Self-Expanding or Balloon-Expandable TAVR in Patients with a Small Aortic Annulus.

BACKGROUND: Patients with severe aortic stenosis and a small aortic annulus are at risk for impaired valvular hemodynamic performance and associated adverse cardiovascular clinical outcomes after transcatheter aortic-valve replacement (TAVR). METHODS: We randomly assigned patients with symptomatic severe aortic stenosis and an aortic-valve annulus area of 430 mm2 or less in a 1:1 ratio to undergo TAVR with either a self-expanding supraannular valve or a balloon-expandable valve. The coprimary end points, each assessed through 12 months, were a composite of death, disabling stroke, or rehospitalization for heart failure (tested for noninferiority) and a composite end point measuring bioprosthetic-valve dysfunction (tested for superiority). RESULTS: A total of 716 patients were treated at 83 sites in 13 countries (mean age, 80 years; 87% women; mean Society of Thoracic Surgeons Predicted Risk of Mortality, 3.3%). The Kaplan-Meier estimate of the percentage of patients who died, had a disabling stroke, or were rehospitalized for heart failure through 12 months was 9.4% with the self-expanding valve and 10.6% with the balloon-expandable valve (difference, -1.2 percentage points; 90% confidence interval [CI], -4.9 to 2.5; P<0.001 for noninferiority). The Kaplan-Meier estimate of the percentage of patients with bioprosthetic-valve dysfunction through 12 months was 9.4% with the self-expanding valve and 41.6% with the balloon-expandable valve (difference, -32.2 percentage points; 95% CI, -38.7 to -25.6; P<0.001 for superiority). The aortic-valve mean gradient at 12 months was 7.7 mm Hg with the self-expanding valve and 15.7 mm Hg with the balloon-expandable valve, and the corresponding values for additional secondary end points through 12 months were as follows: mean effective orifice area, 1.99 cm2 and 1.50 cm2; percentage of patients with hemodynamic structural valve dysfunction, 3.5% and 32.8%; and percentage of women with bioprosthetic-valve dysfunction, 10.2% and 43.3% (all P<0.001). Moderate or severe prosthesis-patient mismatch at 30 days was found in 11.2% of the patients in the self-expanding valve group and 35.3% of those in the balloon-expandable valve group (P<0.001). Major safety end points appeared to be similar in the two groups. CONCLUSIONS: Among patients with severe aortic stenosis and a small aortic annulus who underwent TAVR, a self-expanding supraannular valve was noninferior to a balloon-expandable valve with respect to clinical outcomes and was superior with respect to bioprosthetic-valve dysfunction through 12 months. (Funded by Medtronic; SMART ClinicalTrials.gov number, NCT04722250.).

Transcatheter valve-in-valve interventions after aortic root replacement: A systematic review.

Structural valve deterioration after aortic root replacement (ARR) surgery may be treated by transcatheter valve-in-valve (ViV-TAVI) intervention. However, several technical challenges and outcomes are not well described. The aim of the present review was to analyze the outcomes of ViV-TAVI in deteriorated ARR. This review included studies reporting any form of transcatheter valvular intervention in patients with a previous ARR. All forms of ARR were considered, as long as the entire root was replaced. Pubmed, ScienceDirect, SciELO, DOAJ, and Cochrane library databases were searched until September 2023. Overall, 86 patients were included from 31 articles that met our inclusion criteria out of 741 potentially eligible studies. In the entire population, the mean time from ARR to reintervention was 11.0 years (range: 0.33-22). The most frequently performed techniques/grafts for ARR was homograft (67.4%) and the main indication for intervention was aortic regurgitation (69.7%). Twenty-three articles reported no postoperative complications. Six (7.0%) patients required permanent pacemaker implantation (PPI) after the ViV-TAVI procedure, and 4 (4.7%) patients had a second ViV-TAVI implant. There were three device migrations (3.5%) and 1 stroke (1.2%). Patients with previous ARR present a high surgical risk. ViV-TAVI can be considered in selected patients, despite unique technical challenges that need to be carefully addressed according to the characteristics of the previous surgery and on computed tomography analysis.

Clinical Presentation and Management of the Cervical Aortic Arch in the Adult Population: A Review of Case Reports.

