many patients with aortic stenosis are elderly with comorbidities, thus making treatment decision challenging and requiring individual judgement.

Terapia anticoagulante nas valvopatias / Anticoagulant therapy in valvulopathies

As valvopatias, especialmente na presença da fibrilação atrial (FA), aumentam o risco de eventos tromboembólicos que, além de modificar a história natural da doença, têm impacto significativo na sobrevida e na qualidade de vida dos pacientes. Além do envelhecimento da população mundial, com o consequente número crescente de pacientes com fibrilação atrial, há cada vez mais associações de valvopatias com a doença arterial coronariana (DAC). Nesse grupo de pacientes para os quais há indicação emergencial ou eletiva de intervenção coronariana percutânea (ICP) com implante de stents, serão prescritos antiplaquetários e anticoagulantes ao menos nos primeiros meses pós-ICP. A prevenção do tromboembolismo (TE) com anticoagulantes, como a varfarina ou com os anticoagulantes orais diretos (AOD), é recomendada na maioria das diretrizes. O emprego dos escores CHADS2-VASc e HAS-BLED são úteis para a quantificação dos riscos TE e hemorrágicos

Valvulopathies, especially in the presence of atrial fibrillation (AF), increase the risk of thromboembolic events, which in addition to modifying the natural history of the disease; have a significant impact on survival and quality of life of patients. In addition to the aging of the world's population, with a consequent increase in the number of patients with atrial fibrillation, there are increasing cases of associations of valvular diseases with coronary artery disease (CAD). In this group of patients, in whom there is an emergency or elective indication for percutaneous coronary intervention (PCI) with the implantation of stents, antiplatelet and anticoagulant therapies will be prescribed, at least in the first months after PCI. The prevention of thromboembolic events (TE) with anticoagulants, such as warfarin, or with direct oral anticoagulants (DAOCs), is recommended in most of the Guidelines. The use of the CHADS2-VASc and HAS-BLED scores are useful in the quantification of TE and hemorrhagic risks

Transcatheter Mitral Valve Repair Therapies: Evolution, Status and Challenges.

Mitral regurgitation is a common cardiac valve lesion, developing from primary lesions of the mitral valve or secondary to cardiomyopathies. Moderate or higher severity of mitral regurgitation imposes significant volume overload on the left ventricle, causing permanent structural and functional deterioration of the myocardium and heart failure. Timely correction of regurgitation is essential to preserve cardiac function, but surgical mitral valve repair is often delayed due to the risks of open heart surgery. Since correction of mitral regurgitation can provide symptomatic relief and halt progressive cardiac dysfunction, transcatheter mitral valve repair technologies are emerging as alternative therapies. In this approach, the mitral valve is repaired either with sutures or implants that are delivered to the native valve on catheters introduced into the cardiovascular system under image guidance, through small vascular or ventricular ports. Several transcatheter mitral valve technologies are in development, but limited clinical success has been achieved. In this review, we present a historical perspective of mitral valve repair, review the transcatheter technologies emerging from surgical concepts, the challenges they face in achieving successful clinical application, and the increasing rigor of safety and durability standards for new transcatheter valve technologies.

Potassium and Magnesium Supplementation Do Not Protect Against Atrial Fibrillation After Cardiac Operation: A Time-Matched Analysis.

BACKGROUND: Despite a lack of demonstrated efficacy, potassium and magnesium supplementation are commonly thought to prevent postoperative atrial fibrillation (POAF) after cardiac operation. Our aim was to evaluate the natural time course of electrolyte level changes after cardiac operation and their relation to POAF occurrence. METHODS: Data were reviewed from 2,041 adult patients without preoperative AF who underwent coronary artery bypass grafting, valve operation, or both between 2009 and 2013. In patients with POAF, the plasma potassium and magnesium levels nearest to the first AF onset time were compared with time-matched electrolyte levels in patients without AF. RESULTS: POAF occurred in 752 patients (36.8%). At the time of AF onset or the matched time point, patients with POAF had higher potassium (4.30 versus 4.21 mmol/L, p < 0.001) and magnesium (2.33 versus 2.16 mg/dL, p < 0.001) levels than controls. A stepwise increase in AF risk occurred with increasing potassium or magnesium quintile (p < 0.001). On multivariate logistic regression analysis, magnesium level was an independent predictor of POAF (odds ratio 4.26, p < 0.001), in addition to age, Caucasian race, preoperative ß-blocker use, valve operation, and postoperative pneumonia. Prophylactic potassium supplementation did not reduce the POAF rate (37% versus 37%, p = 0.813), whereas magnesium supplementation was associated with increased POAF (47% versus 36%, p = 0.005). CONCLUSIONS: Higher serum potassium and magnesium levels were associated with increased risk of POAF after cardiac operation. Potassium supplementation was not protective against POAF, and magnesium supplementation was even associated with increased POAF risk. These findings help explain the poor efficacy of electrolyte supplementation in POAF prophylaxis.

Therapeutic alternatives after aborted sternotomy at the time of surgical aortic valve replacement in the TAVI Era-Five centre experience and systematic review.

