Outcomes of left-sided heart valve surgery after heart transplantation: a systematic review.

As the survival after heart transplantation (HTx) is steadily improving, an increasing number of patients with late cardiac pathologies such as valvular disease is expected to rise. Nevertheless, no guidelines for indication of redo cardiac surgery after HTx exists. The aim of the present systematic review is to describe the results reported in the literature of surgical management of severe aortic and/or mitral valve disease. A systematic review was conducted including studies reporting on adult patients with severe mitral or aortic valve pathology needing surgery after their previous HTx. Exclusion criteria consisted in surgery with no left heart valve surgery, concomitant valve surgery during heart transplant, transcatheter interventions, and heterotopic HTx. A total of 35 papers met our inclusion criteria out of 2755 potentially eligible studies with 44 mitral valve surgery patients and 20 aortic valve surgery patients. In the entire population, the mean time from HTx to reintervention was 6.19 ± 5.22 years. After a mean follow-up of 2.78 ± 3.54 years and 1.53 ± 2.26 years from reintervention, 65.6% mitral and 86.7% aortic patients were reported as alive, respectively. As guidelines on cardiac surgery after HTx are currently lacking, left-sided valvular cardiac reinterventions can be considered a possible therapeutic approach in carefully selected patients. These interventions may not only improve the patient's functional status and survival, but may ultimately reduce the need for re-transplantation due to the chronic shortage of donor hearts. However, the support of more robust data is warranted.

Outcomes of tricuspid valve prostheses after heart transplantation: a systematic review.

Tricuspid regurgitation (TR) is the most common valvular pathology after heart transplantation (HTx) and endomyocardial biopsy (EMB) remains responsible for the majority of cases due to the high probability of structural valve damage. The aim of the present review was to describe the results of surgical management of severe tricuspid regurgitation through tricuspid valve replacement (TVR) after a previous HTx. A systematic review was conducted by searching Pubmed, ScienceDirect, SciELO, DOAJ, and Cochrane databases until June 2023 for publications reporting patients undergoing TVR surgery after a previous HTx. If no right heart valve surgery was undertaken, or a heterotopic heart transplant was performed, or if the concomitant procedure was performed during the transplant itself, the paper was excluded. Twenty articles met our inclusion criteria out of 1532 potentially eligible studies, with a total of 300 patients. Mean age was 55.1 ± 9.6 years, and 85.1% were male. The mean number of EMB per patient was 31.1 ± 5.5 with a mean time between HTx and TVR of 7.64 ± 3.31 years. Bioprostheses were used in 83.3% of cases and 75.0% of patients with a bioprosthesis were reported as alive at last follow-up. Tricuspid valve repair is a valuable option, but these patients will be susceptible to recurrent TR after EMB. TVR with a bioprosthesis may provide the optimal solution for this subset of patients, as EMB is not feasible with a mechanical valve.

Transcatheter valvular interventions after heart transplantation: A systematic review.

An increasing number of patients experience late valvular disease after heart transplantation (HTx). While mostly being primarily addressed through surgical interventions, transcatheter valve procedures to treat these conditions are rising, particularly for unsuitable surgical candidates. This review aims at analyzing the outcomes of transcatheter valvular procedures in this subset of patients. A systematic review was conducted including studies reporting on adult patients requiring any form of transcatheter valvular intervention after a previous HTx. Studies involving a surgical approach, heterotopic heart transplants, or concomitant procedures performed during the transplant itself were excluded. Twenty-five articles with a total of 33 patients met the inclusion criteria, 10 regarding the aortic valve (14 patients), 5 the mitral valve (6 patients), and 6 the tricuspid valve (13 patients). In two cases, the procedure was recommended to stabilize the valvular lesion before re-transplantation, as both were very young patients. Overall, the mean time from heart transplantation to reintervention was 14.7 ± 9.5 years. The mean follow-up was 15.5 ± 13.5 months, and only one patient died 22.3 months after the intervention. There is a growing emergence of transcatheter interventions for valvular disease after heart transplantation, especially in cases where surgery is deemed high-risk or prohibitive. A different strategy may also be considered in young patients to permit longer allograft life before later re-transplantation. Although encouraging outcomes have been documented, additional research is required to establish the most appropriate approach within this specific subset of patients.

Frozen elephant trunk technique for aortic arch surgery: the Bordeaux University Hospital experience with Thoraflex hybrid prosthesis.