The cervical aortic arch (CAA) is an uncommon congenital anomaly in aortic development, characterized by an elongated aortic arch extending at or above the medial ends of the clavicles. Our objective was to examine the clinical and surgical characteristics of this infrequent condition in the adult population. PubMed, ScienceDirect, SciELO, DOAJ, and Cochrane Library databases were searched until December 2023 for case reports describing the presence of a cervical aortic arch in patients aged ≥18 years. Case reports and series were included if the following criteria were met: (1) description of the cervical aortic arch, (2) age ≥18 years, and (3) English language. The literature search identified 2,325 potentially eligible articles, 61 of whom met our inclusion criteria and included a combined number of 71 patients. Mean age was 38.6 ± 15.4 years, with a female prevalence of 67.1% (47/70). Two-thirds of the CAA were left-sided (48/71, 67.6%), and 62.0% (44/71) of patients presented a concomitant arch aneurysm. Asymptomatic patients were 45.7% (32/70), while of those that were symptomatic, 60.5% (23/38) had symptoms related to vascular-induced compression of trachea and esophagus. Surgery was performed in 42 patients (62.7%) among 67 cases that reported the patient's treatment, and 5 patients (11.9%) among those surgically treated underwent the procedure through an endovascular approach. CAA is an uncommon congenital abnormality that presents challenges in diagnosis and treatment due to its high anatomical variability, diverse clinical manifestations, and presence of concomitant diseases. Surgery seems to be a safe and effective option for the resolution of symptoms.

Direct aortic cannulation versus femoral arterial cannulation for early outcomes in acute type A aortic dissection: A study-level meta-analysis.

PURPOSE: To investigate the impact of direct aortic cannulation (DAC) versus femoral arterial cannulation (FAC) on clinical outcomes of surgery for acute type A aortic dissection. METHODS: PubMed/MEDLINE, Scopus, and Cochrane Central Register of Controlled Trials were searched until August 25, 2023, to conduct a meta-analysis. Primary endpoints of the study were operative mortality and postoperative stroke. Secondary endpoints were cardiopulmonary bypass time, myocardial ischemic time, hypothermic circulatory arrest time, temporary neurological dysfunction (TND), combined stroke and TND, re-exploration for bleeding, and need for renal replacement therapy. A random-effect model was used to estimate the pooled effect size, and a leave-one-out method was used for the primary endpoints for sensitivity analysis. RESULTS: 15 studies met our eligibility criteria, including a total of 7941 samples. Operative mortality was significantly lower in the DAC group with a pooled odds ratio (OR) of 0.72 [95% confidence interval (CI): 0.61-0.85)]. Incidence of postoperative stroke was also lower in the DAC group with a pooled OR of 0.79 (95% CI: 0.66-0.94). However, after excluding one study with the greatest weight, the difference became nonsignificant. DAC was also associated with a lower incidence of postoperative TND, and re-exploration for bleeding with a pooled OR of 0.52 (95% CI: 0.37-0.73), and 0.60 (95% CI: 0.47-0.77), respectively. CONCLUSIONS: This meta-analysis showed that patients who underwent ATAAD repair with DAC had a lower incidence of operative mortality, postoperative stroke, TND, and re-exploration for bleeding compared to those who underwent FAC.

Cusp-overlap versus coplanar view in transcatheter aortic valve implantation with self-expandable valves: A meta-analysis of comparative studies.

BACKGROUND: Permanent pacemaker implantation (PPI) is a common complication after transcatheter aortic valve implantation (TAVI). The cusp-overlap view (COV) was adopted to reduce PPI risk after TAVI with self-expandable valves (SEVs); however, the evidence remains scarce. We performed a systematic review with meta-analysis comparing COV and the standard coplanar view (CPV) technique to evaluate their effectiveness and safety. METHODS: Following the PRISMA statement, data were extracted from studies published by August 2022 and found in PubMed/MEDLINE, EMBASE, CENTRAL/CCTR, ClinicalTrials.gov, SciELO, LILACS, and Google Scholar. The primary outcome of interest was post-procedural PPI and the secondary outcomes were new left bundle branch block (LBBB), moderate/severe paravalvular leak (PVL), valve dislocation (pop-out); need of second transcatheter heart valve, 30-day mortality, stroke, conversion to surgery, coronary obstruction, implantation depth (mm), and post-TAVI mean gradients (mmHg). RESULTS: Eleven studies met our eligibility criteria and included 1464 patients in the COV group and 1743 patients in the CPV group. Patients who underwent TAVI with COV had lower risk of PPI (odds ratio 0.48; 95% confidence interval [CI] 0.33-0.70; p = 0.001) and higher implantation depths with COV (mean difference -0.83; 95% CI -1.2 to -0.45; p < 0.001). We did not observe any statistically significant differences in the rates of new LBBB, moderate/severe PVL, valve dislocation, need of second transcatheter heart valve, 30-day mortality, stroke, conversion to surgery, coronary obstruction, and post-TAVI mean gradients (mmHg). CONCLUSION: In TAVI with SEVs, the application of COV is associated with lower risk of PPI compared with the standard CPV without increasing risk for adverse outcomes.