BACKGROUND: We aimed to analyze causes, management, and outcomes of the unexpected need to abort sternotomy in aortic stenosis (AS) patients accepted for surgical aortic valve replacement (SAVR) in the transcatheter aortic valve implantation (TAVI) era. METHODS: Cases of aborted sternotomy (AbS) were gathered from 5 centers between 2009 and 2014. A systematic review of all published cases in the same period was performed. RESULTS: A total of 31 patients (71% males, 74±8years, LogEuroSCORE 11.9±7.4%) suffered an AbS (0.19% of all sternotomies). Main reasons for Abs included previously unknown porcelain aorta (PAo) in 83.9%, mediastinal fibrosis due to radiotherapy in 12.9%, and chronic mediastinitis in 3.2%. Median time between AbS and next intervention was 2.3months (IQR: 0.7-5.8) with no mortality within this period. Only a case was managed with open surgery. In 30 patients (96.8%) TAVI was performed with a rate of success of 86.7%. Three patients (9.7%) presented in-hospital death and 17 (54.8%) had in-hospital complications including heart failure (9.6%), major bleeding (6.9%), and acute kidney injury (9.6%). Older patients (76±8 vs. 70±8years, p=0.045), previous cardiac surgery (60% vs. 15.4%, p=0.029), and shorter time from AbS to next intervention (5.1±5 vs. 1±0.7months, p=0.001) were related to higher six-month mortality (22.6%). CONCLUSIONS: The main reason for AbS was PAo. This entity was associated to a higher rate of complications and mortality, especially in older patients and with prior cardiac surgery. A preventive strategy in these subgroups might be based on imaging evaluation. TAVI was the most extended therapy.

Impact of institutional volume and experience with CT interpretation on sizing of transcatheter aortic valves: A multicenter retrospective study.

BACKGROUND: Computed tomography (CT) has become the standard imaging modality for pre-procedural aortic annular sizing prior to transcatheter aortic valve replacement (TAVR). We hypothesized that the accuracy of CT derived annular measurements would be greater at sites with higher TAVR procedural volume. METHODS: Within a large integrated health system, TAVR was performed at low (<40 cases), intermediate (40-75 cases), and high-volume sites (>75 cases). 181 patients underwent TAVR with a Sapien XT transcatheter heart valve (THV). Two blinded experienced readers independently remeasured the annulus on CT and compared their measurements to site reported measurements. Hypothetical THV sizes were chosen based on measurements from site CT reports and independent readers' measurements, and compared to the implanted THV size. RESULTS: Correlation between site reported measurements and independent readers measurements of mean annulus size varied between low-volume (r=0.31, p=0.18), intermediate-volume (r=0.34, p=0.01), and high-volume sites (r=0.96, p<0.01). On multivariate analysis, interpretation of ≥20 CT scans (OR 0.29; 95% CI 0.03-0.81; p 0.02) and high-volume site (OR 0.16; 95% CI 0.10-0.82; p 0.02) were associated with reduced mismatch between the site predicted THV size and independent readers predicted THV size. Mismatch between site predicted THV size and implanted THV size was associated with a worse 30-day composite of mortality, dialysis-dependent renal failure, cerebrovascular accident, new permanent pacemaker, and hospital readmission (55.3 vs. 38.7%; p=0.05). CONCLUSIONS: Accuracy of CT aortic annular sizing is improved with higher individual experience and site TAVR volume. These findings should be confirmed in larger, prospective studies.

Assessment of quality of life in patients after surgical and transcatheter aortic valve replacement.

OBJECTIVES: Transcatheter aortic valve implantation (TAVI) and minimally invasive aortic valve replacement (mini-thoracotomy, mini-sternotomy, MIAVR) have become an appealing alternative to conventional surgical (SAVR) treatment of severe aortic stenosis (AS) in high-risk patients. BACKGROUND: Aim of the study was to evaluate the quality of life (QoL) in patients with AS and treated with transfemoral TAVI, SAVR, mini-thoracotomy and mini-sternotomy. METHODS: One hundred and seventy-three patients with symptomatic AS were enrolled in 2011-2013. TAVI group consisted of 39 patients (22.5%), mini-sternotomy was performed in 44 patients (25.5%), mini-thoracotomy in 50 (29%), and AVR in 40 patients (23%). QoL was assessed perioperatively, 12 and 24 months after aortic valve replacement (AVR) by Minnesota Living with Heart Failure Questionnaire (MLHFQ) and EQ-5D-3L. RESULTS: Median follow-up was 583.5 (IQR: 298-736) days. Improvement of health status after procedure in comparison with pre-operative period was significantly more often reported after TAVI in perioperative period (90.3%; P = 0.004) and 12 months after procedure (100%, P = 0.02). Global MLHFQ, physical and emotional dimension score at 30-day from AVR presented significant improvement after TAVI in comparison with surgical methods (respectively: 8.3(±8.6), P = 0.003; 4.1(±5.9), P = 0.01; 1.5(±2.6), P = 0.005). Total MLHFQ score was significantly lower (better outcome) in TAVI patients 1 year after procedure (4.8(±6.8), P = 0.004), no differences in somatic and emotional component were found. No differences were found in MLHFQ score 24 months after AVR. Data from EQ-D5-3L questionnaire demonstrated significant improvement of QoL at 30-day follow-up after TAVI in comparison with surgical methods (1.2(±1.7), P = 0.0008). CONCLUSIONS: TAVI improves QoL in perioperative and 12 months observation in comparison with mini-thoracotomy, mini-sternotomy and SAVR. Improvement in QoL was obtained in both generic and disease specific questionnaires. © 2016 Wiley Periodicals, Inc.