BACKGROUND: Aortic arch surgery still represents a challenge, and the frozen elephant trunk (FET) allows a one-step surgery for complex aortic diseases. The aim of the study was to analyze the results of patients undergoing FET procedure for aortic arch surgery at Bordeaux University Hospital. METHODS: Patients undergoing FET procedure for multisegmented aortic arch pathologies were analyzed in this single-center retrospective study. Further subgroup analyses were performed according to the degree of urgency of the operation (elective versus emergent surgery) and cerebral protection technique: bilateral selective antegrade cerebral perfusion (B-SACP) versus the unilateral one (U-SACP), regardless of the degree of urgency. RESULTS: From August 2018 to August 2022, 77 consecutive patients (64.1±9.9 years, 54 males) were enrolled: 43 (55.8%) for elective surgery and 34 (44.2%) in emergency. Technical success was 100%. 30-day mortality was 15.6% (N.=12, 7% elective vs. 26.5% emergent, P=0.043). Six (7.8%) non-disabling strokes occurred (1.9% B-SACP vs. 20% U-SACP, P=0.021). Median follow-up was 1.11 years (interquartile range, 0.62-2.07). The 1-year overall survival was 81.6±4.45%. The elective group showed a survival trend when compared to the emergency one (P=0.054). However, further examination at landmark analysis elective surgery showed a better survival trend compared to emergency surgery up to 1.78 years (P=0.034), after which significance was lost (P=0.521). CONCLUSIONS: Thoraflex hybrid prosthesis for FET technique demonstrated feasibility and satisfactory short-term clinical outcomes, even in emergent settings. In our practice B-SACP seems to offer better protection and less neurological complications compared to U-SACP, nevertheless further analyses are warranted.

Starting A New Robotic Surgery Program for Mitral Valve Repair. Lessons Learned from The First Nine Months.

(1) Background: Although transcatheter technology is rapidly growing and represents a promising strategy, the surgical approach remains the best way to repair a degenerative mitral valve regurgitation. In this context, robotic surgery is technologically the most advanced method of minimally invasive mitral valve repair. The aim of this study is to present the preliminary results of the initial single-center experience with a new robotic mitral valve repair program. (2) Methods: We retrospectively reviewed the records of patients who underwent robotic mitral valve repair at our Institution between January and September 2021. (3) Results: A total of 29 patients underwent mitral valve repair with annuloplasty and chordal implantation to treat degenerative mitral regurgitation. The procedure's success was achieved in 97% of patients. The 30-day cardiac-related mortality was 0%. The median CPB and cross-clamp times were 189 and 111 min, respectively, with a progressive reduction from the beginning of the robotic program. (4) Conclusions: Considering all the limitations related to the small sample, the presented results of robotic mitral valve repair appear to be encouraging and acceptable. A careful patient selection, a dedicated team, and a robust experience in surgical mitral valve repair are the fundamentals to start a new robotic mitral surgery program.

Rapid-deployment aortic valve replacement in high-risk patients with severe endocarditis.

BACKGROUND: Surgical management of aortic valve endocarditis in high risk patients is controversial and the ideal treatment has not been found yet. We describe a selected series of eight patients treated with rapid-deployment aortic valve prosthesis as a therapeutic solution for minimizing the risks associated with annulus manipulation in case of severe aortic infective endocarditis. METHODS: Eight consecutive patients (five men and three women) with a mean age of 74.3±7.2 years, mean logistic EuroSCORE II of 16.0%±0.1%, affected by aortic native (1 patient), or prosthetic valve endocarditis (7 patients), were treated with Edwards Intuity Elite implantation. Hemodynamic performance and infective data were collected pre-, intra-, and postoperatively with a mean follow-up of 2.7±0.7 years. RESULTS: One case of in-hospital mortality was noted. None of the patients had any embolic or infective complication postoperatively. The cardiopulmonary bypass and aortic cross-clamp times were 148.4±41.6 and 90.5±25.3 min, respectively. The postoperative echocardiographic controls indicated a mean transvalvular gradient of 16.7±3.0 mmHg and one case of paravalvular leaks (2 +). Two patients underwent epigastric permanent pacemaker implantation. During the follow-up, seven patients were alive, with no evidence of symptoms or recurrences of endocarditis or embolic episodes. No new paravalvular leaks were noted, and the mean gradient on the valves was 12.4±3.4 mmHg. CONCLUSIONS: Rapid deployment aortic valve replacement in selected very high-risk patients affected by infective endocarditis could be a reasonable choice with acceptable results. However, further studies are needed to confirm these results.