Computed tomography-derived membranous septum length as predictor of conduction abnormalities and permanent pacemaker implantation after TAVI: A meta-analysis of observational studies.

BACKGROUND: Permanent pacemaker implantation (PPI) after transcatheter aortic valve implantation (TAVI) is associated with higher risk of mortality and rehospitalization for heart failure. Efforts to prevent conduction abnormalities (CA) requiring PPI after TAVI should be made. The membranous septum (MS) length and its interaction with implantation depth (ID-ΔMSID) could provide useful information about the risk of CA/PPI following TAVI. OBJECTIVES: To identify MS length and ΔMSID as predictors of CA/PPI following TAVI. METHODS: Study-level meta-analysis of studies published by September 30, 2022. RESULTS: Eighteen studies met our eligibility including 5740 patients. Shorter MS length was associated with a significantly higher risk of CA/PPI (per 1 mm decrease: odds ratio [OR] 1.60, 95% confidence interval [CI] 1.28-1.99, p < 0.001). Similarly, lower ΔMSID was associated with a significantly higher risk of CA/PPI (per 1 mm decrease: OR 1.75, 95% CI 1.32-2.31, p < 0.001). Meta-regression analyses revealed a statistically significant modulation of the effect of shorter MS length and lower ΔMSID on the outcome (CA/PPI) by balloon postdilatation (positive regression coefficients with p < 0.001); with increasing use of balloon postdilatation, the effect of shorter MS length and lower ΔMSID on the outcome increased. MS length and ΔMSID demonstrated excellent discriminative abilities, with diagnostic ORs equaling 9.49 (95% CI 4.73-19.06), and 7.19 (95% CI 3.31-15.60), respectively. CONCLUSION: Considering that short MS length and low ΔMSID are associated with higher risk of CA and PPI, we should include measurement of MS length in the pre-TAVI planning with MDCT and try to establish optimal ID values before the procedure to avoid CA/PPI.

Alternative Application Technique for the MANTA Vascular Closure Device for Percutaneous Large-Bore Arterial Access Closure: The Fluoroscopic DOT Technique.

BACKGROUND: Vascular complications are a cause of increased morbidity and mortality when performing percutaneous procedures requiring large-bore arterial access. MANTA vascular closure device (VCD) is currently the only large-bore VCD using an intraluminal foot plate and an extraluminal collagen plug. The traditional depth locator approach might be compromised in; emergent cases without the required measurements, cases of hematoma formation, or other patient, procedure, or operator-specific variables. Furthermore, this technique can be used for postclosure in cases without the required measurement of depth. We describe vascular outcomes using fluoroscopy (fluoroscopic DOT technique) rather than traditional depth locator approach for vascular closure with the MANTA VCD. METHODS: Fifty patients who underwent transcatheter aortic valve implantation (TAVI) were retrospectively analyzed using fluoroscopic DOT technique with 18F MANTA VCD between May and August 2021. All patients >18 years of age who qualified for transfemoral TAVI were included. Access was obtained with ultrasound guidance with vessel diameter of at least > 6 mm and free from anterior vessel wall calcification. Patient related factors and primary outcomes of access site bleeding and acute flow-limited limb ischemia requiring intervention were prospectively analyzed. Furthermore, 1 patient who failed hemostasis with suture-mediated VCD had successful hemostasis with fluoroscopic DOT technique as dry postclosure after balloon aortic valvuloplasty. RESULTS: In total, 50 patients were analyzed with a mean age of 81 years and majority were male (56%). Majority had comorbidities of hypertension (88%) and hyperlipidemia (94%), 24% had peripheral arterial disease, 38% coronary artery disease, and 58% were former smokers. Importantly, 40% were obese with an average body mass index (BMI) of 29 kg/m2. There were no bleeding or ischemic limb complications post MANTA VCD deployment using the fluoroscopic DOT technique. Furthermore, none of the patients required peripheral intervention from index procedure to 1 month post verified during their 1-month post TAVR follow-up. CONCLUSION: Fluoroscopic DOT technique using the MANTA VCD is highly reproducible and allows hemostasis in a predictable manner for procedures requiring large-bore arterial access in the absence of MANTA depth measurement.

Transcatheter Aortic-Valve Replacement with a Self-Expanding Valve in Low-Risk Patients.