Terapia de ressincronização cardíaca após implante por cateter debioprótese valvar aórtica / Cardiac resynchronization therapy after transcatheter aortic valve implantation

O tratamento da estenose aórtica com implante por cateter de bioprótese valvar aórtica é sabidamente eficaz. Contudo, os distúrbios de condução são complicações frequentes e associam-se a elevada taxa de implante de marcapasso definitivo. Questões referentes ao melhor modo de estimulação, ao papel do cardiodesfibrilador na profilaxia de morte súbita e ao prognóstico ainda não apresentam consenso. Relata-se, portanto, um caso de paciente que, após o implante valvar, evoluiu com bloqueio completo de ramo esquerdo agudo e bradiarritmia, insuficiência cardíaca refratária ao tratamento medicamentoso, com fração de ejeção gravemente comprometida e intolerância ao betabloqueador por bradiarritmia. Optou-se, então, pela terapia de ressincronização ao invésdo marcapasso convencional, com boa resposta clínica. A associação com cardiodesfibrilador foi descartada paraprofilaxia de morte súbita após o estudo eletrofisiológico, o qual não evidenciou instabilidade elétrica ventricular...

Treatment of aortic stenosis with valve of transcatheter implant is known to be effective. However, conduction disorders are common complications and are associated with a high permanent pacemaker implantation rate. Questions regarding the best pacing mode, the role of the defibrillator in sudden death prevention and prognosis, do not have consensus yet. We report, therefore, the case of a patient who developed complete blockage of acute left bundle branch and bradyarrhythmia, heart failure refractory to drug therapy, poor ejection fraction and intolerance to betablocker due bradyarrhythmias after valve implant. Thus, we chose resynchronizationtherapy instead of conventional pacemakers and obtained a good clinical response. The association with adefibrillator was ruled out for sudden death prevention after the electrophysiological study, which did not show ventricular electrical instability...

Propensity score analysis of outcomes following minimal access versus conventional aortic valve replacement.

OBJECTIVES: Minimal access aortic valve replacement has become routine in many institutions. Aim of this study was to compare the clinical outcomes between conventional and minimal access aortic valve replacement. METHODS: We retrospectively analysed the data of 2103 patients who underwent primary, isolated aortic valve replacement (AVR) in our institution between January 2001 and May 2012 with a minimal access AVR (MAAVR) via the upper partial ministernotomy approach (n = 936) or conventional AVR (CAVR) via the full sternotomy approach (n = 1167). After propensity score matching considering potential confounders [age, sex (female), weight, height, preoperative serum creatinine level, previous myocardial infarction, LV-EF and aortic valve pathology (isolated AS)], 585 matched patients were included in each group. RESULTS: Mean age (65 ± 10.5 vs 65.7 ± 11.5 years, P = 0.23), gender (females 37.2%, P = 0.9), aortic cross-clamp time (65.6 ± 18.4 vs 64.3 ± 19.8 min, P = 0.25) and postoperative blood loss [median (IQR) 400 (224-683) vs 400 (250-610) ml, P = 0.83) were similar in MAAVR and CAVR group. Thirty-day mortality was also not significantly different (1.5 vs 1.7%, P = 0.74, respectively). In contrast, CPB times were significantly longer in MAAVR (93.5 ± 25 vs 88 ± 28 min, P < 0.001). Intraoperative and postoperative autologous blood transfusions were significantly lower in MAAVR (927.2 ± 425.6 vs 1036.4 ± 599.6 ml, P < 0.001 and 170.2 ± 47.6 vs 243.5 ± 89.3 ml, P < 0.001, respectively). Intubation time was significantly shorter in MAAVR [median (IQR) 7 (5-11) vs 8 (6-14) h, P = 0.01). The incidence of renal insufficiency (creatinine ≥1.5 mg/dl) and respiratory insufficiency (need for non-invasive ventilation, reintubation or tracheotomy) was significantly lower in MAAVR (9 vs 16%, P < 0.001 and 8.5 vs 11.8%, P = 0.03, respectively). CONCLUSIONS: In comparison with CAVR, our study shows that MAAVR is a safe and effective procedure associated with low mortality rate and good long-term survival rates. In addition to that, MAAVR was associated with shorter ventilation times, lower rate of autologous blood transfusion, as well as a lower rate of postoperative respiratory and renal insufficiency. Because of the superior cosmetic results, we therefore advocate MAAVR as the procedure of choice for primary isolated AVR.