BACKGROUND: Transcatheter aortic-valve replacement (TAVR) is an alternative to surgery in patients with severe aortic stenosis who are at increased risk for death from surgery; less is known about TAVR in low-risk patients. METHODS: We performed a randomized noninferiority trial in which TAVR with a self-expanding supraannular bioprosthesis was compared with surgical aortic-valve replacement in patients who had severe aortic stenosis and were at low surgical risk. When 850 patients had reached 12-month follow-up, we analyzed data regarding the primary end point, a composite of death or disabling stroke at 24 months, using Bayesian methods. RESULTS: Of the 1468 patients who underwent randomization, an attempted TAVR or surgical procedure was performed in 1403. The patients' mean age was 74 years. The 24-month estimated incidence of the primary end point was 5.3% in the TAVR group and 6.7% in the surgery group (difference, -1.4 percentage points; 95% Bayesian credible interval for difference, -4.9 to 2.1; posterior probability of noninferiority >0.999). At 30 days, patients who had undergone TAVR, as compared with surgery, had a lower incidence of disabling stroke (0.5% vs. 1.7%), bleeding complications (2.4% vs. 7.5%), acute kidney injury (0.9% vs. 2.8%), and atrial fibrillation (7.7% vs. 35.4%) and a higher incidence of moderate or severe aortic regurgitation (3.5% vs. 0.5%) and pacemaker implantation (17.4% vs. 6.1%). At 12 months, patients in the TAVR group had lower aortic-valve gradients than those in the surgery group (8.6 mm Hg vs. 11.2 mm Hg) and larger effective orifice areas (2.3 cm2 vs. 2.0 cm2). CONCLUSIONS: In patients with severe aortic stenosis who were at low surgical risk, TAVR with a self-expanding supraannular bioprosthesis was noninferior to surgery with respect to the composite end point of death or disabling stroke at 24 months. (Funded by Medtronic; ClinicalTrials.gov number, NCT02701283.).

Early and late outcomes of surgical aortic valve replacement with sutureless and rapid-deployment valves versus transcatheter aortic valve implantation: Meta-analysis with reconstructed time-to-event data of matched studies.

Sutureless/rapid-deployment (SURD) valves are options different from the stented prostheses included in the pivotal trials comparing surgical aortic valve replacement (AVR) and transcatheter aortic valve implantation (TAVI). We performed a meta-analysis with reconstructed time-to-event data of matched studies published by November 2021 to compare SURD-AVR and TAVI. Primary endpoints were 30-day mortality and overall survival in the follow-up. Secondary endpoints included: 30-day stroke, acute kidney injury (AKI), major bleeding, permanent pacemaker implantation (PPI), paravalvular leak (PVL), prosthesis-patient mismatch (PPM), postoperative aortic valve area (AVA), and mean gradients. Ten studies met our eligibility criteria, including a total of 5134 patients (2567 underwent SURD-AVR and 2567 underwent TAVI). Pooled risk of 30-day mortality did not favor any group (odds ratio [OR]: 0.69; 95% confidence interval [CI]: 0.31-1.53; p = 0.360). Patients undergoing SURD-AVR had lower risk of PVL (OR: 0.09; 95% CI: 0.05-0.17; p < 0.001). No statistically significant differences were observed for 30-day stroke, AKI, major bleeding, PPI, PPM, and postoperative AVA. In the follow-up, we observed a higher risk of mortality (hazard ratio: 1.74; 95% CI: 1.26-2.40; p < 0.001) with TAVI. Patients who underwent SURD-AVR experienced better survival, however, the interpretation of these results warrant caution due to the fact that SURD-AVR patients tended to be younger than TAVI patients. Structural heart surgeons and interventional cardiologists should consider initial risk and life expectancy when referring patients for one approach over the other.

Late Outcomes After Aortic Root Enlargement During Aortic Valve Replacement: Meta-Analysis With Reconstructed Time-To-Event Data.

OBJECTIVES: The present authors aimed to assess the late outcomes of patients undergoing aortic root enlargement (ARE) at the time of surgical aortic valve replacement (SAVR). DESIGN: Study-level meta-analysis with reconstructed time-to-event data. SETTING: Follow-up of patients after surgical procedure. PARTICIPANTS: Adult patients with aortic valve disease requiring surgery. INTERVENTIONS: SAVR with ARE versus SAVR without ARE. MEASUREMENTS AND MAIN RESULTS: This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guideline. The following databases were searched for studies meeting the authors' inclusion criteria and published by November 30, 2021: PubMed/MEDLINE, Embase, SciELO, LILACS, CCTR/CENTRAL, and Google Scholar. Nine nonrandomized studies met the authors' eligibility criteria. All studies were nonrandomized. A total of 213,134 patients (SAVR with ARE: 7,556 patients; SAVR without ARE: 205,578 patients) were included from studies published from 1997 to 2021. The total rate of AAE was 3.7%, varying in the studies from 2.9% to 28.1%. The studies consisted of patients whose mean age varied from 63 to 79 years. Patients in the SAVR with ARE group had a significantly better overall survival (hazard ratio [HR] 0.94, 95% confidence interval [CI] 0.90-0.99, p = 0.016) in the unmatched populations, but the matched analysis revealed no difference between SAVR with/without ARE in terms of overall survival (HR, 1.06; 95% CI, 0.90-1.25; p = 0.474). CONCLUSIONS: In the context of patients undergoing SAVR with or without ARE, patients who undergo ARE do not experience worse late outcomes. Further randomized controlled trials are needed to confirm or refute the authors' current findings.

Sternal-sparing aortic valve replacement with sutureless valve in bicuspid valve.

Over the last decade, sutureless valves (Perceval, LivaNova PLC) were brought to the market as an alternative to stented valves for patients requiring surgical aortic valve replacement (SAVR). However, Perceval demands special steps for implantation, among which we can mention specific training for the surgical team members. Sternal-sparing cardiac procedures are conceived to limit surgical trauma, but the technical requirements and preoperative planning are more challenging than those for conventional sternotomy. SAVR is frequently carried out through an upper hemisternotomy, but the right anterior thoracotomy (RAT) represents an even less traumatic, technical advancement. In the context of SAVR with RAT, Perceval has been considered the "perfect marriage." In patients with bicuspid aortic valve (BAV), some surgeons initially avoided the Perceval valve but, with growing experience, the prosthesis has been used for a wide variety of indications. According to an international consensus statement recently published, there are 3 BAV types: the fused BAV, the 2-sinus BAV and the partial-fusion BAV, each with specific phenotypes. The 2-sinus BAV has 2 cusps, roughly equal in size and shape, each cusp occupying 180° of the annular circumference, with only 2 aortic sinuses, resulting in a 2-sinus/2-cusp valve without raphe and with 180° commissural angles. Since the elliptic aortic annulus in BAV patients poses a challenge for sutureless valves and the RAT approach has been increasingly adopted for minimally invasive SAVR, our description of the surgical technique focuses on the specific procedural details in the scenario of 2-sinus BAV laterolateral phenotype.

Specific causes of death among patients with cardiac sarcoma in the United States-An analysis of The Surveillance, Epidemiology, and End Results (SEER) Program.

Representing 10%-25% of the primary cardiac neoplasms, primary malignant cardiac tumors (PMCT) have a poor prognosis, yet with rare incidence. Constituting more than 50% of the PMCT, cardiac sarcoma has increased not only in incidence over the past five decades but also in severity. Patients with PMCTs, especially sarcomas, have the worst prognosis when compared with other cardiac or extracardiac tumors. This retrospective study was performed using SEER*stat software, latest version 8.3.9.2(5) by accessing seer 18 registries plus data (excl AK) Nov 2020 Sub (2000-2018) for standard mortality ratio (SMR). A total of 235 patients were identified of whom 49.4% were females. Most of our patients were Stage 4 (n = 81) and distant in location (n = 92). The most common treatment method was tumor-directed surgery (n = 164), chemotherapy (n = 146), and radiotherapy (n = 55). Furthermore, other associated cancers with cardiac sarcoma were rare, with ten cases with lung and bronchus cancer (SMR: 37.95, 95% confidence interval [CI]: 18.2, 69.8), four with bone and joints (SMR: 1726.05, 95% CI: 470.2, 4419.3). During a 5-year follow-up, 235 patients died primarily due to cardiac sarcoma (n = 182, 77.4%), other cancers (n = 34, 14.4%), and other noncancerous causes (n = 19, 8%), while the noncancerous causes were attributed mainly to cardiovascular diseases (n = 4, 21%, SMR: 4.95, 95% CI: 1.35, 12.67), septicemia (n = 2, 10.5%, SMR: 41.23, 95% CI: 4.99, 148.95).

Impact of left ventricle outflow tract calcification on the outcomes of transcatheter aortic valve implantation: A study-level meta-analysis.

OBJECTIVES: To assess the impact of left ventricle outflow tract calcification (LVOT) on the outcomes of transcatheter aortic valve implantation (TAVI). METHODS: Meta-analysis including studies published by October 2021. Primary endpoints were operative and 1-year mortality. The secondary endpoints were stroke, myocardial infarction, paravalvular leakage (PVL), new permanent pacemaker implantation (PPI), aortic annulus/root rupture. RESULTS: Nine studies met our eligibility criteria, including a total of 4459 patients (1330 patients with significant LVOT calcification and 3129 patients without significant LVOT calcification). Pooled risk of operative death was higher in the group with significant LVOT calcification (odds ratio [OR]: 2.28; 95% confidence interval [CI]: 1.33-3.91; p < .001). Worse 1-year survival was observed in the group with LVOT calcification (hazard ratio 1.53, 95% CI: 1.26-1.87, p < .001). Patients with significant LVOT calcification had higher risk of stroke (OR: 1.83; 95% CI: 1.08-3.09; p = .032), myocardial infarction (OR: 1.74; 95% CI: 1.08-2.80; p = .034), PVL (OR: 1.88; 95% CI: 1.09-3.22; p = .028) and aortic annulus/root rupture (OR: 7.48; 95% CI: 3.58-15.65; p = .002). We did not observe a statistically significant difference in the pooled results for new PPI between the groups (OR: 1.19; 95% CI: 0.79-1.80; p = .337). CONCLUSION: The presence of significant LVOT calcification increases the risk of periprocedural and 1-year mortality, stroke, myocardial infarction, PVL and aortic annulus/root rupture after TAVI. Self-expandable valves may be a preferrable option in this scenario. Structural heart surgeons and interventional cardiologists should consider this factor when referring patients for TAVI and technical aspects (such as the type of transcatheter heart valve to be deployed or the use of pre-/post-dilatation) should be factored in.

Urgent robotic hybrid coronary revascularization in patient with high STS score. A case report.

INTRODUCTION: Robotic-assisted coronary artery bypass grafting (CABG) outcomes in patients with a high society of thoracic surgery (STS) score in urgent settings remain hindered. PRESENTATION OF CASE: A high-risk female patient presented with dyspnea and low ejection fraction (EF = 15%) and was diagnosed with pulmonary edema post myocardial infarction. She was medically stabilized with intraaortic balloon pump and the heart-team decided to intervene with off-pump robotic hybrid coronary revascularization (HCR). The patient had the planned with left internal mammary artery (LITA) anastomosis to the left anterior descending artery (LAD) and the postoperative recovery was uneventful and patients discharged after few days at home. DISCUSSION: CABG has proven to be superior to percutaneous coronary intervention (PCI) even when guided by fractional flow rate and using the last generation stents according to fractional flow reserve versus angiography for multivessel evaluation 3 clinical trial. In moderate SYNTAX score patients that have been historically (SYNTAX trial) treated with multivessels PCI, robotic CABG has been shown to offer the advantage of LITA-LAD in combination with stent for non-LAD territory. CONCLUSION: High-risk, fragile patients, with low EF and high STS score that undergo urgent CABG can benefit from heart-team collaboration, and HCR is an important tool in the armamentarium.

Hybrid robotic off-pump versus conventional on-pump and off-pump coronary artery bypass graft surgery in women.

OBJECTIVE: To compare outcomes of three methods of coronary artery bypass graft surgery (CABG): robotic off-pump hybrid coronary revascularization (HCR) versus conventional CABG off-pump (off-pump coronary artery bypass [OPCAB]) and on-pump (on-pump coronary artery bypass [ONCAB]) in women. METHODS: Data on women who underwent robotic off-pump HCR or conventional OPCAB or conventional ONCAB between May 2005 and January 2021 were collected. Inverse probability of treatment weighting (IPTW) with doubly robust method was used to analyze the data. RESULTS: A total of 731 women were included (181 robotic off-pump HCR, 138 conventional ONCAB, and 412 conventional OPCAB cases). IPTW-adjusted analyses revealed the following: (1) for operative times, robotic off-pump HCR presented longer times when compared with OPCAB, but shorter times when compared with ONCAB; (2) compared with ONCAB and OPCAB, robotic off-pump HCR presented lower rates of reintervention for bleeding, intra- and postoperative blood transfusions, higher rates of extubation in the OR with less prolonged ventilation, lower rates of postoperative atrial fibrillation, and shorter intensive care unit and hospital length of stay; (3) no statistically significant differences for operative mortality were observed comparing robotic off-pump HCR with ONCAB (IPTW-adjusted odds ratio [OR]: 0.77; 95% confidence interval [CI]: 0.07-7.85; p = .822) and with OPCAB (IPTW-adjusted OR: 4.27; 95% CI: 0.27-66.88; p = .301); 4. long-term survival was similar with HCR compared with ONCAB (hazard ratio [HR]: 0.74, 95% CI: 0.36-1.50, p = .401) and OPCAB (HR: 0.89, 95% CI: 0.50-1.58, p = .683). CONCLUSIONS: In our local experience, robotic off-pump HCR in women was as safe as conventional ONCAB and OPCAB and may further improve postoperative outcomes when performed frequently by a dedicated team, producing better perioperative outcomes without compromising survival in the long run.

Robotic hybrid coronary revascularization versus conventional off-pump coronary bypass surgery in women with two-vessel disease.

BACKGROUND: Hybrid coronary revascularization (HCR) treats coronary artery disease (CAD) by combining a minimally invasive surgical approach with the left internal mammary artery (LIMA) to the left anterior descending (LAD) artery and percutaneous coronary intervention (PCI) for non-LAD vessels. This study aimed to compare immediate and long-term outcomes between robotic HCR and off-pump coronary artery bypass (OPCAB) via sternotomy in women with two-vessel CAD. METHODS AND RESULTS: We compared all robotic HCR (LIMA-to-LAD plus stent; n = 55) and OPCAB (LIMA-to-LAD plus saphenous vein graft; n = 54) performed at a single institution between May 2005 and January 2021. To adjust for the selection bias of receiving either HCR or OPCAB, we performed a propensity score analysis of 31 matched pairs. In the immediate postoperative period, no statistically significant difference was observed for operative mortality and HCR was associated with lower rates of blood transfusion (25.8% vs. 54.8%; p = .038), and shorter hospital length of stay (4.0 vs. 6.0 days; p = .009). After a mean follow-up of 7.0 ± 4.9 years, we observed no statistically significant differences between the groups for overall survival (hazard ratio [HR]: 0.48, 95% confidence interval [CI]: 0.09-2.64, p = .401), myocardial infarction (HR: 1.60, 95% CI: 0.14-17.64, p = .703), stroke (HR not assessable; almost zero events), target vessel revascularization (HR: 0.45, 95% CI: 0.08-2.47, p = .359), angina (HR: 0.64, 95% CI: 0.20-2.01, p = .444) and major adverse cardiac and cerebrovascular events (HR: 0.46, 95% CI: 0.14-1.52, p = .202). CONCLUSIONS: Robotic HCR provides for women with two-vessel CAD a shorter postoperative recovery with fewer blood transfusions, with similar long-term outcomes when compared with conventional OPCAB via sternotomy.

Complete transcatheter versus complete surgical treatment in patients with aortic valve stenosis and concomitant coronary artery disease: Study-level meta-analysis with reconstructed time-to-event data.

OBJECTIVES: To compare outcomes of complete transcatheter (TAVI plus PCI) versus complete surgical (SAVR plus CABG) approach to treat patients with aortic stenosis (AS) and concomitant coronary artery disease (CAD). METHODS: Study-level meta-analysis with reconstructed time-to-event data including studies published by November 2021. The primary endpoints were 30-day mortality, overall survival, and major adverse cardiovascular and cerebrovascular events (MACCE). The secondary endpoints were 30-day stroke, myocardial infarction, and permanent pacemaker implantation (PPI); in-hospital major vascular events and acute kidney injury (AKI). RESULTS: Eight studies met our eligibility criteria, including a total of 33,286 patients (3448 for TAVI plus PCI and 29,838 for SAVR plus CABG). The pooled risk of 30-day mortality was lower for TAVI plus PCI (OR 0.63; 95% CI 0.51-0.80; p < .001). Patients undergoing TAVI plus PCI had lower risk of in-hospital AKI (OR 0.49; 95% CI 0.28-0.85; p = .01), however, higher risk of major vascular events (OR 7.33; 95% CI 1.80-29.85; p = .005) and higher risk of PPI (OR 2.96; 95% CI 1.80-4.85; p < .001). No statistically significant difference was observed for myocardial infarction and stroke between the groups. In the follow-up analyses, we observed a higher risk of mortality (HR 1.64, 95% CI 1.36-1.96, p < .001) and MACCE with TAVI plus PCI (HR 1.35 (95% CI 1.08-1.69, p = .009). CONCLUSION: Patients who undergo TAVI plus PCI (in comparison with SAVR plus CABG) initially experience lower rates of in-hospital death and AKI; however, they experience significantly lower survival rates and more MACCE at 5-year follow up. Structural heart surgeons and interventional cardiologists should consider these aspects when referring patients for one approach or the other.

Lifetime management of aortic valve disease: Aligning surgical and transcatheter armamentarium to set the tone for the present and the future.

Transcatheter aortic valve replacement (TAVR) has already received the green light for high-, intermediate- and low-risk profiles and is an alternative for all patients regardless of age. It is clear that there has been a push towards the use of TAVR in younger and younger patients (<65 years), which has never been formally tested in randomized controlled trials but seems inevitable as TAVR technology makes steady progress. Lifetime management as a concept will set the tone in the field of the structural heart. Some subjects in this scenario arise, including the importance of optimized prosthetic hemodynamics for lifetime care; surgical procedures in the aortic root; management of structural valve degeneration with valve-in-valve procedures (TAVR-in-surgical aortic valve replacement [SAVR] and TAVR-in-TAVR) and redo SAVR; commissural alignment and cusp overlap for TAVR; the rise in the number of surgical procedures for TAVR explantation; and the renewed interest in the Ross procedure. This article reviews all these issues which will become commonplace during heart team meetings and preoperative conversations with patients in the coming years.

Immediate and late outcomes of transcatheter aortic valve implantation versus surgical aortic valve replacement in bicuspid valves: Meta-analysis of reconstructed time-to-event data.

BACKGROUND: Outcomes of transcatheter aortic valve implantation (TAVI) versus surgical aortic valve replacement (SAVR) in patients with aortic stenosis and bicuspid aortic valve (BAV) must be better investigated. METHODS: A meta-analysis including studies published by January 2022 reporting immediate outcomes (in-hospital death, stroke, acute kidney injury [AKI], major bleeding, new permanent pacemaker implantation [PPI], paravalvular leakage [PVL]), mortality in the follow-up (with Kaplan-Meier curves for reconstruction of individual patient data). RESULTS: Five studies met our eligibility criteria. No statistically significant difference was observed for in-hospital death, stroke, AKI, and PVL. TAVI was associated with lower risk of major bleeding (odds ratio [OR]: 0.29; 95% confidence interval [CI]: 0.12-0.69; p = .025), but higher risk of PPI (OR: 2.00; 95% CI: 1.05-3.77; p = .041). In the follow-up, mortality after TAVI was significantly higher in the analysis with the largest samples (HR: 1.24, 95% CI: 1.01-1.53, p = .043), but no statistically significant difference was observed with risk-adjusted populations (HR: 1.06, 95% CI: 0.86-1.32, p = .57). Landmark analyses suggested a time-varying risk with TAVI after 10 and 13 months in both largest and risk-adjusted populations (HR: 2.13, 95% CI: 1.45-3.12, p < .001; HR: 1.7, 95% CI: 1.11-2.61, p = .015, respectively). CONCLUSION: Considering the immediate outcomes and comparable overall survival observed in risk-adjusted populations, TAVI can be used safely in selected BAV patients. However, a time-varying risk is present (favoring SAVR over TAVI at a later timepoint). This finding was likely driven by higher rates of PPI with TAVI.

Robotic-assisted versus conventional off-pump coronary surgery in women: A propensity-matched study.

BACKGROUND: Off-pump coronary artery bypass (OPCAB) previously demonstrated its potential benefits in women; however, robotic-assisted OPCAB was scarcely studied. OBJECTIVES: To investigate whether robotic-assisted OPCAB could further improve the outcomes in women and the potential impact of hybrid approaches with stents and completeness of revascularization on the late outcomes. METHODS: Women who underwent robotic-assisted or conventional OPCAB (with sternotomy) between May 2005 and January 2021 at Lankenau Heart Institute were included. Propensity score matching was used to match 273 pairs on 27 characteristics. RESULTS: In the intraoperative period, women who underwent robotic-assisted OPCAB presented longer operative times (6.00 vs. 5.38 h; p < 0.001), higher rates of extubation in the operating room (83.9% vs. 75.5%; p = 0.019) and lower rates of blood transfusion (13.2% vs. 32.2%; p < 0.001). In the postoperative period, women who underwent robotic-assisted OPCAB presented lower rates of new onset atrial fibrillation (16.8% vs. 25.6%; p = 0.016), need of blood transfusion (33.0% vs. 54.9%; p < 0.001), shorter intensive care unit (ICU) (46.1 vs. 49.8 h; p = 0.006) and hospital length of stay (5.0 vs. 6.0 days; p < 0.001). We observed no statistically significant differences in the rates of operative death between the groups (1.47% vs. 1.47%; p = 0.771). In the follow-up, we observed no differences in terms of overall survival regardless of hybrid procedures with stents and completeness of revascularization. CONCLUSIONS: Robotic-assisted OPCAB in women is as safe as conventional OPCAB and may further improve outcomes. Hybrid coronary revascularization was a valuable adjunct in the robotic scenario and completeness of revascularization did not play a role in this setting.